In a classic episode of Seinfeld, Elaine Benes peeks at her medical chart while waiting in an exam room and notices that she has been labeled “difficult,” presumably for refusing to change into a paper gown at a prior appointment. When she asks her physician about it, he dismisses her concerns but refuses to treat her. Unable to get another doctor to see her, she later tries to steal her chart, which reinforces her bad reputation.
Difficult patients come in many varieties. Some, like Elaine, are insubordinate and evasive. Others simply don’t comply with doctor’s orders or show up for appointments. And a fair number of patients have drug dependency or mental health problems that adversely influence their behavior.
“Patients suffering from addiction are often considered difficult,” says David Best, DO, a family physician and addiction medicine specialist in South Boardman, Michigan. “If you treat patients with compassion, they, in turn, will be more respectful and adherent.”
Dr. Best and other DOs discuss four different types of difficult patients they’ve worked with and provide tips on dealing with such patients and preventing problem behavior in the first place.
Patients who refuse to follow medical recommendations are vexing to physicians, especially now that the U.S. health care system has started to tie reimbursement to outcomes.
Carman A. Ciervo, DO, a family physician in Vorhees, New Jersey, uses a direct approach when he encounters patients who won’t take medications as directed or follow other medical recommendations.
“I’ll say to them, ‘You are affecting my ability to take care of you in a way that is going to be effective,'” he says. “‘If this continues, I’m probably not the best choice to be your physician.'”
When confronting patients with similar non-compliance issues, David J. Park, DO, a family physician in Las Vegas, will often focus the blame on himself to avoid sounding too harsh. “I’ll ask if I’m communicating ineffectively,” he says.
However, if the problem continues, he usually recommends that the patient find another doctor.
A more lenient approach is often needed when treating patients with addiction or mental health issues, according to Dr. Best, who explains that patients turned away from his rural practice might not be able to access health care anyplace else.
“The patient is still welcome to come back,” he says. “I don’t want to close the door.”
Patients who don’t show up for appointments—those who repeatedly don’t bother to call ahead of time to cancel them—are also problematic. Some DOs discharge such patients from their practices after three or four missed visits, giving 30 days’ written notice.
Physicians who treat patients with chronic health problems frequently encounter irritability and frustration.
“I try to have empathy with these patients because a lot of times, they’re suffering,” says Dr. Best. “If they’re irritable, I don’t take it personally.”
Maintaining a steady and compassionate demeanor can go a long way toward calming an irritable patient.
“The best approach is to be patient and develop a rapport with them,” says Dr. Park. “This is really the osteopathic approach, in which we sit down close to them instead of standing and we engage in active listening, showing compassion in our voices and in our facial expressions and gestures.”
Creating a comforting environment should begin in the waiting room, Dr. Park points out. “As soon as patients check in, they should be greeted by a friendly staff person,” he says.
Dr. Park tries to be on time. But if he’s behind schedule, he’ll ask the receptionist or nurse to explain that he is delayed. “If you acknowledge that you know patients are waiting, they won’t feel they’ve been forgotten or they don’t matter,” he says.
Patients who are a little too friendly
During her decades in solo practice, family physician Elaine W. Joslyn, DO, has developed a standard response when confronted with the occasional patient who makes inappropriately flirtatious comments. “I immediately redirect the conversation back to the patient’s medical issue,” she says.
When she established her Kansas City, Missouri, practice many years ago, Dr. Joslyn worked to develop a professional persona. “I have always been Dr. Joslyn to my patients,” she explains. “I don’t encourage them to call me by my first name.”
Setting clear boundaries for the doctor-patient relationship enables Dr. Joslyn to communicate clearly with her patients from the start. “I set the tone that I’m not their buddy. I’m their doctor,” she says. “And it has worked. I’ve never gotten in a situation where I’ve felt very uncomfortable or vulnerable.”
Of course, if patients were to cross the line from flirtatiousness to sexual harassment, Dr. Joslyn would take more serious measures, such as dismissing the patient from her practice, she notes.
Physicians often need to set behavioral limits for their patients, agrees Dr. Ciervo, who has treated a number of patients exhibiting traits of borderline personality disorder, an often undiagnosed mental health condition characterized by an inability to form stable relationships.
Patients with such disorders tend to become overly friendly too soon, he says. They may call their doctor by his or her first name without being invited to do so. They may ask intrusive personal questions or request their doctor’s cell phone number.
Keeping the focus on the patient is the best way to ward off personal questions and unwanted attention, stresses Dr. Ciervo. “I redirect patients by saying, ‘When you come here, it’s for a reason. I want to make sure we address that and not take any of your time to talk about me,'” he says.
Many people with major psychiatric problems don’t receive the care they need due to difficulty in accessing mental health resources, Dr. Ciervo notes. Such patients often present challenges when they come into a primary care physician’s office.
Unstable patients may yell at front-office staff, use profanity, kick walls, turn over chairs and storm out of the office. “It’s very disruptive to the other patients, and it scares them,” Dr. Ciervo says.
His practice recently had to call the police when a psychotic patient entered the office and threatened to hurt the staff and a doctor.
“We tried to de-escalate the situation on our own, but the patient needed more of a significant intervention,” he says.
Physicians must make sure their office personnel know how to handle urgent situations and violent behavior, says Dr. Joslyn, who not long ago called 911 when an intoxicated man staggered into her waiting room and passed out. She has established a code word that her staff uses to alert her in an emergency.
“We use the name ‘Rachel,'” Dr. Joslyn says. “If the person at the front desk is uncomfortable and needs help, she will work ‘Rachel’ into the conversation in a loud enough voice that I can hear her.”
To prevent violence, practices can boost on-site security and keep doors locked between the exam rooms and waiting room, suggests Physicians Practice, which offers other tips on preparing for an armed attacker. Hiding under a desk or table should just be a last resort—better options would be trying to hinder the shooter by barricading a door from the other side or turning off the lights. Practices should consider hiring a security firm to conduct active shooter training drills for physicians and staff.
In addition, staff can be taught to be more aware and warn others of odd behavior.
Fortunately, say DOs, most difficult patients aren’t dangerous, and physicians will need little more than compassion, firmness and professionalism to deal with them.