What is a difficult patient, and how doctors may be responsible

What, exactly, is a difficult patient?

Doctors can tell many tales of what they term as a difficult encounter.  Just as many patients can recall doctors whom they would say are difficult to work with as well.

According to a study from the Journal of General Internal Medicine, here’s a definition:

Patients deemed difficult included those with more than five symptoms, severe symptoms or an underlying mental disorder or were less functional. These patients were less likely to fully trust or be satisfied with their physician, and they were more likely to report a worsening of symptoms two weeks after their visit.

It’s important to note that patients weren’t the only responsibly party to the difficult encounter.  Physicians play a role in this as well.

As such,

researchers found that physicians who were involved in difficult encounters generally tended to have less experience and fewer psychosocial skills. “When you have someone who has 15 to 20 years of experience, they have learned how to deal with these patients,” [study co-author] Dr. Jackson said.

There will always be patients with multiple medical problems, or psychiatric disorders that will make the encounter more challenging. But it depends on a physician’s psychosocial experience whether that encounter will traverse into the realm of “difficult.” Of course, that experience comes with time.

Perhaps more training during residency is needed on how to deal with complex patient interactions is needed, so that new doctors would be more comfortable in handling a broader spectrum of patients.

 is an internal medicine physician and on the Board of Contributors at USA Today.  He is founder and editor of KevinMD.com, also on FacebookTwitterGoogle+, and LinkedIn.

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  • anonymous

    I don’t consider patients with difficult diagnoses or presentations to be difficult patients. The ones I consider difficult patients: ones who ask a question but interrupt me in the first ten seconds while I am trying to answer their question; ones who promise to do their labs repeatedly but have no better excuse than “I forgot” at their return visits; ones who refuse to come in but instead want me to diagnose them over the phone and call in an Rx for their cough or abdominal pain.

  • anon for this one

    Me! I’m a difficult patient! Actually I think I’m fairly intelligent, straightforward, and empathetic, and I am treated as such until my clothes come off and the doctor sees the evidence of my self-destructive teenage tendencies. Then there is, not always but sometimes, a palpable shift, a coolness and abruptness. I don’t want to blame the doctor; he sees the scars, combines that with my psych history, and he thinks, “Oh, crap. I’m never going to be rid of this one.” I don’t think he realizes how much it hurts to be regarded with an expression of disgust.

    Most physicians I’ve met are professional and compassionate; I know this, and I’m truly sorry that I’m afraid of you because of a couple bad experiences.

    • anon for this one

      Sorry, I guess my point was, we can tell when you think we’re difficult, and it colors how we interact with you too. (In my case, I just avoid the doctor whenever possible, which maybe solves your problem!) I realize that’s probably beside the point of Dr. Pho’s article. :)

  • Anon

    Thanks so much for this post. I was recently diagnosed with a disease that can cause a wide variety of symptoms. I saw more than 20 doctors for the same problems before receiving this diagnosis. I tried to put my best foot forward with new doctors, but it was hard to deal with their biases as well as my own fears about not being taken seriously. This problem just seemed to snowball over time. I sometimes asked for another opinion, but several other doctors terminated me when I would’ve preferred to maintain continuity of care. I told one doctor that I felt like I had trouble making energy from the food I eat, and she replied that this didn’t make any sense and sounded a bit dramatic. I turned out to have a mitochondrial respiratory chain deficiency.

    For difficult patients who are still undiagnosed, a quick review of the case can reveal an important detail that might have been missed. Many doctors overlooked or misinterpreted some items in my history that were very relevant to the correct diagnosis.

    I really appreciate it when doctors understand that anxiety in a patient doesn’t signify that there’s no physical disease. Anxiety and depression can be symptoms of many different “organic” diseases. Also, chronic illness can contribute to loss of social support, not just the other way around. I think, to some extent, anxiety and depression are normal feelings when a patient has trouble fulfilling work and social responsibilities. Most people don’t want to sit at home and watch TV, but some doctors are so vigilant against malingerers that patients can’t talk with them about how their symptoms affect their productivity. Often, what these patients need is not so much to talk about emotional problems, but for their doctor to feel motivated enough to stick with them so they eventually get the correct diagnosis and the best available treatment.

  • http://www.idealmedicalcare.org/blog/ Pamela Wible MD

    Great topic Kevin ~

    I have a tendency to attract these “difficult” patients. Maybe they sense my compassion and open-hearted approach to medicine. I find it fascinating the patients doctors attract. Six years ago I held town hall meetings and invited citizens to design their own clinic. We opened one month later and I realized soon thereafter that I now attract a subset of patients who distrust allopathic medicine. As a result I treat third-world conditions in clients who have boycotted western medicine for decades. Definitely makes for an academically and psychosocially-stimulated career!

    ~ Pamela

    Pamela Wible, MD
    Blog with me:) http://www.idealmedicalcare.org/blog/

    • Fam Med Doc

      Dear Dr. Wible,

      I went to your website. Very interesting. Could you discuss how payment is given in your clinic? Do you accept Medicaid? Medicare? HMO contracts? Are you cash only?

      Regards

      • http://www.idealmedicalcare.org/blog/ Pamela Wible MD

        Fam Med Doc ~ Payment is primarily by insurance FFS (80%). I do not turn anyone away for lack of money and give 30% off for payment at time of service. No HMO. No longer accept Medicaid or Medicare though continue to see these patients at discount or free. Basically I take a humanitarian, creative approach. I’ll do what makes sense. Anyone who wants to see me I’ll make it work.

