Approach to the Difficult Patient

DefinitionTop

The term “difficult patient” does not denote a specific diagnostic entity and does not assign blame but rather reflects certain characteristics of the interaction between the physician and the patient.

A difficult patient is defined more by the physician’s response than by specific criteria. The description “difficult patient encounter” is more accurate. Here we define “the difficult patient” as one towards whom the physician experiences strong negative emotions: anxiety, dread, fear, anger, frustration, irritation, despair, or hopelessness.

The concept of the difficult patient has emerged out of medical rather than psychiatric settings. We have chosen to present the discussion of the difficult patient within the psychiatry section of the McMaster Textbook of Internal Medicine, as key principles in psychiatric assessment and management are relevant to the care of these individuals.

Many medical and psychiatric conditions present intrinsic difficulties with diagnosis or treatment: cancer, diabetes, chronic obstructive pulmonary disease, schizophrenia. However, this is different from the concept of “difficult patient” or “difficult patient encounters” as used in the literature. Such patients cut across all diagnostic groups.

It is estimated that 15% to 20% of patient encounters in medical settings are perceived as “difficult.”Evidence 1Moderate Quality of Evidence (moderate confidence that we know true effects of the intervention). Quality of Evidence lowered due to limited generalizability of 2 cohort studies. Hahn SR, Kroenke K, Spitzer RL, et al. The difficult patient: prevalence, psychopathology, and functional impairment. J Gen Intern Med. 1996 Jan;11(1):1-8. Erratum in: J Gen Intern Med 1996 Mar;11(3):191. PubMed PMID: 8691281. Hinchey SA, Jackson JL. A cohort study assessing difficult patient encounters in a walk-in primary care clinic, predictors and outcomes. J Gen Intern Med. 2011 Jun;26(6):588-94. doi: 10.1007/s11606-010-1620-6. Epub 2011 Jan 25. PubMed PMID: 21264521; PubMed Central PMCID: PMC3101981. Physicians may describe such patients as demanding with high expectations, emotionally draining and time-consuming, or requesting special treatment. The patients may appear angry, intimidating, or noncompliant.

Patient characteristics identified in studies included psychosomatic complaints, mild to moderate depression, and personality problems. Symptoms may be vague, and the patients may be perceived as overreacting to them. These patients had more physical symptoms, higher use of services, and worse functional status. They had frequently experienced recent stress and depressive or anxiety disorders.

Certain patient vulnerability factors may be predictive of difficult encounters, such as the presence of a comorbid psychiatric disorder, risky behaviors (eg, violence, substance abuse), high use of health-care services, and social determinants (isolation, lack of housing, finances, language barrier), in addition to illness complexity and chronicity.

In observational studies physicians involved in encounters perceived as difficult were less experienced, less disposed to dealing with the psychosocial aspects of medicine, and had a less open communicative style.

Difficult interactions may lead to physician and patient dissatisfaction, conflict, demoralization, patient complaints, higher liability claims, and poorer treatment outcomes.

Etiology and PathogenesisTop

Difficult encounters cut across all diagnoses and result from individual patient factors, physician factors, and organizational factors.

Patient Factors

All of us possess a unique range of personality traits and interpersonal patterns. These patterns develop as a result of inborn temperament combined with early attachment experiences and multiple social, genetic, and environmental factors. Some patterns are maladaptive. “Personality disorder” refers to problems in a person’s way of viewing himself or herself and others, problems with emotional regulation, and in patterns of behavior. This in turn is associated with difficulties in relationships and social functioning.

In the present psychiatric diagnostic systems, the fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and the International Classification of Diseases (ICD), personalities are grouped into specific categories, although in actuality personality traits are dimensional and there is no absolute cutoff between “normal” and “abnormal.”

Difficult patient encounters may reflect problems with the capacity to regulate emotions; feelings of shame, self-hatred, and mistrust of others; problems with empathy, that is, the ability to appreciate other people’s experiences and motivations; inability to see things from the other person’s point of view and not understanding the effects of one’s own behavior on others; difficulty connecting with other people; problems with closeness to others; and insecure attachment behavior. Although we list them as patient factors, all of those traits may be present in clinicians as well (see Physician Factors, below).

