Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

The 9 types of manipulative patients

Jeffrey E. Keller, MD
Physician
June 7, 2019
161 Shares
Share
Tweet
Share

One of the more common complaints that I hear from medical practitioners in jails and prisons (especially new practitioners) is, “These manipulative patients are driving me crazy!” Well, to be honest, I ran into a lot of manipulative patients when I worked in the ER, as well. But it is true that many of our patients in jails are especially skilled in manipulation. They have practiced this skill their whole lives and have become proficient. Most people, including correctional professionals, are not naturally skilled at dealing with manipulation. This is often not a skill that we have needed before coming to work in a jail or prison. But once there, learning to manage manipulation is an essential skill if you want to be happy in correctional practice. I call the art of dealing with manipulation “Verbal Jiu-Jitsu.” In order to become a skilled practitioner of verbal jiu-jitsu, we must first start with an analysis of what “manipulation” actually is.

My definition of manipulation is this: in a medical encounter, it’s what happens after a patient wants something he shouldn’t have — like a narcotic, a special diet, gabapentin, an MRI, a double mattress — and won’t take “no” for an answer.

Then comes the manipulation, the attempt to coerce the practitioner into changing a “no” into a “yes.” Manipulation comes in many forms.

1. Exaggeration. “This is the worst pain in the world!” “I can’t stand it any longer!” “I am so much worse now than when I came to prison!” Exaggeration is an attempt to make this a special case, worthy of special consideration compared to other patients.

2. Belittling. “Only crappy doctors work in jails. No wonder you can’t understand how to treat my pain. My outside doctor gave me what I need – oxycontin. Now there was a good and kind doctor! You should be ashamed.” Belittling goes hand-in-hand with splitting.

3. Splitting. This consists of comparing you to someone else who would give the patient what he wants. The other person is commonly an outside practitioner. But splitting is especially effective when the other practitioner is someone within your own facility. “The other doctor who works at this prison gave an extra mattress to my cellie! And he is not in as much pain as I am!”

4. Threatening. This comes in various forms. First is the threat of physical violence. Inmates can get quite skilled at communicating physical threats without saying a word. A particular hard look of a tight jaw, narrowed eyes, tense muscles, and clenched fists – coming from a muscular guy with facial tattoos – can make anyone feel the hair stand up on the back of their neck, even if there is no way the inmate could/would ever act on the threat. The second type of threats are various forms of complaints. Basically, the inmate is saying, “If you don’t give me what I want, I’ll make your life miserable.” Complaints may start with written grievances (that you have to spend time and effort to answer), but then can quickly escalate to letters written to the ACLU, formal complaints written to your State Board of Medicine, pro se tort claims, even malpractice lawsuits. Everyone who has worked in corrections for a very long has heard these words: “You’ll be hearing from my lawyer!”

5. Fawning. Fawning is, of course, the exact opposite of threatening and belittling. “You’re the best doctor I have ever met! I tell all the other girls in the pod how great you are!” Many inmates are exceedingly good at fawning because, again, they have practiced their whole lives. A particularly insidious — and often effective — variation of fawning is flirting and sexual innuendo. “You always smell so good Dr. Smith. What cologne do you use?” I remember one inmate who told me, “Dr. Keller, you really know how to wear a suit. I worked at a clothing store, so I know.”

6. Filibustering. Filibustering is being so relentless in the demand that you finally relent. Filibustering is done in two distinct ways. Method one is this: “I won’t leave your office until you give me what I want! I will argue with everything you say.” An hour later, the patient is still haranguing you and your clinic schedule (as well as your nerves) are shot. Even more effective is the sequential strategy: “I will be in your clinic every week with the same complaint. Nothing you do (except for what I want) will ever work.” After 3, 5, or 10 visits for the same complaint of “intolerable headaches,” you might finally give in and write the prescription for gabapentin that the patient wants.

7. The straw-man victim. This is where the manipulator charges you with acting against a protected class rather than based on your clinical findings. “You’re only refusing me opioids because of my race/I am transgendered/my religion,” etc.