        Check this out:
        http://www.youtube.com/user/pamelawible?feature=mhum#p/u/1/6giE_eymsAo

        That pretty much sums up my philosophy.

        Pamela Wible MD

  • http://paynehertz.blogspot.com Payne Hertz

    Part of the problem is the very concept of “difficult patient” as it is generally understood in that it tends to assume some sort of behavioral pathology in patients with multiple problems or symptoms. A patient should not be stigmatized for no other reason than he has a particular illness or collection of symptoms.

    Some truly problematic behaviors, like drug-seeking, are sometimes rational responses on the part of the patient to the realities of the system, and not a pathology in itself. If people could treat their own pain, whether physical or psychological, no one would drug-seek.

    The difficulties of finding adequate pain relief in a system in which patients are subject to the whims of practitioners and the state often leaves them with little choice but to try and game the system, a situation which obviously leads to frustration and anger all around.

    • Fam Med Doc

      Sorry Mr Hertz, but if you “game” me, I’m probably gonna notice and label you a problem patient. I wanna work with, and actually do work with alot of pain patients, some on high dose narcs. I have no problem with that. But I draw the line on rudeness to me or my staff, gaming, lying etc. Not acceptable. At all.

      But to the point of this above article by Dr. Pho, I dont find patients with difficult diagnoses, multiple symptoms, mental health issues, or less functioning patients “difficult patients”. I just dont. In my office, just be honest, relatively free from rudeness, and mostly cooperative and I’m fine with you. But when you become a difficult, oppositional person to me or my staff, then you ARE labeled a “difficult patient” and I will ask you to leave my practice.

      Do you agree?

      • http://paynehertz.blogspot.com Payne Hertz

        With respect, Farm Doc, you are asking me to agree with a series of adjectives.

        I don’t know, for example, what “oppositional” means to you. I know what it means to me, and it doesn’t include the patient exercising his legal and moral right to refuse certain treatments, or disagree with his doctor.

        The real question to ask here, is what degree of misbehavior on the part of a patient warrants a temporary, if not permanent, sentence of torture, because that’s what withholding treatment and labeling someone a “difficult patient” amounts to. I’m not being melodramatic here. Pain *is* torture. It is hell on Earth. In the absence of prompt treatment, patients lose their jobs, their ability to function and often their homes and families, too. It’s not a game where anyone gives you points for being nice, but step out of line once, and the hammer comes down.

        When you label someone a “difficult patient” or worse, a “drug-seeker,” you pretty much guarantee that patient will find it very hard, if not impossible, to get his pain treated.

        If I were a doctor, this is the question I would ask, and the answer would be you would have to pose a severe physical threat to my staff or myself before I’d treat you this way. I couldn’t gamble with a human being’s life that way. Rudeness wouldn’t even come close to getting you fired, you’d have to be a real abusive jerk.

        • http://paynehertz.blogspot.com Payne Hertz

          I just want to clarify that when I say “threat” I mean “threat,” not actual violence. At no point should any medical practitioner be forced to endure physical violence, except by personal discretion of that practitioner. There is no “acceptable” level of physical violence. If someone hits you or your staff, you are well within your rights to do whatever you have to do protect yourself, including discharging the patient or calling the police.

          When I say “threat” I mean a person who is emotionally volatile and may be perceived by some to be capable of violence. A severe threat, would be someone I am reasonably certain is on the verge of violence, or someone who has directly threatened an act of violence. Obviously, this is a judgment call that is not always easy to make, but acting like a jerk, being “oppositional,” or insulting me would fall pretty far short of this mark for me.

          No one is asking you to be a martyr. Just be humane and tolerant.

    • http://www.idealmedicalcare.org/blog/ Pamela Wible MD

      If physicians were not in such a rush we’d have more time to be human. That was the original intent upon entering medical school for most. Now we have factory-farmed physicians – some are able to escape McMedicine and model a more compassionate way to deal with “difficult patients” – mostly because they have time to sit, listen, and problem solve.

      Escape from McMedicine:
      http://www.idealmedicalcare.org/blog/escape-from-mcmedicine/

      Pamela Wible MD

  • J’s Mom

    Firstly, my son has leukemia and required a bone marrow transplant at a major childrens hospital. I’m sure I was labeled “difficult”. I was his advocate and can’t tell you how many medication errors were caught because we asked what are you giving our son and which IV line are you running it in. A major research hospital is like a huge locomotive, and anything or anyone that gets in the way or slows down its routine is labeled as difficult. Secondly, just as the doctors can tell of their multiple encounters with patients that are difficult to work with, the consumer of your care have just as many examples of doctors who are difficult to work with; but you hold either our life or that of our loved one in your hands. So we wait for 2 hours in the waiting room after driving an hour to get to your office; fill out 4 pages of medical history your office sent us prior to the appointment; gave the nurse our history, complaints, and medications; then the resident our history, complaints and medication (which we wrote down on the 4 pages before we arrived); all just to see you – the attending physician. And you ask all the same questions again. If this is a return, 4-6 week return appointment, you don’t even have the courtesy to read your last appointment’s notes. My favorite line is, “So what are we seeing you for today?” No wonder your patient is difficult.

  • soloFP

    The most difficult patients are the chronic pain patients. They have a list of “allergies” to meds and have to have only one kind of narcotic pain med 6 times a day or only 1 kind of bzd for anixety 4 times a day. My front office now screens all new patients and turns away any patients on high dose narcotics or bzd meds. In addition, any patient who has had 3 or more doctors in the last 5 years is turned away.

