Label the interaction as difficult, not the patient

Kevin Pho, at KevinMD.com, posted a commentary about encounters with “difficult patients.”  He correctly notes that physicians themselves contribute to these interactions. To reduce the likelihood of these encounters, he suggests that physicians would benefit from more training in “psychosocial skills.”

Kudos to Kevin for adjusting his own language by the second sentence of his post: He makes the distinction between difficult patient and difficult encounter.

A vital step in decreasing the likelihood of difficult encounters is recognizing the language we use for these events. The words we use affect our perceptions.

Compare:

  • “That’s the liver guy. He’s a complete train wreck!” versus
  • “That man has liver cancer. He has an infection in his blood, needs a mechanical ventilator to breathe, and now he might be having a heart attack.”

The phrase “difficult patient” automatically suggests that the patient alone is responsible for any conflicts or problems during the appointment. Uncomfortable emotions, like helplessness or anger, that the physician may feel are attributed solely to the patient. If only the patient would change, then everything would be fine!

As a result, the doctor may then feel absolved of any responsibility to alter his own behavior to improve the interaction. The assumption is that the physician is right and the patient is wrong.

If we instead label the interaction—rather than a single person—as difficult, this can help both patient and physician to step back, assess what each is contributing to the situation, and work together to resolve it. The assumptions doctors and patients have about each other are often inaccurate and impede cooperation. Using the time to understand, rather than blame, the other person can decrease the likelihood of these difficult interactions.

Doctors, like most people, often assign adjectives to patients because it can be hard to identify and then acknowledge emotions. It is much easier to say, “She is such a difficult patient! She is never happy with her care!” than to say, “I feel angry and helpless when I see her because it seems like nothing improves her symptoms!” Leaving out the subjective “I” gives the illusion of objectivity and professionalism.

Physicians are only human. Sometimes we have bad days; sometimes our “psychosocial skills” aren’t well developed. However, we must do our best to engage and build rapport with patients to provide optimal care. Watching what we say and choosing our words with care is a valuable first step.

Maria Yang is a psychiatrist who blogs at In White Ink.

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  • pheski

    Over my 30 years in primary care, it has seemed to me that the patient is at least as aware of the ‘difficultness’ phenomenon. I have tried to capitalize on that by taking the following approach when I notice myself thinking of a patient as difficult:

    “There’s something I struggle with that I’ve been looking for a chance to discuss with you, Mr. Smith. It seems that some of our conversations seem uncomfortable, and I wonder if you’ve noticed it too?”

    If I get an affirmative response, I suggest we set aside some time perhaps at a separate visit to talk about how we can make the relationship and conversation work better so we can do a better job managing the diabetes without letting this get in the way.

    If I get a negative response, I say “Great. I’m glad it’s only me. Don’t hesitate to let me know, though, if you notice it too.” And then at a subsequent visit I’ll be a bit more directive: “Remember when I asked if you noticed that sometimes we seemed to be on a different page? I’ve been thinking and I wonder if its because I’m worried about things that aren’t that big a deal for you and you’re worried about things that I’m not helping you with?”

    It doesn’t always work, but it’s been gratifying how often patients respond to the concept that the relationship itself is one of the tasks on the table and that I’m open to feedback about it.

    • http://www.ServantLawyership.com Kathleen Clark

      Dear Pheski: Thank you so much for your post. I so appreciate the way you use language and talk to your patients in such an open, honest way. Was talking to friends about this the other night I recall being on a conference call with Don Berwick, M.D. presenting. He said he never uses “non-compliant” to refer to a patient. There is always a reason a patient isn’t doing what he recommends, he just needs to talk to her/him to find out what that is.

  • horseshrink

    Talking with difficult patients … working with patients who lie … who threaten … who fake …

    Prison and jail work taught me much. I had to learn the hard way.

    I finally learned to not take lying personally, or to struggle with it. After careful questioning, I’d merely point out all “voices” don’t require medication, and theirs were not a kind to be so treated because of the risk (I’d act out tardive dyskinesia in detailing the risk.) I wasn’t disagreeing with them. I was looking after their welfare. It puzzled them.

    I rarely used the word malingering. Put that in a chart and an inmate’s crushing exertional chest pain next year will be written off as faked. Rather, I’d write “low probability of valid psychosis” and try to see if there was some other way to be helpful. Many responded to this, because I avoided contest.

    I learned that the inmates most upset with me re: diagnostic disagreement didn’t decompensate, so storming, threatening, entitled indignation became good news.

    And I learned to have a little vestigial bit of hope for even the most unpleasant of my patients, for sometimes they’d surprise me with astonishing revelations. Even if they learned little, I learned much.

  • http://myheartsisters.org Carolyn Thomas

    Thank you Dr. Yang (and especially thank you ‘pheski’ for your profoundly thoughtful insights into improving doctor-patient communication! Your advice should be embroidered on cushions and distributed to all medical students!)

    Here’s how to be a “GOOD PATIENT”: Contract an acute illness. Go see your doctor. Get diagnosed. Take your meds. Get better. Thank the doctor. Now, here’s how to be a “DIFFICULT PATIENT”: Contract a chronic, progressive illness. Go see your doctor. Take your meds. Get diagnosed with something different. Many, many times. Take your meds. Keep going back because symptoms are now getting worse. Get more tests. Take your meds. Get referrals to specialists. Get more tests and meds. Keep going back. You get the picture.

    Most such patients live in fear of being dismissed as “difficult”, on top of knowing something is terribly wrong. For a truly compelling example of this, read: “It Wasn’t Heart Disease – But What Was It?” at: http://myheartsisters.org/2011/03/14/mystery-diagnosis/

    • Campykid

      Carolyn, your definition of “difficult patient” is spot-on and describes perfectly my 12 year ordeal with atrial fibrillation!

      And thank you Dr. Yang for acknowledging the need for better patient-doctor communication.

  • Reta Russell Houghton

    I dislike the use of of the term “difficult” because the label falls on the patient and not their health. Why can’t you use the term “complicated”, which implies there may be several illnesses or an illness that is not responsive. but does not cast the patient in a negative light?