The quality of childhood attachment with caregivers influences the development of neurocircuits involved in emotion regulation and is a major determinant of adult capacity for empathy and establishment of close relationships. Attachment status affects how patients interact with physicians and influences their responses to illness. Individuals with secure attachment tend to be trusting and positive in their approach to seeking help. They will more readily collaborate with the health-care team. Individuals with insecure attachment may be guarded and wary. They may not follow through with treatment and appointments.

Patients whose caregivers in childhood were distant or rejecting can develop “avoidant” attachment, which manifests as inability to establish a trusting relationship. Some may be fearful of dependency, intimacy, or rejection. This may present as active hostility and criticism of the health-care providers.

Certain personality types may have specific difficulties in medical settings. Physical illness may lead to an intensification of preexisting interpersonal difficulties as a result of fear and feelings of loss of control and helplessness. For example:

1) Narcissistic patients have problems with self-esteem and are hypersensitive to perceived rejection or mistreatment. They cannot see things from the other person’s point of view because of impaired empathy. They may compensate for these deficits by an outward sense of superiority and feelings of entitlement. They may demand special treatment and complain forcefully if they perceive any shortcomings.

2) Patients with antisocial or psychopathic personality traits may be withholding or dishonest. They may have a hidden agenda. They may attempt to manipulate the physician by means of flattery or, failing that, threats. They may not conform to lawful and normative ethical behavior. They are orientated towards personal gratification. They lack concern for the feelings or suffering of others. They do not display feelings of empathy, guilt, or remorse. Their relationships with others are characterized by exploitation and may involve deceit, coercion, and intimidation to control others.

3) Patients with borderline personality traits are characterized by emotional dysregulation, with more intense mood reactivity and a slower return to baseline. This leads to impulsivity, frequent self-harm, and thoughts of suicide. Angry confrontations with clinical staff are common. Physicians may feel anxious because of the high levels of emotional arousal and the fear that the patient may become violent, elope, or attempt to self-harm.

Physician Factors

These factors may contribute as much or more to difficult encounters. Physician factors include personality traits, psychosocial orientation, and the impact of their own developmental experiences. Those include:

1) Physician emotional factors: Self-awareness is very important. Physicians need to become aware of the types of patients or situations that trigger their discomfort, irritation, or anxiety. This is in part determined by patient factors but also by the physician’s own past experiences. Physicians may respond to patients in a way that is not appropriate to the current context but reflects an emotional reaction based on the physician’s early childhood. This is referred to as “countertransference.” It is exactly the same phenomenon as the patient’s transference but in the reverse direction. Transference and countertransference are the unconscious processes in which feelings, attitudes, and expectations from key childhood relationships are transferred or projected onto present relationships and encounters.

Difficult encounters may undermine the physician’s own sense of competence and their own self-esteem. If the physician has narcissistic or perfectionistic traits, this can be more difficult and lead to an urge to avoid the patient. Overwork, burnout, and personal health problems may also be factors in the physician’s response.

2) Physician cognitive biases: Cognitive biases are unconscious thinking modes that may lead to clinical error. Again, physician self-awareness is paramount, as cognitive biases may lead to an incorrect evaluation of the situation, misdiagnosis, and inappropriate management.

a) Stereotyping is when the physician’s thinking is preshaped by expectations that are triggered by other aspects of the patient’s presentation.

b) Anchoring is the tendency to fixate on specific features of the patient’s presentation too early in the diagnostic process, leading to premature closure.

c) Confirmation bias is the tendency to look for evidence that supports the physician’s initial impressions while overlooking information that contradicts them. It is caused by an unconscious selective tendency to focus on certain data only. This can lead to erroneous conclusions about the patient’s physical issues, behavior, or personality.

d) Attribution error is the tendency to blame the patient when things go wrong. It may reflect the physician’s difficulty in empathizing with the patient or fully appreciating the impact of their physical or psychiatric symptoms.

Patients may be experienced as “difficult” due to the direct effects of an underlying medical illness (eg, systemic lupus erythematosus, multiple sclerosis, hyperthyroidism), an adverse drug effect (eg, glucocorticoids, levodopa, antidepressants), an underlying psychiatric problem, or some combination. This needs to be carefully explored in a way that minimizes the cognitive biases that can result in serious medical errors.

