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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