When Patients Are A Pain For Their Doctor


 
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By Sumathi Redddy

Sometimes it’s the patient who gives the doctor a headache.

Studies have estimated that as many as 15% of patients are considered difficult. Some are aggressive. Others don’t believe anything a doctor says. Still others are demanding, asking for an endless array of tests doctors may deem unnecessary. And then there are the plain mean ones.

A 1988 research paper by Tom O’Dowd coined a term describing such patients and the feeling doctors get when they have one: heartsink.

Difficult patients are more than just a nuisance to their providers. They may jeopardize their own medical care. A study published in March, found that such patients have an increased likelihood of misdiagnosis. In complex cases—for example, an overactive thyroid—doctors made 42% more mistakes with disruptive patients compared with non-disruptive ones. The difference was just 6% with simple cases like pneumonia, says Henk Schmidt, lead author of the study and a professor of psychology at Erasmus University in Rotterdam, Netherlands.

The researchers presented written vignettes of six clinical cases—three simple and three complex—to 63 family practice residents. Three of the vignettes described patients acting difficult and three had neutral or normal patients. The residents were asked to evaluate and then diagnose the patients’ conditions, as well as rate the patient’s likability.

Dr. Toni Brayer, an internist in San Francisco and chief executive of a multispecialty medical group, has seen plenty of these cases.

“They take an inordinate amount of time to deal with because you can’t zero in on the real problem,” she says. “These are the patients when you see their name on your schedule you say, ‘Uh-oh.’ ”

Patients who have multiple medical problems and are unable to focus on them can also be difficult, she says. She finds it’s best to try to understand what is driving a difficult patient—a mental-health issue, fear, a previous bad experience with another doctor or something else.

“Doctors need to be more attuned to focusing on the health problem and not getting distracted,” she says. “You can get caught up in all the chaos and actually miss clinically relevant things.”

In a separate study, the researchers surveyed 74 internists and found “the doctors remembered the behaviors of the disruptive behavior at the expense of memory for clinical signs and symptoms.”

The conclusion: Doctors had to expend so much mental energy on dealing with the difficult patients that they had fewer mental resources available for remembering details of the health condition.

Research has found that more-experienced doctors tend to deal with difficult patients more gracefully.

“It’s not just patient characteristics that are involved in a patient being called difficult, but also provider characteristics,” says Jeffrey Jackson, a professor of medicine at the Medical College of Wisconsin in Milwaukee and a primary-care physician. A 1999 study he co-wrote, found that younger, less-experienced physicians labeled a higher percentage of patients as difficult and had more trouble managing them.

Dr. Jackson says based on his own experience with patients he wasn’t surprised by the study’s finding. “When the demanding patient comes in, 99% of that visit is consumed with trying to deal with the patient’s agenda,” he says.

Such patients generally have a lot of physical complaints and symptoms and rate the severity of them higher. Some have undiagnosed mental disorders and many have somatization disorder, a mental condition in which patients have vague multiple, recurring symptoms.

“It’s difficult to sort out what’s new and real and potentially scary from the same old symptoms,” Dr. Jackson says.

Carl Olden, a family physician in Yakima, Wash., says patients with low health literacy can be difficult, as can those who have self-diagnosed either through the Internet or television advertising for a drug. He also encounters parents who believe vaccinations cause autism, or that their child needs antibiotics for a virus. “It’s very hard to convince people of scientific efficacy and safety when they already believe what they believe,” Dr. Olden says.

He tries to steer such patients to credible educational websites. “Those can be challenging and exhausting conversations and can’t be resolved in a single visit many times,” he says.

A 2014 study in the journal Family Medicine surveyed 161 patients and found about 20% were deemed difficult by the family-medicine residents who treated them. The survey found the difficult patients reported greater ease of communication than patients who weren’t labeled difficult, contradicting earlier research on the subject.

“Interestingly, we realized these patients who are considered difficult by their provider actually adore their physician,” says Jennifer Edgoose, first author of the study and a family physician and assistant professor at the University of Wisconsin School of Medicine and Public Health.

Dr. Edgoose theory is that the residents in the study expended so much time and energy—perhaps overcompensating for feeling guilty about finding these patients “difficult”—that while the residents may have felt more tired and burned out, the patients were happy to receive the extra attention. Mental-health and personality disorders may also help explain some of the mismatched perspectives.

Some doctors have come up with strategies to deal with difficult patients.

Dr. Edgoose has her own teaching mnemonic called BREATHE OUT. A 2015 study tested the mnemonic in a group of 57 health professionals and found those who used it were more satisfied with their difficult patient encounters than those who didn’t.

The mnemonic prompts health professionals to ask a series of questions of themselves before and after a visit with a difficult patient. Pre-visit questions include having the clinician consider their own potential biases, reflecting upon why the patient is difficult and articulating their agenda for the visit. Post-visit questions include thinking about whether the agenda was accomplished, and what to look forward to addressing in the next visit. “It’s meant to be a structured, clinical tool to support clinicians overwhelmed by these challenging patients,” says Dr. Edgoose, who has taught it at Wisconsin and at national medical conferences.

Diane Timberlake, a family physician at a county hospital in Seattle, says her approach is to listen and react with compassion and empathy when she has difficult patient encounters. She teaches her medical students an approach that she calls the four R’s.

The first step is to recognize that there is an issue with a difficult patient. The second step is to reason through the problem. Finally, the doctor should become aware of and give priority to their responsibility and respond to the patient by coming up with an action plan.

Traits associated with difficult patients:

  • Mental-health disorders.
  • Multiple symptoms or conditions.
  • Chronic pain.
  • Unmet expectations.
  • Greater use of health-care services.


 
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