    • Carrie (@LizzPiano)

      Your post is exactly the type that Kevin’s post is making some sort of attempt to correct – the assumption that it is always the patient, that the practitioner plays no role in the difficult encounter. I’ve been a neonatal nurse in an academic medical center for nearly 6 years and a chronic pain patient (chronic migraine and cluster headache and rheumatoid arthritis) for 10 years. I actually do have true allergies (anaphylaxis, tongue swelling, etc) to 4 medications (none of them pain medications), each tried at various times in and outpatient to treat chronic headaches. I definitely have had 3 or more doctors in the last 5 years because I’ve got compartmentalized specialists for neuro, rheum, GI. I’m most definitely your typical “train wreck” on paper. (I’m a nurse – I know the distinction well!) And I even had one physician tell me that she thought I was going to be that way, and then turned out not to be so. Not everyone who fits a certain stereotype is automatically difficult. Most people with chronic pain were just regular people, living their lives, before the pain entered that changed everything. They can seem overzealous in attempts to return to normal functioning, but imagine if you were that person – wouldn’t you do everything you could to be rid of it and return to life as you previously knew it?

      I’m not naive enough to think that all chronic pain patients are like me. In fact, I personally know many that have some very challenging issues. However, it really bothers me when a provider jumps to the stereotype without even taking the time to speak to the patient or find out their story. I’m very fortunate that I was able to find providers who took me seriously and worked with me – even though not all I ran across were that way, and after many years of suffering from some pretty hefty pain, I received a nerve stimulator implant that has significantly reduced the headaches. I’m now studying at an ivy league school for two masters degrees. I even laugh at my own story for how ridiculous I know it seems sometimes.

      I was just a regular person – a 20 year old college student who always got straight A’s and loved playing the piano – when the headaches came on. I don’t suffer from poor family dynamics or psychiatric illness (other than resulting anxiety from the things I’ve been through over the years), but yet I am a patient with chronic pain. We’re not all horrible. :)

    • http://paynehertz.blogspot.com Payne Hertz

      Why does having more than 3 doctors in 5 years strike you as suspect? If you bring your car to a mechanic for a transmission problem, and he fails to fix it, do you stop seeing mechanics, or do you keep going to mechanics until you find one that can fix your car? Why is this perfectly logical behavior suspect when it is concerns the most important possession you own, your body?

      I have been to three separate doctors over a fungal infection in the last two months, and am working on a fourth. I finally pressured one of them, today, into doing a culture to determine that it is, in fact, a fungal infection, something that should have happened on day one.

      Unfortunately, you are not the only doctor that turns away chronic pain patients based on completely arbitrary criteria like these. Your patient has likely met with many doctors that refuse to treat pain before coming to you, and has had his behavior shaped by the experience of endless rejectionism. Non error adverse reactions to drugs kill tens of thousands of Americans every year and injure hundreds of thousands more, not to mention the millions that are simply made intolerably uncomfortable by them. It is estimated that 10 to 15 percent of hospitalized patients will experience adverse reactions to the drugs they are given. Yet you seem to think that whenever a patient reports an adverse reaction to a drug, particularly NSAIDs, which is the class of drug that causes the most adverse reactions, they must somehow be faking it. Is it morally justifiable to risk a patient’s health and life on such flimsy reasoning?

    • Fam Med Doc

      Im a Fam Med doc, but I do ALOT of pain managment. Several comments to your post with some suggestions:
      1) a list of allergies with only one narcotic medically acceptable is definetely a red flag.
      2) a patient using a narcotic 6 times a day is in need of a long acting narcotic like MS Contin, Methadone, Oxycontin, etc. 6 times a day for break thru pain without a long acting on board is unacceptable. Offer a long acting. If they refuse, discharge the patient. I do.
      3) a benzo 4 times a day is also probably inappropriate. They need an SSRI. Also another reason to discharge a patient, but its not as a strong suggestion as the previous one.
      4) Dont be afraid of high dose narcs just because its high dose. They might actually need the high dose. Maybe not, but be brave and do the eval. They might be legit. You might actually help the patient where everyone else gets scared and refuses to help. The worse that can happen is you feel unsafe in prescribing and you send them away empty handed, but you at least tried. DONT feel bad about using your clinical judgement, but your clinical judgement starts when you are actually in front of the patient.
      5) 3 (or 4) docs in the last 5 years doesnt seem like alot to me. Especially in this day and age where people are getting new insurance plans every year from their jobs, patients are moving around to to where the jobs are, docs are dropping plans, or dropping out of medicine in general. 3-4 docs in 12 months seems too much, but not in 5 years.
      6) PLEASE tell me you do a pain contract. It can keep you sane. And when someone violates it, discharge them. But at least you tried to offer the best of care.

      Finally, if you dont like pain management (and why should you? you are are Fam Med doc, not Pain Management), dont do it at all and refer them out.

      Good luck. Pain management can be QUITE challenging, and yes, some of the patients are drug seeking and diverting, and OBNOXIOUS. But most are not and really need us. And to reduce someones pain is truly amazing and I find it a real privledge to be a part of someones journey to a higher level of functionality and decreased pain.

      Regards

      • http://paynehertz.blogspot.com Payne Hertz

        So if a patient violates a pain “contract” which he signed under duress even once, you are comfortable withholding treatment and essentially inflicting pain on him? If a doctor commits a medical error through negligence and destroys a patient’s life, are you comfortable seeing that doctor lose his license to practice medicine until such time as it can be determined he is not a threat to his patients?

