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.
Difficult patients come in many varieties. Some, like Elaine, are uncooperative or 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 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.
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 David Best, DO, a family physician and addiction medicine specialist in South Boardman, Michigan. “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, adding that patients should be informed about delays upfront when physicians are behind schedule.
“If you acknowledge that you know patients are waiting, they won’t feel they’ve been forgotten or they don’t matter.”
Patients who are a little too friendly
Early in her career, Kansas City, Missouri-based family physician Elaine W. Joslyn, DO, quickly developed strategies to prevent inappropriately flirtatious behavior. “I immediately redirect the conversation back to the patient’s medical issue,” she says, adding, “I have always been Dr. Joslyn to my patients. I don’t encourage them to call me by my first name.”
Physicians often need to set behavioral limits for their patients, according to Dr. Ciervo, who has treated a number of patients exhibiting traits of borderline personality disorder.
Patients with such disorders tend cross boundaries and become personal, 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. 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.
Physicians must make sure their office personnel know how to handle urgent situations and violent behavior, says Dr. Joslyn, who once 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.”