8. Champions. A “champion” is someone who pleads the patient’s case from the outside. The champion can be an attorney or an advocacy group, but most commonly is a family member. Champions use all of the manipulative techniques above, such as exaggeration, splitting, and incessant filibustering. Since champions are not incarcerated, they have access to many people whom inmates themselves cannot reach, such as the sheriff, the newspaper, and even the governor!

9. Self-harm. Self-harmers are patients who deliberately harm themselves to force you to do something they want. Examples of self-harmers include patients who cut themselves (“cutters”), patients who insert foreign bodies into their penis or anywhere they don’t belong (“inserters”), and diabetics who try to induce severe hypoglycemic or hyperglycemic events in themselves. Self-harmers are often particularly hard to deal with.

Like any other skill, dealing successfully with manipulation requires training, practice, and experience. A good start is to go through this list and have your response prepared and practiced in advance. What would you say if a patient belittles you or accuses you of racial bias?

Jeffrey E. Keller is an emergency physician who blogs at Jail Medicine. This article originally appeared in MedPage Today.

Image credit: Shutterstock.com

Prev

3 steps to reconnect to who you are behind the white coat

June 7, 2019 Kevin 0
…
Next

Bringing hospitality back to the hospital: lessons from a bartender

June 7, 2019 Kevin 0
…

Tagged as: Emergency Medicine

Post navigation

< Previous Post
3 steps to reconnect to who you are behind the white coat
Next Post >
Bringing hospitality back to the hospital: lessons from a bartender

More by Jeffrey E. Keller, MD

  • I’m a jail physician. Here’s what likely happened to Jeffrey Epstein.

    Jeffrey E. Keller, MD

Related Posts

  • Are patients using social media to attack physicians?

    David R. Stukus, MD
  • You are abandoning your patients if you are not active on social media

    Pat Rich
  • Physician Suicide Awareness Day: Where are the patients? 

    Jennifer M. Sweeney
  • Is physician shadowing immoral?

    David Penner
  • A love letter to patients

    Marcie Costello
  • Patients are not passengers

    Christopher Noll, RN, MSN

More in Physician

  • Tom Brady’s legacy and the importance of personal integrity in end-of-life choices

    Kevin Haselhorst, MD
  • The hidden truths of hospital life: What doctors wish you knew

    Emily Stanford, DO
  • The heart of a Desi doctor: Balancing emotions and resources in oncology

    Dr. Damane Zehra
  • The Iranian diaspora’s fight for liberty: Overcoming challenges in the largest women’s rights movement of our century

    Montreh Tavakkoli, MD
  • The harmful effects of shaming patients for self-education

    Maryanna Barrett, MD
  • The power of self-appreciation: Why physicians need to start acknowledging their own contributions

    Wendy Schofer, MD
  • Most Popular

  • Past Week

    • It’s time for C-suite to contract directly with physicians for part-time work

      Aaron Morgenstein, MD & Corinne Sundar Rao, MD | Physician
    • What is driving physicians to the edge of despair?

      Edward T. Creagan, MD | Physician
    • The untold struggles patients face with resident doctors

      Denise Reich | Conditions
    • The psychoanalytic hammer: lessons in listening and patient-centered care

      Greg Smith, MD | Conditions
    • Breaking free from a toxic relationship with medicine [PODCAST]

      The Podcast by KevinMD | Podcast
    • Revolutionizing COPD management with virtual care solutions [PODCAST]

      The Podcast by KevinMD | Podcast
  • Past 6 Months

    • The real cause of America’s opioid crisis: Doctors are not to blame

      Richard A. Lawhern, PhD | Meds
    • The fight for reproductive health: Why medication abortion matters

      Catherine Hennessey, MD | Physician
    • The vital importance of climate change education in medical schools

      Helen Kim, MD | Policy
    • Nobody wants this job. Should physicians stick around?