        Somehow, i don’t think you would be as comfortable with such arbitrary and draconian punishments if you were on the receiving end of them.

        • I’m a Family Doctor

          Dear PH,

          You wrote: “you are comfortable withholding treatment and essentially inflicting pain on him?”

          Nonsense. I do not inflict pain on anyone. If a patient violates the pretty serious aspects of his pain contract, it’s his own doing. I discharge patients for serious inappropriate behavior. Yeah, I know in your eyes that’s wrong, and I’ve read your blogs on your website but that’s my professional judgement. Lying to me, diverting your narcs, using illegal substances (like cocaine, heroin, crystal meth), verbally abusing my staff (or me) gets you booted.

          Most rational people would agree.

          • stitch

            This one agrees. Fool me once, shame on you, fool me twice, I’m not giving you another opportunity to do so.

      • DocL

        Tricyclic antidepressants are the most effective type of antidepressant used for pain, not SSRIs.

        • ButMadNNW

          Most antidepressants are not statistically-significantly more effective than placebo. They should be pulled from the market.

          • Peter

            ButMadNNW – get your medical data from an actual medical source, not the MSM. According to the latest metaanalyses, SSRIs are not stat-sig more effective for mild depression…they are effective for severe depression, anxiety disorders, and a host of other conditions, including chronic pain (though not as effective as narcs, obviously). The mainstream media published a bunch of stories a few months back saying that antidepressants were not better than placebo, but they failed to read the actual studies (or figured that catchy headline would sell more ad space), when the studies actually found no improvement over placebo for mild depression only.

    • DocL

      I am curious where did you get the “3 or more doctors in the last 5 years” standard? Anyone who has changed jobs, insurance, or cities, or had a baby in 5 years could reasonably have 3 or more doctors. Heck, there are some diseases that are treated by multiple specialists at the same time.

      • ButMadNNW

        As someone who has moved a lot in my life and witnessed what my housemate has been put through by doctors, this “3 doctors in 5 years” policy infuriates me.

        My housemate has seen more than 3 doctors since last Christmas because she kept getting passed around and around by doctors too cowardly to help her. I’m not joking. One surgeon told her a surgeon would have to be nuts to operate on her. A lot of doctors simply washed their hands of her without so much as the courtesy of a referral to someone more qualified. And this was with a 10cm fibroid tumor causing her chronic pain to the point that she couldn’t work!

        She finally ended up going to Mayo, who recognized the seriousness of the problem and fast-tracked her into surgery. A complete hysterectomy. She’s 4 weeks out from surgery, but already feeling much better than the agony she went through in the 2 months leading up to the surgery.

  • Anonymous

    I used to be a good patient. Then I developed a complication and didn’t get better. My doctor discouraged me from seeking a second opinion. I got a second opinion, along with a copy of my records, and discovered my doctor had lied to me, on many occasions. Mostly to cover herself, but sometimes just so I wouldn’t question her, I guess. Mind you, prior to reading the records, I had no idea she was being less than truthful with me. I just wanted to get better.

    Now I suppose am a bad patient, and I don’t really care. I avoid doctors, anyhow.

  • Hueydoc

    The well known Bell curve will point out that 10% of patients will be wonderful people and 10% will be people you cannot please no matter what. If you’re not happy with your doctor, find another one- you’ll both be happier for it.

  • http://www.causes.com/causes/416895-reeds-awareness-hlrcc/ Kat

    Most doctors and nurse practioners I see and have seen over the years deserve the utmost respect. There have been times when I try to self advocate, asking (*in my mind) reasonable questions about my conditions, drugs, and follow up care, I feel dismissed. When anyone does not feel validated, they become a bit defensive. I am one of those patients that has many adverse effects to many medicines, if there is a side effect I usually end up with it or an allergy. I am NOT a benzo or narcotic taking patient! When I ask a physician about trying something different because of said side effects, I do not expect to be treated like a drug addic. (Yes I have had a few doctors treat me as such.) Again, I too (like other patients here stated) give respect and try to remain open to suggestions of new/current MD’s , PA’s, NP’s. I guess I would ask doctors who seem to have issue with problem patients, is do not talk down to us, value an articulate dialog, and help us make informed choices when it comes to our treatment plan; and really listen to your patients before you come to the conclusion it is psycho sematic. With out my digging to find an answer with all my health issues my HLRCC (Reed’s syndrome) would have never been detected. Thank you for this wonderful article.

  • http://davidbeharmdejd.blogspot.com David Behar, MD, EJD

    The most tricky, scary, difficult to control patients? Docs.

    • http://www.idealmedicalcare.org/blog/ Pamela Wible MD

      Hit the nail on the head. We’re the worst by far.

      Pamela Wible MD

      • http://www.drmartinyoung.com Martin Young

        I second that.

        • family practitioner

          Nurses are worse than doctors.

          • anonymous

            Try pharmacists who want meds they don’t need.

  • CandiO, WHNP-BC

    I would point out to the frustrated patient who is tired of being asked the same questions by different people, there is a purpose to it. 1. I like to know what the person is there for, before I go in the room. I may need to gether supplies, bring an anatomical model with me etc. 2. The story so often CHANGES. What gets told to my nurse is often so different from what I get told. Also what the nurse gets told is often missing key pieces of data that I need and that may or may not get told to even me. I just hope you can understand why the same questions get asked.

    • ninguem

      I had a particular pain patient a while ago. Yeah, she was tired of being asked to “prove” to the doctors that she actually had the disease. Professor Smith at Yale told me I had multiple sclerosis and I need the OxyContin.