Context

Organizational values and expectations impact on the physician-patient encounter. The prevailing organizational culture influences morale and team functioning.

Team members who become frustrated with particular patients may attempt to redefine the problem as “not my problem.” Medical or psychiatry staff may try to label the patient problem as “supratentorial rather than organic,” malingering, or a “low pain threshold.” Staff may feel that the patient does not belong on a particular service and should be transferred.

These responses may be based on unconscious stigmatization of those with, for example, mental illness, addictions, and certain infections, or belonging to specific socioeconomic or cultural strata, and the false belief that patients are responsible for their symptoms. In the case of mental illness, but also particular medical conditions, some health professionals still cling to outdated ideas that certain illnesses (depression, alcoholism, obesity, carcinoma of the lung) are caused by weakness, personal inadequacy, or irresponsibility. This may result in clinical staff acting out in a punitive way towards the patient, leading to escalation of the problems.

Treatment and InterventionsTop

Approaches to difficult patient encounters can be regarded as specific and generic. Specific treatment depends on a careful and thorough assessment of physical, psychiatric, psychosocial, and contextual aspects. The patient should be assessed for specific psychiatric disorders, with specific psychotropic medications targeting probable underlying psychiatric syndromes, such as anxiety or depression.

Psychiatric consultation is of value in assessing the contribution of psychiatric morbidity to the clinical presentation. To the extent that acute or chronic psychiatric illness is contributing to the problematic interactions, there may be appropriate evidence-based pharmacologic and psychotherapeutic interventions that are indicated.

Clinical Interview

Generic interventions cut across diagnoses and relate to the conduct of the clinical interview. The Calgary Cambridge guide to the medical interview provides a robust and evidence-based approach to communicating with patients. Below we have extracted some key points.

The following are some of the key areas adapted and emphasized for application to the difficult patient encounter:

1) Building the relationship: Greet the patient. Introduce yourself. Demonstrate respect and interest. Maintain appropriate eye contact, facial expression, posture, as well as pacing, volume, and tone of speech. Accept the legitimacy of patient’s views and feelings; be nonjudgmental. Be empathic, communicate understanding and appreciation of the patient’s feelings or predicament, express concern, understanding, and willingness to help.

2) Gathering information: Encourage the patient to tell the story of the problems. Use open and closed questioning technique, appropriately moving from open to closed. Listen attentively, allowing the patient to complete statements without interruption. Periodically summarize to verify understanding of what the patient has said. Explore:

a) The patient’s ideas and beliefs regarding the illness.

b) The patient’s concerns regarding each problem.

c) The patient’s expectations.

Encourage the patient to express their feelings.

3) Explaining and planning: Achieve a shared understanding incorporating the patient’s perspective. Provide opportunities and encourage the patient to ask questions, seek clarification, or express doubts. Elicit reactions and feelings regarding information given, acknowledge and address where necessary. Share your own thinking. Make suggestions rather than give directives. Encourage the patient to contribute their own suggestions and preferences. Negotiate a mutually acceptable plan.

4) Closing the encounter: Summarize the session briefly and clarify the plan of care. Check the patient’s reactions and concerns about plans and treatments including acceptability.

We believe that adopting this approach will reduce physician uncertainty and avoidance, that empathy and engagement will reduce burnout and anxiety. In the inpatient setting, team support, debrief meetings, and consultation can also be used.

Psychopharmacology

In the context of difficult patient encounters it should be emphasized that drug treatment may not be appropriate. For use of medications for delirium, agitated patients, or depression, see appropriate chapters. In general, nonspecific agitation or anxiety can be treated in the short term with benzodiazepines. However, it should be noted that benzodiazepines can occasionally have a paradoxical effect with increased disinhibition and anger.

Prevention of Difficult EncountersTop

1. The key is for physicians to develop awareness of their own feelings and biases.

2. Make adequate time for the encounter.

3. Use specific validated interview methods.

4. Develop an agreed treatment plan.

5. Treat underlying psychiatric and medical disorders.