      Katie Klingberg, MD | Physician
    • It’s time for C-suite to contract directly with physicians for part-time work

      Aaron Morgenstein, MD & Corinne Sundar Rao, MD | Physician
    • Resetting the doctor-patient relationship: Navigating the challenges of modern primary care

      Jeffrey H. Millstein, MD | Physician
  • Recent Posts

    • Breaking free from a toxic relationship with medicine [PODCAST]

      The Podcast by KevinMD | Podcast
    • Tom Brady’s legacy and the importance of personal integrity in end-of-life choices

      Kevin Haselhorst, MD | Physician
    • The hidden truths of hospital life: What doctors wish you knew

      Emily Stanford, DO | Physician
    • 10 commandments of ethical affiliate marketing for physicians

      Aaron Morgenstein, MD & Amy Bissada, DO | Finance
    • The heart of a Desi doctor: Balancing emotions and resources in oncology

      Dr. Damane Zehra | Physician
    • Safe sex for seniors: Dispelling myths and embracing safe practices [PODCAST]

      The Podcast by KevinMD | Podcast

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

Leave a Comment

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

CME Spotlights

From MedPage Today

Latest News

  • Journal Shows Its Commitment to Exploring AI in Medicine
  • Do Away With 'Lockout' Period in iPLEDGE, FDA Advisors Urge
  • Cluster Headache, Migraine Linked to Circadian System
  • Smaller Liver Transplant Candidates Wait Longer, Less Likely to Receive Organ
  • A 'Double Whammy' for Gastric Cancer Risk

Meeting Coverage

  • Oral Roflumilast Effective in the Treatment of Plaque Psoriasis
  • Phase III Trials 'Hit a Home Run' in Advanced Endometrial Cancer
  • Cannabis Use Common in Post-Surgery Patients on Opioid Tapering
  • Less Abuse With Extended-Release Oxycodone, Poison Center Data Suggest
  • Novel Strategies Show Winning Potential in Ovarian Cancer
  • Most Popular

  • Past Week

    • It’s time for C-suite to contract directly with physicians for part-time work

      Aaron Morgenstein, MD & Corinne Sundar Rao, MD | Physician
    • What is driving physicians to the edge of despair?

      Edward T. Creagan, MD | Physician
    • The untold struggles patients face with resident doctors

      Denise Reich | Conditions
    • The psychoanalytic hammer: lessons in listening and patient-centered care

      Greg Smith, MD | Conditions
    • Breaking free from a toxic relationship with medicine [PODCAST]

      The Podcast by KevinMD | Podcast
    • Revolutionizing COPD management with virtual care solutions [PODCAST]

      The Podcast by KevinMD | Podcast
  • Past 6 Months

    • The real cause of America’s opioid crisis: Doctors are not to blame

      Richard A. Lawhern, PhD | Meds
    • The fight for reproductive health: Why medication abortion matters

      Catherine Hennessey, MD | Physician
    • The vital importance of climate change education in medical schools

      Helen Kim, MD | Policy
    • Nobody wants this job. Should physicians stick around?

      Katie Klingberg, MD | Physician
    • It’s time for C-suite to contract directly with physicians for part-time work

      Aaron Morgenstein, MD & Corinne Sundar Rao, MD | Physician
    • Resetting the doctor-patient relationship: Navigating the challenges of modern primary care

      Jeffrey H. Millstein, MD | Physician
  • Recent Posts

    • Breaking free from a toxic relationship with medicine [PODCAST]

      The Podcast by KevinMD | Podcast
    • Tom Brady’s legacy and the importance of personal integrity in end-of-life choices

      Kevin Haselhorst, MD | Physician
    • The hidden truths of hospital life: What doctors wish you knew

      Emily Stanford, DO | Physician
    • 10 commandments of ethical affiliate marketing for physicians

      Aaron Morgenstein, MD & Amy Bissada, DO | Finance
    • The heart of a Desi doctor: Balancing emotions and resources in oncology

      Dr. Damane Zehra | Physician
    • Safe sex for seniors: Dispelling myths and embracing safe practices [PODCAST]

      The Podcast by KevinMD | Podcast

MedPage Today Professional

An Everyday Health Property Medpage Today iMedicalApps
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

Leave a Comment

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...