      Problem was, when the problem was actually researched, Professor Smith at Yale had said no such thing.

      “Maybe it was Harvard”

      Universities changed to protect the innocent.

      I actually have two such patients right now, in a practice that sees a lot of medical pain patients. I spend a lot of time unwinding convoluted stories. The three doctors in five years stuff, I’ve seen far worse than that, is a way to get the story to change from:

      “Professor Smith at Yale said I have a simple back strain, but let’s look to make sure it’s not something worse like multiple sclerosis.”

      to

      “Professor Smith at Yale said I have multiple sclerosis.”

      And resistant to workup of the disease, not out of a desire to be spared another diagnostic test, to trying to keep the doctor from understanding the truth behind the disease, keep the patient misdiagnosed and drugged.

      MRI and lumbar puncture both negative.

      I’ve had the car accident major trauma with multiple surgeries turn out to be a fender-bender, after searching every hospital in a two-county area. Topping the list for me was a made-up HIV diagnosis. I was the evil doctor refusing to treat the AIDS patient suffering. Doctor Jones at Mayo told me I had AIDS.

      Mayo records revealed a ER visit after a bar fight.

  • keepingthyme

    I am not a doctor. I am a patient and a mother of patients as well as a staff member of a medical speciality group. Prior to working in the medical field, I worked in many other fields requiring constant interaction with the general public.

    My definition of a “difficult” patient/client/customer has always been based on their level of arrogance and expectations and treatment of myself and coworkers. This has everything to do with how these things line up with my own beliefs, morals and attitudes and nothing whatsoever to do with who is right or wrong.

    I have learned over the years how to listen and to try and put myself in the other persons’ situation. It does not mean I will not still find them “difficult” , but it does mean I have attempted a fair shot at helping them (hopefully with some level of compassion), and thus am okay with passing them on to someone who may not find them as “difficult” if we still cannot reach a level of satisfaction acceptable to both of us.

    Having a child with a chronic condition (that some see as a nonsense diagnosis) and having him on a medicaid-type insurance plan means we have seen many “specialists” over the years. I see nothing wrong with a doctor who will honestly say to me that he is not capable of handling my son’s condition, but this means a referral elsewhere. I do see something wrong with being lumped into the “medicaid” category and being discharged at the slightest of “digressions”. Looking at my son’s medical history, I have no doubt that someone like soloFP would be turning us away as “difficult”. Seeking a second opinion, or requesting a change in doctors should not be held against us.

    I would never tell someone how to run their business (and let’s be honest, the medical field is still a business), but only I can decide which business best suits my needs and expectations. And that business has the right to determine their own survival by the type of clientele and reputation they strive to attain.

  • Tina Gruner,MS,RD,CDE,LD

    I am a difficult patient. I am also a Healthcare professional.
    I had a bilateraladrenalectomy at Cedars Sinai Medical center due to pheochromocytomas, with no final diagnosis.
    Then I had pancreatic islet cell tumors removed with no diagnosis. Later a smart MD diagnosised me with von Hippel Lindau Syndrome (2 tumors plus DNA testing), at age 48 (20 years later, REALLY, duh). Now I am being treated at NIH (Thank GOD), but while I was hospitalized to have my right upper lobe of my lung removed due to Large tumors of unknown tissue type,
    I had to ask every 12 hours for my cortisone (necessary due to my bilateraladrenalectomy) for 5 days because the Resident did not know how to put the order in the computer to be a STANDING ORDER. I had to yell and scream at the nurses and the docs to get a med I needed to SURVIVE at the best in the world. I am very grateful for the care I recieve at NIH but we are all still learning and mistakes do happen. I’ll bet that Resident never makes that mistake again. This is only one of my stories. I could write a book.

  • http://www.scabiehelp.com Les

    Well I really like this topic for discussion! Here is a disease that has really got the Doc’s and patients reeling around a bit. It can cause difficulties in Doc and patient relationships. Diagnosis of the patient having scabie mites is often very elusive for the patient and the Docs. Reason being is this disease mimics so many other types on the surface and is often missed. Patients suffering constant itch and loss of sleep leads to irritable patient visits of which makes for a not so good day for the medical staff involved. Yes they are trained for this…however it can be tiresome to deal with day in and day out. Hospital staff are told to report & treat any symptoms that resemble scabie mite infections in an effort to contain a very contagious disease from spreading to the rest of the staff and patients. We applaud this quick thinking and action to eradicate this disease expeditously! Let’s keep in mind though that handing out a RX is only one part of what needs to be done. Environmental issues prevale with this disease and to be successful one must have a plan for success! Our Scabie Help E-book (www.scabiehelp.com) enjoins with the medical community for the eradication of the scabie mites on the person as well as the surrounding environment. To find out more please visit our website!

    To your Success!

  • Heart Patient

    To SoloFP: To your statement “In addition, any patient who has had 3 or more doctors in the last 5 years is turned away”, seems rather short-sighted to me. I take no pain meds, am allergic to no meds, am a compliant patient, always take my meds, always use generic when available. However, I’ve had hand, and back surgery (2 physicians), have a cardiologist, neurologist, and a PCP. So, I have 5 doctors that I’ve seen in the last five years. Unexpected surgical conditions come up, which added 2 doctors, but the other 3, cardio, neuro, and PCP are seen routinely.

    I can’t imagine any reason you would refuse to see me…I am a “great” patient, according to my doctors.

    You may be missing out of some good patients yourself with that statement.

  • http://paynehertz.blogspot.com Payne Hertz

    Nonsense. I do not inflict pain on anyone.

