1. DEALING WITH
DIFFICULT PATIENTS
Aileen B. Pascual, MD, FPAFP
11July 2013

2. Think of a difficult situation…
 What made it difficult?
 What was the outcome you were
hoping for?
 What actually happened?
 What would have made it go better?

3. What makes an interaction
difficult?

4. What makes an interaction
difficult?
Fear – of the unknown, of not knowing how the
other person will react, of hurting someone’s
feelings or of feeling hurt
Conflict – few people enjoy conflict and most go
out of their way to avoid it
Surprise – catching someone off guard can make
an otherwise smooth interaction difficult
Change – interactions involving having to make a
change often make people feel uncomfortable

5. Why we avoid difficult
interactions
We’re afraid we’ll make the situation worse
We don’t want to feel bad, and we don’t want
others to feel bad
We may hear things about ourselves that we
don’t want to hear
We, and the other person, may get emotional
We don’t know how the interaction will end,
and we fear the consequences

6. The label “difficult” is subjective
 Interpersonal in nature
 A function of the relationship
 Based upon discomfort with:
What has happened
What might happen

7. “Difficult”: different for different
individuals
 Someone labeled “difficult” by a
person may not be seen as quite so
difficult by another
 Differences in expertise and
experience account for differences in
perception

8. Unfortunately… impossible people
exist.
 You will encounter them.
 You can’t avoid them.
 You can’t fix them.
 You can’t make them like you.
 You can’t beat them.
 They may not want your help

9. How to minimize difficult
interactions
 Know your purpose
 Frame your message
 Use an assertive approach
 Use cooperative language
 Use active listening skills

10. Responding ASSERTIVELY
(DESC vs. DISC)
• Describe the situation
• Express your feelings
• Specify the change you
want
• Consequence
“I have been coming
here for PT to treat my
pain. I feel frustrated
that the pain is still
there and worse, I
have to stand in line.
May I at least have a
place to sit, so that I
can be more
comfortable as I wait?”

11. Responding ASSERTIVELY
(DESC vs. DISC)
• Describe the
situation
• Indicate problem the
behavior is causing
• Specify the change
you want
• Consequence
“I have been coming
here for PT to treat my
pain. There’s no
improvement & waiting
in line further adds to
my pain. May I at least
have a place to sit, so
that I can be more
comfortable as I wait?”

13. Case Vignette 1
 You have a group mate whom you notice
has always been taking advantage of
other people. During one of your
laboratory sessions, she asks you to cover
for her as she has to make an important
call. She disappears and does not return
until after two hours.

14. CASE VIGNETTE 2
 In the middle of a patient encounter
activity, your “patient”, a young attractive
member of the opposite sex, grabs your
arm and tells you that she/he finds you
cute and wonders if you might meet
privately or be textmates.

15. Doctor-Patient Relationship

16. Patient’s Needs
need to be
recognized and
treated with respect;
need to feel
important
need for specialized
knowledge and
medical expertise
PERSONAL
NEEDS
PRACTICAL
NEEDS

17. Types of Patients
There are FOUR types of PATIENTS…
1. PRAISERS (Happy & will tell you so)
2. PATRONS (Happy but won’t say anything)
3. TALKERS (Unhappy and are sure to let
you know)
4. WALKERS (Unhappy and just leave, never
to return)

18. Good physician communication
can lead to:
 increased patient satisfaction
 increased health care professional
satisfaction
 improved patient health outcomes
 decrease in complaints and lawsuits

19. Clinicians can have fewer
“difficult” relationships by:
 Discovering what factors contribute to
the label “difficult”
 Exploring techniques that can lead to
more satisfactory relationships
 Experimenting with new skills

20. Factors that influence doctor-
patient communication
 Patient-related factors
 Doctor-related factors
 The interview setting (environment)

21. Difficult Patients
 Prevalence estimated at 15%
 Patients who exhibit the following:
 Repeated visits without apparent
medical benefits
 Do not seem to want to get well
 Abrasive personalities, demanding
 Focus on issues seemingly unrelated to
medical care
 Poor adherence to treatment

22. Patient Characteristics
 Angry, defensive, frightened, resistant
 Grieving
 Manipulative/Demanding
 Somatizing/“Frequent fliers”

23. A considerable number of patients who
are labelled difficult may meet the DSM
criteria for:
 Mood disorders
 Anxiety disorders
 Borderline personality disorders

24. Physician Factors
 Fatigued or harried
 Angry or defensive
 Dogmatic or arrogant

25. Situational factors
 Language and literacy issues
 Companions during consult
 Breaking bad news
 Environmental issues (setting)

26. Strategies in dealing with difficult
patients

27. Psychiatric Management
 Prompt assessment, treatment and
referral

28. When confronted with difficult
patients… take HEART
 Hear them out.
 Empathize.
 Acknowledge/Apologize for the
inconvenience
 Respond appropriately.
 Take responsibility for action/Thank your
patient for bearing with the

29. Physician self-care
 Ensure personal well-being
 Know trigger issues
 Know your limits
 Bracket. Bracket. Bracket.

30. Coping with Difficult Patients
 Avoid being judgmental
 Be patient, tolerant
 Get good history to understand
patient
 Use direct communication
 Humor
 Selective personal disclosure

31. Counterproductive Strategies
 Ignoring the problem
 Accusing the patient of being
problematic
 Telling the patient that there is
nothing wrong or that there is nothing
you can do for him
 Attempt to solve the problem with
psychopharmacology alone

32. References
Essary AC, Symington SL. How to make the “difficult” patient less difficult.
JAAPA May 2005.
Haas LJ, Leiser JP, Magill MK, Sanyer ON. Management of the Difficult
Patient. Am Fam Physician, 2005 15;72(10): 2063-2068.
Hull Skew and Broquet K. How to Manage Difficult Patients. Family Practice
Management | www.aafp.org/fpm | June 2007
Spickerman F. The Fine Art of Refusal. Family Practice Management 2004.
Feb; 11(2):80.