That Son of a Bitch – Dealing With The Difficult Patient.

Derek C. McCalmont M.D., FACEP, MS Management Service Chief

Henry Ford West Bloomfield Hospital EDMarch 7, 2012

Goals for the next 30 min.

• Identify some common difficult patients

• Identify some common difficult doctors.

• Understand where both are coming from.

• Develop strategies to make these interactions easier on both sides.

• Earn 30 min. of CME credit!

Why Do We Bother?

http://www.youtube.com/watch?v=TmwqWBJahto&feature=email

Why should I care?

• One out of 6 visits are considered “difficult”

• Physician burnout (and lower work satisfaction) 12x more likely

• Difficult patients have lower satisfaction with their care

The Bottom Line

• Difficult patients represent a relationship problem, not a clinical one.

• It is the clinician’s responsibility more than the patient’s to address and resolve the relationship problem.

• Physician’s have more access to and control over our own reactions than we have over the patient’s.

It’s Not A Contest!

Who Are These Patients Demographically?

• Older• More often separated or divorced• Women>men• More Acute and Chronic Problems• More medications• More x-rays and tests• More visits• Lower satisfaction with their care

Who Are These Patients Diagnostically?

• More likely to have mental disorder- multisomatoform disorder, panic disorder, dysthymia, generalized anxiety, major depression, alcohol abuse or dependence.

• Personality disorders- Borderline, OCD, Dependent, Self-defeating, narcissistic, paranoid etc.

• Chronic Pain

What About The Easy Patients?

• Objective signs and symptoms of a treatable disease.

• Make no emotional demands on the clinician

• Cooperates in the treatment process

• Displays gratitude for the help received

A Common Definition?

• One who impedes the clinician’s ability to establish a therapeutic relationship.

• One who’s behaviors are perceived to challenge provider’s competence and/or control.

• One who- by a variety of behaviors related to profound dependency stimulates negative feelings in most doctors.

Who Are These Doctors?

• At some level- all of us. • Younger (less experienced)• Female• Overworked• Lower job satisfaction• Medical rather than a biopsychosocial approach

(most of us).• Lack of communication skills training (most of

us)• Lack of self-awareness (most of us)

Clinician Awareness

• Negative emotional reactions not fully recognized

• Negative reactions are the primary controllable determinant in these interactions

• Increased physician awareness=decreased perception of difficult patients=increased physician satisfaction

We Have All Been There

• Being self-aware and patient centered and incorporating knowledge about the patient’s personality are baseline requirements for working with all difficult patients.

Do’s

• Allow more time for these patient encounters

• Continue to listen• Continue to educate• Encourage the patient to gain control• Maintain hope• Frame referrals to Psych in terms of the

stress produced by mysterious or intractable symptoms.

Dont’s

• Brush them off

• Tell them nothing is wrong

• Use “stress” or “anxiety” as a diagnosis without considering what can be done about it.

• Be angry

• Be punitive

• Propagate despair.

Patient 1

• 37 y.o. female

• CC- Chest Pain

• HPI- Pressure-like sub-sternal pain radiating to the left arm for two days unrelieved by NTG

• PMH- Unremarkable

• PSH- Smokes 5-10 cigarettes daily. Denies alcohol or drug abuse.

Dependent Clingers

• Escalate from appropriate request for reassurance to excessive demands for attention, medications etc.

• Naïve about their effect on physicians.

• Run the gamut from healthy to life threatening.

• Self perception of bottomless need and physician/healthcare as inexhaustible.

Strategy

• Identify as early as possible

• Specify limits of physician knowledge/time

• Provide specific follow-up appointments

• Remind patient to utilize office visits for recurring problems.

Patient 2

• 56 y.o. male

• CC- Abdominal Pain

• HPI- Patient with epigastric pain of 2 hours duration with nausea.

• PMH- Hypertension, GERD

Entitled Demanders

• Like Clingers- profound neediness

• Use intimidation, devaluation, guilt-induction to obtain attention/testing/meds

• Less naïve about their effect on physicians

• Threatening (litigation/complaints)

• Exude a repulsive sense of innate deservedness

Strategy

• Recognize Hostility is born of fear of abandonment

• Entitlement is their religion- don’t blaspheme it.

• Support but re-channel the entitlement. “You deserve the very best care we can give you but you need to help”.

• Avoid logical/illogical arguments

Patient 3

• 32 y.o. male

• CC Low back Pain

• HPI- Left LLB Pain radiating down left leg for 5 days.

• PMH- Chronic back pain with radiculopathy

• Current Meds- Vicodin (out)

• Allergies- NSAIDS, Ultram

Manipulative Help-Rejecters

• “Crocks”

• Feel that no regimen will help

• Frequent flyers happy to report that yet another treatment has failed

• Pessimism increases in proportion to physician’s efforts

Strategy

• Suspect depression

• “Share” the pessimism. Agree that treatment may not be entirely curative.

• Provide simple reasoning. Avoid complicated explanations.

• If needed schedule psych follow-up but also PCP follow-up AFTER psych vist to avoid abandonment issues

Patient 4

• 65 y.o. male

• CC- Constipation

• HPI- No BM for 3 days

• PMH- Metastatic bone CA.

• Current Meds- none

• PSH- Lives alone. Family lives nearby but not involved in care.

Dr. Cox Responds

http://www.youtube.com/watch?v=RK8dMRLVWvg&feature=email

Self-Destructive Deniers

• Unconsciously self-murderous behaviors

• Profoundly dependent but have given up hope of ever having their needs met

• Non-compliant with medical regimen and take pleasure in defeating family and physician attempts to save their lives.

• Prize their independence and deny infirmity

Strategy

• Limited Options

• Acknowledge your own frustration

• Best you can while you can

• Psych consult- usually refused.

Final Thoughts

• Difficult patients and their frustrated physicians fail each other. We flop together. We lose hope. And there is no more useless doctor than one who has lost all hope.

• Difficult patients are an opportunity to further define ourselves as clinicians. To be compassionate, not hostile in the most trying of circumstances.