    You inflict a punishment based on completely arbitrary rules on another human being which is guaranteed to result in pain for that person. There is a legal difference between this and deliberately torturing someone, but in a system where pain patients have no alternative but to go to a doctor to get their pain treated with meds, little moral difference that I can see.

    Most rational people would agree.

    Rational? If a diabetic smokes a joint, is it rational to withhold his diabetes medication? If a cancer patient does heroin, is it rational to withhold his chemotherapy? What if you catch the diabetic at Pizza Hut gorging himself on pizza and beer? Should you cut off his insulin?

    If a prison warden punished prisoners like this—by deliberately withholding their medication to the point they suffered intense pain as the result of their illnesses, he could be tried and likely convicted for brutality and violating the Eight Amendment prohibition against “cruel and unusual punishment.”

    But doctors do this every day, without any legal or constitutional framework, no judge or jury or right of appeal, or even any meaningful ethical guidelines from medical societies. Cruel, but certainly not unusual. It would not be an exaggeration to say that chronic pain patients have less rights than incarcerated child rapists when it comes to appealing this kind of treatment.

    No civilized person would consider a legal system as arbitrary and absolute as this to be “rational.” Yet this is accepted practice in our medical system.

    • Tom

      it seems reasonable to point out that the physicians who will terminate a patient for violating a pain contract do so for, among other reasons, liability exposure. If a patient violates his pain contract with heroin while I’m prescribing oxycodone and he drops dead, who will the family blame? And yes, it would be my fault, because I continued a dangerous substance despite the knowledge that harm could result, due to non-compliance. That is what a pain contract is all about; doing no harm, by treating the pain without worrying about other substances entering the mix.

      • ninguem

        It’s not a “contract” strictly speaking; there may be medicolegal consequences to calling it by that name.

        I use the form in question, but it’s more appropriately called “informed consent”. I use the form for controlled drugs generally.

        I’ve had the occasional coroner call from a patient receiving controlled drugs from me, where the corpse was found in a suicide scene, or a multidrug polypharmacy drug abuse scene.

        • http://paynehertz.blogspot.com Payne Hertz

          The term ‘contract” has a specific meaning in law. Under the law, both parties have to be fully informed of the terms of the contract, must enter into the contract freely, and be equally bound by it. None of these criteria are met by the typical pain contract. The idea of calling it a “contract” is to falsely give the patient the idea he has entered into a legally-binding agreement, and therefore any penalty for violating it has the force of law behind it, when that is entirely untrue.

          Indeed, I have seen some “medico legal” types state that it is unwise to call these things ‘contracts” because they might be construed to create a legal duty to perform on the part of the doctor, though few pain contracts contain any provisions specifying the doctor’s responsibilities.

          While some contracts double as informed consent agreements, many do not even bother to spell out the consequences of using opioids or inform the patient exactly what he is getting into, but instead present a list of obligations the patient is expected to obey, or else.

      • http://paynehertz.blogspot.com Payne Hertz

        You could employ similar reasoning with any drug you prescribe. If you prescribe Tylenol, and the patient goes home and drinks a bottle of whiskey and dies from the interaction of acetaminophen and alcohol, wouldn’t “the family” blame you for that, as well? Why aren’t diabetics made to sign contracts? Noncompliance can result in death for them as well, as can abusing insulin.

        Tell me how pain “contracts” that include criteria like “patient will be discharged if he misses more than two appointments,” or which threaten to terminate treatment for failing to undergo treatments which may include invasive and unproven procedures like injections and surgery have anything to do with drug compliance.

        It is difficult to see anyone winning a lawsuit for behavior that was completely out of your hands. Do you have a few examples?

        • Greg

          “If you prescribe Tylenol, and the patient goes home and drinks a bottle of whiskey and dies from the interaction of acetaminophen and alcohol, wouldn’t “the family” blame you for that, as well?”

          Yes.

          That’s why doctors keep harping about malpractice reform. We are often blamed for others’ stupid decisions.

          • http://paynehertz.blogspot.com Payne Hertz

            Can you give me any examples of doctors being sued for failing to warn patients about the dangers of acetaminophen/alcohol? Most of the high profile lawsuits I am aware of were directed at the manufacturers of Tylenol for failing to include label warnings on these dangers despite the fact the FDA has been trying to get them to do so since 1977. If this information was kept from doctors and the public for so long, why would you consider patients to be “stupid” for making this mistake?

            But now that this information is known, surely doctors have a duty to inform their patients of the risks?

            http://vimeo.com/4617606

  • candiceleonard

    “Difficult patients” are also those who come in with more information about their condition than the doctor expects – many doctors are not on board with the trend toward informed and engaged patients – they still want to be the ultimate authority and speak to patients in a directive, condescending way. Patients that are outliers (in the positive direction) on health literacy may actually get worse care.

    • ninguem

      Same old, same old. No, the difficult patient is the one coming in with more information than the doctor expects……all of which is wrong, and the doctor has to spend twice as much time trying to disabuse the patient of misinformation.

