When a patient evokes an emotional reaction from a physician

When it comes to caring for the sick, it’s often assumed that health professionals and their patients usually get along.

But that’s not always true.  Sales people call some of their customers difficult.  Turns out that doctors do exactly the same thing with theirs.  An article in the current issue of the journal Neurology provides a catalog of difficult patients.

The article — written by a couple of psychiatrists at the University of Colorado — lists four kinds of difficult patients, each so-named because they exemplify a different kind of maladaptive behavior.

First, there’s what they call the dependent clinger.  That’s a patient who makes insatiable and unreasonable demands on the physician before, during and often after regular office hours.  That kind of patient – so the good doctors say – demands and receives special access in the form of the doctor’s cell phone, home phone and email address.

The second kind of difficult patient is called the entitled demander.  This patient orders the doctor to perform diagnostic tests, prescribe medications, make referrals and perform other services as if it’s the patient’s right to have any and all of these orders carried out without question.  If the doctor does question the demand, the patient becomes hostile.

The third kind of difficult patient is called the manipulative, help-rejecting complainer.  Such patients are chronically unsatisfied with the efforts of their doctor on everything from diagnosis to treatment.  This person sounds a lot like the dependent clinger, but the key here is that this deeply needy type of patient engages the doctor in endless cycles of seeking help from the doctor and then rejecting the help when offered because it’s too horrible or too expensive.  When the doctor backs off, the patient accuses the physician of not caring.

The fourth kind of difficult patient is called the self-destructive denier.  This type of patient engages knowingly and purposefully in behaviors that are likely to worsen their condition.  Examples include the diabetic who stops taking insulin and the patient with emphysema who smokes cigarettes.

Now, I wouldn’t have given the article a moment’s notice.  But last month, when we were having our monthly department conference, a psychiatrist came in and gave us the low-down on the same four types of patients.  That’s when I realized my colleagues are starting to take this sort of analysis very seriously.

There’s something in the way the patient behaves that is at odds with what the doctors expect patients to act.  The patient may have personal characteristics that conflict with health care professionals’ beliefs and values.  In some cases, the patient acts in a way that is perceived to challenge the health care workers control and perhaps even their competence.  There is no universal definition of difficult patient.  I’ve seen it defined as a patient who impedes the doctor’s ability to care for the patient – to establish what doctors refer to as a therapeutic relationship between health professional and patient. One author referred to difficult patients as people who do not assume the patient role expected by the healthcare professional, who may have beliefs and values or other personal characteristics that differ from those of the care-giver, and who causes the caregiver to experience self-doubt.

What makes some patients difficult is that they evoke emotional reactions in some health professionals.  I’ve had patients who have irritated me and even made me angry.  When I treated patients with chronic pain, I would sometimes sigh to myself when I knew a certain patient was coming to see me.  Any MD who says that doesn’t happen in their practice isn’t telling the truth.  It’s important to keep in mind that patients aren’t always difficult because there’s something pathological in the patient’s personality that has some toxic effect on the doctor.  It’s often a case of something in the patient’s personality that has an effect on the doctor because the doctor himself or herself has come personality issues.  For instance, a doctor who is insecure about his or her own medical knowledge is apt to find patients who challenge their knowledge and skill very difficult.

I saw the way some of my colleagues were lapping it up and felt a bit of a pit in my stomach.  Maybe I’m a bit more comfortable with my own personal psychopathology.  Frankly, I think it’s a bit of a silly exercise in labelling patients.  I think those labels pathologize and insult patients.  The proof is whether or not the doctor would be willing to call a patient an entitled demander or a dependent clinger to their face.  If not, then I think it’s dishonest to call them that behind their back.  Besides, that kind of labelling doesn’t leave any room for the doctor to play a role in the patient’s behaviour.

Take the example of the dependent clinger.  To MDs plagued by this kind of difficult patient, the solution seems obvious to me:  don’t give out your cell or home phone number or your email address.

Most important, I say drop the labels.  Instead, I’d point out the areas things that I feel are going off the rails.  In other words, if the patient isn’t taking their prescribed medications, I’d point that out and use it as a jumping off point to find out if there are any issues.  If the patient asked for more tests after a number of tests came back normal, I’d use that as an opportunity to ask if there’s something that’s making them feel particularly anxious and vulnerable regarding their health at that point in time.  In other words, I’d use the difficulty as an opportunity to give me and my patient an opportunity to acknowledge what we’re feeling.

Adapted from a blog post that appeared on
White Coat, Black Art.

Brian Goldman is an emergency physician and author of The Night Shift: Real Life In The Heart of The E.R., published by HarperCollins.

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  • John Ryan

    Give us docs some credit, Dr. Goldman. Patients become “difficult” by lacking the self-awareness to see their problem and accept help correcting it. Most react negatively when asked to take ownership of their behaviors and work to solve them. By the time I see them as adults, the die is cast. Which is not to say that I don’t try initially, in a professional manner. But life is short and there are many patients who want my help, not just to use me as a foil.

