How should doctors handle the difficult patient?

by Toni Brayer MD

I am willing to bet that patients do not know that the medical community talks formally about “The Difficult Patient”. Courses are taught on how to handle these patients and there is even an ethics study on Medscape about it. So what is the difficult patient?

Every practice encounters them and they come in many varieties. They are the patients who abuse the staff, miss appointments repeatedly, “lose” their prescriptions for pain medication and then demand instant refills. They may not follow up with important tests or stop taking needed medication and then show up with acute medical problems. Some doctors have a low tolerance for patients who are not “compliant” but even the sainted physicians experience “difficult patients.”

So when the therapeutic relationship is damaged, doctors are taught the ethical ways of firing a patient from the practice. Once a relationship has been established, a physician may not abandon a patient. Medical ethics demand that a physician may discharge a patient from the practice only after attempts to resolve the matter have failed. Adequate replacement care must be available and the patient’s health should not be jeopardized in the process. The physician must ensure that the reasons for discharging a patient are justifiable and ethical.

Once the doctor-patient relationship has broken down, the doctor must make sure:

* She has done everything possible to address the patient’s problems
* She has informed the patient of the consequences of his actions, both for his own health and his relationship with the physician; and
* She must tell the patient that he would better off with another physician and help the patient find another doctor.

Ending a doctor-patient relationship should be a rare event. Like any relationship, there should be discussions that take place openly long before things get bad enough for the doctor to “fire” the patient.

Of course, an unhappy patient needs only to leave a practice and move on. But all physicians know that one disgruntled patient will tell 20 friends about his bad experience.

Tony Brayer is an internal medicine physician who blogs at EverythingHealth.

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