      • Fam Med doc

        “many doctors are not on board with the trend toward informed and engaged patients – they still want to be the ultimate authority and speak to patients in a directive, condescending way”

        wow, you must have a bad experience. but dont put me in that category you described above. nor the collegues at my medical center. gosh, i love it when i tell a patient s/he has a certian diagnosis and before i get to speak they start talking describing preobtained and accurate information on the topic. that saves me alota time. i wish i had more patients like that! unfortunately, i rarely come across that. i usually come across patients with rather peculiar and down right wrong medical ideas they got from the internet that takes me even MORE time to reeducate and redirect them. then sometimes they get oppositional and say “but i read on the net…”.

        now thats a difficult patient.

        please, patients reading my comment, ONLY READ doctor written websites. theres alota junk out on the net. and it can mislead and even harm you.

        regards to all

        • anon

          That’s why candiceleonard said “many”, not “most”. She points out a problem that “many” patients experience. Thanks for addressing the information literacy issue in a non-sarcastic way. Some of us know junk on the internet when we see it. Some of us read the same journal articles you do.

          You make a valid point about the time it takes to correct misinformation. You also know that the way you respond to patients (not being condescending, giving patients a chance to talk) can ultimately save time. Frustrated docs should take note.

    • Every Patient Matters

      Oh I’ve been there. I went into the hospital and told them I had appendicitis and I needed antibiotics and surgery. Multiple doctors and nurses spent hours trying to tell me I was wrong so I said prove it – show me that my appendix is ok and I’ll leave. By the time they did the CT 17+ hours later, it had ruptured. Then they spent more hours trying to convince me that I needed painkillers rather than antibiotics, so I refused the morphine and had to threaten to pull my saline lock out of my arm and crawl out of the hospital to get the antibiotics. Then they spent days trying to convince me that I was making it up that I was getting worse, even as blood results and clinical symptoms worsened. The second CT proved me right, but still no surgery. I had to find the second CT results in my records a few months later. Then they tried to get me to sign a discharge paper which said I was admitted after the worst part of the episode, which was untrue. All this time, they yelled at me for not being able to bend over to use the toilet, etc. And it got quite a bit worse than this. Difficult, eh? Sometimes that means knowledge and tenacity.

  • ninguem

    How is it that the USA can be so terrible about treating pain compared to some supposed perfect country elsewhere, and at the same time be the leading consumer of prescription opioids, by far, compared to the rest of the world?

    • http://paynehertz.blogspot.com Payne Hertz

      I’m not sure where anybody made a comparison with anywhere else in the world, but pain is undertreated everywhere, not just here. I could think of a lot of reasons why the US might lead the world in opioid consumption and still have a greater problem with undertreated pain than elsewhere. Some of these are known facts, others just speculation on my part.

      1. Racial and class discrimination: Known fact. White, middle class people are more likely to get their pain treated than minorities, the poor, working class or those without insurance. So you might see high consumption among the white middle class and low or inadequate treatment in other groups simultaneously.

      2. Speculation: US leads the world in surgeries, so there may be a far greater use of pain meds for post surgery pain that balances out, to a degree, the undertreatment of chronic pain.

      3. Speculation: More generous medical leave and aggressive pain treatment and access to physical therapy at the onset of injury prevents the development of more severe pain that requires treatment with high dose opioids. European doctors may prescribe less opioids because there is simply less need for them overall when proper therapy is delivered in a timely manner.

  • elmo

    @payne
    re: “and the answer would be you would have to pose a severe physical threat to my staff or myself before I’d treat you this way”

    So Payne what is an “acceptable” level of “moderate” threat of physical violence that we providers should tolerate and ignore. A punch in the face or a kick in the nether regions as opposed to being stabbed or shot?

  • Reta Russell Houghton

    The title is misleading. What is described is a patient with a complicated case but the impression many get from the title is about a patient that may be difficult to work with.

    People with complicated cases are often frustrated because many doctors focus on the small picture and do look at the big picture to connect all the dots.

  • Difficult Mom

    According to your definition, my son is a difficult patient. He has 5 or more symptoms, that requires us to work with doctors in several fields of medicine. I suppose the term “severe symptoms” would be relative to who you are speaking with. Any symptom can be viewed as severe from the patients point of view until they are educated, and then many times even after. It is my responsibility to learn what I can about the disease and the symptoms of my family. However, It is my Doctor’s responsibility to get me pointed in the right direction by giving me complete and understandable information while I am at their office. What I learn on my own, mostly through the internet, is very generalized and can be overwhelming and very scary. But in order to be able to get sound educated answers from my kids doctors, I have to ask very specific questions. And without having someplace to start, then we are lost and only have the word of our doctors to go by. Not knowing is what creates our fear.

    I am not knocking any of the specialists that we have, they are all very good at what they do and their office staffs are very good.

    Each severe symptom belongs to a different specialist and even though we let each one know that there are other issues going on, sometimes we seem to be torn between 2 or 3 doctors that feel that their case should take priority. In the meantime, I am becoming more stressed and worried and scared, confused and can see myself as being a DIFFICULT MOM on occasion. Not because I want to be, not because I am uneducated, but because I am overwhelmed and want to make the best choice for my child.

    I ask my doctors to “talk to each other” so that all are informed on what is going on with my kids, when it happens, all is good, but when it doesn’t it becomes tough.. Because Doc 1 has not contacted Doc 2 or vise versa, I am put in a position of doing my best to get all the information I need, not an easy chore for someone who doesn’t know what they should be asking about.

    As business changes so does everything and my family doctors office has fallen prey to some family medical health group and has become very impersonal, they have gotten rid of the staff that knew our family and cared about us. The ones that would would help advocate for us are gone and their replacements very obviously don’t care and don’t care to know and are just trying to get through the day. So, when I am trying to get information from them, it can be tough, I am already on edge, they don’t know or care about our situation so they become defensive and hmmm. I become Difficult.