  • Sheri Souch

    Dr. Goldman, Thank you for this insightful take on a study that is very inflammatory. I suppose I would fit into at least one of those “difficult patient” boxes but I am lucky to have a family doctor who is compassionate and professional. When I came down with a very serious, yet undiagnosable illness, the emotional reactions from the specialists I did not know astounded me. I was, in a round about way, labeled as a difficult patient because I questioned diagnoses . . . but the specialists all disagreed as well, so it was my family doctor and I who had to sit down, with all these diagnoses and decide which fit best and what treatment would work. My family doctor never treated me as though he, somehow, was superior to me, but as someone who had knowledge and experience to help me make decisions – decisions I, alone, would have to live with.
    Dr. Ryan (I assume you are a doctor,) It was self-awareness that led me to the correct treatment. Please remember that it is the patient, ultimately, that must live in his/her own body and live with the benefits and/or consequences of any given course of action. Please give the patients some credit.

  • Sideways Shrink

    Dr. Goldman
    I would like to share an idea from psychiatry by way of a basic diagnostic category I cannot treat due the feelings they provoke in me.
    Most therapists of all kinds find it dfficult to treat patients who have personality disorders . II fully admit that I cannot treat patients with borderline and histrionic personality disorders because,
    diagnostically, they introject their feelings into others wordlessly. This process provokes intense anger in me. (if you are unfamiliar with the dx imagine a barely verbal toddler who is endlessly hungry and always needs a nap…). Meds do not help these patients. I refer them out as I lack the specialty therapy training to treat personality disorders. Everyone in their life thinks they are
    “difficult”. The proper treatment in these cases is the proper referral.
    Not every doctor is right for every patient. No one ever got sued for making an appropriate referral after a first meeting OR after trying to work with the patient to help them change their behavior (and lab results) and both parties are unhappy with the process..

  • http://www.littlepatientbigdoctor.com Haleh Rabizadeh Resnick

    I find this description of various forms of difficult patients interesting. I agree that it would best help doctors in their relationships with patients if doctors looked to how to work with different personalities.

    Dealing with people takes tremendous skill and a person who understands how other people work, would not label another – that person would simply adjust his behavior to accommodate the personality that they are face with at the time. Much like how a good teacher can reach all her students on the student’s terms.

    This skill is not one that is taught in medical school- there is so much to cover- but perhaps it needs to be part of doctors’ continuing education courses.

    I am an attorney, teacher and author of Little Patient Big Doctor: One Mother’s Journey and my experience makes it clear to me that the “people relationship” part of a doctor’s job is the one that needs to be mastered in order for a doctor to be an effective healer.

  • J-M

    I’ve seen the needy people too. The ones that brag about all their maladies, their prescriptions, how many specialists they see etc. What do you expect? We have drug advertizements that want you to go to websites which start with MY! myboniva, mythis, mythat. I guess it’s fashionable. On the other end of the spectrum are people like me. Silly me, I still think I own this body. I don’t know everything about it any more than I know everything about my car, but I do know if it isn’t running right! I am labeled “difficult” because I don’t accept a patronizing medical professional. I want an ADULT INTERACTION! I want full disclosure, not platitudes. I want the same respect FOR me that you guys demand FROM me. From my point of view, I could care less if you like me, as long as you’re professional. (yes I do check my chart to make sure that personal attacks aren’t in there) I could care less if I like you, it doesn’t affect this kind of relationship! I only want medical expertise, not a life long commitment.

  • gzuckier

    what a bunch of sickos! (irony)

  • Molly Ciliberti, RN

    Really liked your insight. We medical/nursing professionals would hate to be labeled. In ICU there are patients (the actual conscious ones) who push their call light constantly and are very afraid. I found that by unexpectedly looking in on them or staying with them a bit longer and asking them about their needs stopped the incessant light on. It is frightening to have someone else hold your life in their hands and I think some patients worry that their physician won’t be available when they truly need them. BUT i couldn’t help but think of the movie, “What About Bob”. Many of us have had Bobs and we can only hope we weren’t Bob to some one else.

  • Sideways Shrink

    J-M

    I have read countless records and reports about my patients of all kinds. And though a couple of providers in a group practice I was in never seem to have mastered the syntactical skills required to spontaneously dictate into a telephone, I never saw “personal attacks” by other providers in these outpatient records. (I have seen other mistakes like wrong age, marital status, etc.) However, “checking” a providers notes might well make it difficult to establish and maintain a good working relationship. As you say you are checking the notes to see that you are being “personally attacked” by the doctor. I know providers who transfer patients like this because they suspect/fear that the patient may be inclined to sue. You may not care if they like you, but many doctors will not treat patients who demonstrate a lack of trust in them. Food for thought.

    • L.

      What are you hiding? For trust to work – it’s a two-way street. I have a right to examine my medical records – I realize there is an exception for shrink’s notes. In any case – a physician who will not permit me to read my notes is breaking the law (shrink exception excluded).

  • Debbie

    As a patient who has had to change doctors three times in three years because of insurance reasons, and have worked with large clinics with many physicians, what has amazed me is the amount of distrust doctors have for one another. This makes it very difficult for any of them to adequately provide the treatment I need because they are so hung up on telling me that the former physicians were wrong. I now no longer trust doctors,avoid them unless I just can’t do so any more, and I think most of them have no real idea of what they are doing. Physicians look to your own lack of professional behavior before labeling the patients.The problem is that physicians are also humans who have personality disorders, insecurities, etc. and some should never have become doctors to begin with.

  • Sideways Shrink

    Debby

    Of course, all health care providers are flawed. Who would think otherwise? As a patient your job to calmly advocate for yourself and your family because physicians are in charge of the health care you receive. Keep that in mind and you can hopefully get the care you need.