    I have fired a doctor and went to another doctor that work in the same group, different office because my doctor made committments to me over testing or follow-ups that sat on somebodies desk way beyond a resonable time in my opinion. I had no problem with my doctor, he was a good doctor and I told him so. But he took no responsibility for the committments that he was making to me and did not enforce his word with his office staff, this was not just a one time thing. It was a consistant. While we were a patient of his, I am sure that I was termed as difficult, I have a great partnership with my new Doc, His staff makes sure that follow up appts or testing schedules are at least started, if not completed before I even leave their office.This is from the same practice – 2 different locations.

    I am here to tell you, It is not easy being a difficult patient. I don’t want to be, I need a good partnership with my team of docs, but it does take work on both sides.

  • ButMadNNW

    Two psychologists I know and regard highly have a saying about “difficult” clients: “Resistance only exists if you push back.”

    Some patients are difficult because they’ve had bad experiences and had to fight to be heard/understood by their doctor, who dismissed symptoms or concerns. Or because doctor A wouldn’t release the patient’s chart (excuse me? It’s *MY* information) to it could be passed on to doctor B. Or whatever.

    Sometimes, your (or your colleagues who were jerks to us before) behavior is the cause of ours. Think about it. Don’t want difficult patients? Don’t be a difficult doctor.

    • ButMadNNW

      Oh, how I hate typos. That should be “…SO it could be passed…”

    • http://Www.twitter.com/alicearobertson Alice

      This is good counsel, but our doctor is patient and kind, yet patients still dump him (well…the rule at CCF is to offer the patient another doctor…they call it personality clashes). And sometimes it is your specialty…if you do plastic surgery…..I hear there can be applause or angry outbursts when they see your final decision about things like nose size, etc.

      I, also, think age can typecast patients…and disease. I imagine oncologists see the best and worst of humanity via doctors and patients. I know the waiting room is one of the saddest places I have visited….hope and sorrow intertwined……everyone is aware of it.

  • Donna

    I am a difficult patient. I have a genetic disease (VHL- same as previous poster Tina) that causes multi-system issues.

    While I can understand that most patients come in with simple issues that can easily be resolved, I find it disconcerting that a lot of Doctors really don’t want to deal with a patient that has multiple symptoms or issues. I hate being labled as a “difficult patient” although I had already come to terms with the fact that some of the Doctors I have labeled me that way.

    To the doctor that does not want to see any patients that have had 3 or more Doctors in a year, good for you! I don’t want to see you either. You’ve already decided that I’m just going to be a pain to deal with, so I definately don’t want to be treated by you. I have 5 Doctors that I would consider part of my regular team and have been referred to others for non related issues over the years.

    I vividly recall being yelled at by an endocrinologist early on before I was diagnosed with my first pheo. He was fed up with me constantly going to the ER and Urgent care in Hypertensive Crisis and told me to just stay home until they figured out what was wrong. He told me that I was the one who was causing the symptoms to myself by overreacting to something that was not serious. Anyone who has ever dealt with or who even does some research on Pheo’s should be able to see that the severe affects caused by this are not something that you can just do to yourself. Also, he did not take into account that prior to this I had been very normal and rarely went to the Doctor. I had never before presented myself to a Doctor for anything other than normal routine ailments. For my second Pheo he wanted to send me to see a Psycologist or Councelor as he thought my syptoms were in my head because I just couldn’t seem to get over being sick the first time. Fortunately right after that I started going to NIH and had treatment and surgery for it there.

    Now I am very educated in the various apects of my Disease. When I go to the Doctor I know exactly what tests need to be ordered. I can be very insistent on what tests I feel need to be ordered to rule in or out VHL issues.

    I rarely go to the Doctor now except for my VHL screenings which I tend to put off as long as possible locally. I’m afraid to be considered a hypocrondriac, so opt to only see a Doctor when something is very serious. Part of this is from being labled one before by diagnosis. I’m sure that endo that was so mad at me made a note to my file about it. I’m sure he made a later note when he wanted me to seek psycological help for the symptoms of my second pheo.

    To this day, both my Primary Care Physician and Endo have not educated themselves on VHL. I wonder why? Where’s that drive that sent them to Medical School in the first place? Didn’t they anticipate as Students that one day they would be able treat people like me? Don’t they want a few interesting patients to relieve the boredom of the endless sore throats? My Ophalmologist is such a person. He is the one local Doctor that I never put off seeing. He is well versed in all aspects of my disease even though he only treats my eyes. He stays abreast of the latest in treatments for my eyes. He doesn’t have an issue picking up the phone and calling the Doctor at NEI that sees me to get an opinion. He acts genuinely happy to see me when I come in and never has asked me why I’m there. He has that enthusiastic and caring attitude that I would love to see all Physicians have.

    I am that difficult patient because I have a difficult illness. I don’t want to be a difficult patient but I don’t know any way not be.

  • Alison

    I despise lazy providers who prejudge based on such factors as allergies, diagnosis, or number of previous physicians. I like to size up a new provider by going “incognita” — not bringing up my credentials and just presenting with the same information as any other well-informed patient. The best docs will listen to my complex history and complaint, ascertain that I am able to carry on a rational and very well-informed discussion of the options, and treat me as a partner. Unfortunately, many if not most have already stopped listening before even entering the exam room, either when they saw my chief complaint or noticed that I (many years ago in college) was once diagnosed with PTSD. Yet if I “prove” my “bona fides” suddenly I am treated as at least half human. It should not matter what letters a patient has after her name — all should be evaluated with a neutral starting point and let behavior, presentation, and knowledge direct the course of the visit from there.

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