Difficult Patients, Practitioners, and Encounters

A recent encounter with a patient began with a hushed warning from the administrative staff that this patient was difficult. I entered the room with some trepidation, the resolve to maintain my composure whatever happened, and the faint hope that I may be able to win the patient’s trust. He spent significant time in that initial encounter describing in strongly negative terms the care he had received from a prosthetist who was no longer with the company. Details in the clinical record were limited, but it appeared that some of the patient’s complaints were valid. It was also clear that his primary complaints related to the way the prosthetist had behaved toward him. He had been satisfied with care he’d received from a second prosthetist whose recent retirement added to the patient’s frustration. His animosity toward the first prosthetist had not waned in the many months since those original encounters, and communicating this was clearly his top priority.

Several aspects of the patient’s personality, mannerisms, and behaviors raised questions about his credibility. While many of his complaints related to the poor prosthetic care he believed he had received, he also spent considerable time reporting problems that are commonly associated with initial prosthetic fitting. When his diatribes expanded to include politics and retail customer service, I began to suspect that a generally negative worldview was at the root of his complaints. He reported a high view of his own intellect and abilities that I found inconsistent with his general demeanor and self-care habits. Resisting the urge to dismiss his complaints or correct his perceptions, I chose instead to listen and acknowledge his frustration. (It was relatively easy to not react defensively, since his complaints were not about me or care I had provided.) Those efforts paid off during subsequent encounters. Sufficient trust had developed that when I suggested focusing on current prosthetic problems he responded positively.

Relationship Not Labels

With little prompting, most practitioners can recount specific details of patients who frustrate them. A study by Jackson and Kroenke involving 38 clinicians and 500 patients in a primary care walk-in clinic found that 15 percent of the encounters were considered difficult.¹ A similar percentage in a busy O&P practice would mean practitioners experience multiple difficult encounters weekly, and perhaps even daily. Difficulty is not randomly distributed among all patients, but instead, certain patients present challenges every time they are seen. Experienced clinicians can often identify traits or behaviors that are likely to introduce difficulty into future encounters. Recurrent difficult behaviors and attitudes that form a pattern may seem to justify labeling the patient as difficult. Cautioning others in the practice may help them prepare for dealing with that patient, and I understood the staff person’s warning as having that intent. But such labelling can also have negative effects on future interactions by attributing responsibility for difficulty solely on the patient.

The clinical encounter is a professional relationship, and in every relationship both parties influence the interaction. Psychiatrist R. Gregory Lande, DO, COL (Ret.), FACN, FAOAAM, states: “There is no such thing as a difficult patient…. Focusing on the encounter moves the spotlight off the patient and in its place illuminates a bidirectional relationship.”² The way my reactions and responses in past difficult encounters made things worse come readily to mind. According to Lande, “Labeling an individual as a ‘difficult patient’ effectively absolves the clinician’s role in a difficult encounter, either as a contestant or a conciliator.”² On too many occasions I chose to contest, defend, and correct rather than conciliate. Not surprisingly, both the patient and I usually left these encounters feeling unsatisfied with the results.

Repeated behaviors and ingrained attitudes can be an indication of character, and someone who is consistently negative could fairly be labelled as difficult by others. It is worth keeping in mind that this is as true of practitioners as it is of patients. Referring to difficult encounters rather than difficult patients is more than a semantic choice. It is an important part of changing our focus to the problematic behavior (both the patient’s and our own), what we can control, and what type of influence we wish to have on the encounter.

The Effect of Training

Several studies have demonstrated that receiving training about how to handle difficult encounters can improve interactions. Roter et al. conducted a randomized clinical trial involving 69 primary care physicians and 648 patients.³ The physicians who had completed “communication-skills training courses designed to help physicians address patients’ emotional distress…used significantly more problem-defining and emotion-handling skills than did untrained physicians, without increasing the length of the visit.”³ These physicians “engaged in more strategies for managing emotional problems with actual patients, and scored higher in clinical proficiency with simulated patients. Patients of trained physicians reported reduction in emotional distress for as long as six months.”³ Stein and Kwan reported that 911 physicians who had completed a one-day training workshop on patient interviewing skills “reported a decline in the proportion of visits that they characterized as frustrating.”⁴ This research demonstrates the significant role clinicians play in difficulties, if for no other reason than that our responses to the difficulties of others can influence the direction and outcome of an encounter. It also provides evidence that difficulty may not be an immutable trait of certain patients but instead can be mitigated by how we interact with them.

Patient Difficulties

We may consider the ideal patient to be one who is mature, responsible, professional, respectful, considerate, and grateful. All these traits are challenged when

health fails. In addition to the acute condition that requires our care, most of our patients have multiple chronic diseases and comorbidities as well as challenging life-situations, all of which drain their psychological, social, and financial resources. If the rate of mental illness and other psychosocial diagnoses among our patients was only at the level found in the general population, this would represent a substantial challenge. The reality is that these diagnoses are more common among certain populations who require our care.

Studies by Jackson and Kroenke, and Hahn et al. have found that certain patient characteristics are associated with increased difficulty as perceived by physicians.^1,5 (See Table 1.) O&P practitioners may recognize these characteristics in the patients they find difficult. Interestingly, Hane et al. reported “no association between difficulty and the presence of any of the most common medical disorders—hypertension, arthritis, diabetes, cardiac disease, pulmonary disease, or cancer.”⁵

It is normal to experience strong negative emotions when working with patients with these characteristics, particularly when they are exhibited in repeated encounters. Harvard psychiatrist James Groves, MD, identified four stereotypical patterns of difficulty in a 1978 paper titled “Taking Care of the Hateful Patient.”⁶ Groves defined these patients as “those whom most physicians dread.”⁶ According to Groves, “the insatiable dependency of ‘hateful patients’ leads to behaviors that group them into four stereotypes: dependent clingers, entitled demanders, manipulative help-rejecters, and self-destructive deniers.”⁶ The negative reactions evoked in physicians in response to these stereotypical patients are aversion, a wish to counterattack, depression, and malice, respectively.⁶ While Groves’ descriptions may seem insensitive and harsh, any practitioner who has been in these types of encounters will likely recognize both the patient profiles and the strong reactions to them.

Clinicians’ Beliefs

Clinicians bring their personalities, temperaments, and behaviors into an encounter. Additionally, they may hold attitudes and beliefs regarding psychosocial aspects of treatment that impact their response to patients. The Physician Belief Scale was developed to “measure beliefs about psychosocial aspects of patient care held by primary care physicians.”⁷ Physicians rate their agreement on 32 statements using a Likert scale, with lower scores representing “a more psychosocial approach to patient care.”⁷ (See a sample of the statements in Table 2.) In Jackson and Kroenke’s ambulatory care clinic study, “clinicians who scored greater than 70 on the Physician Belief Scale reported 23 percent of their encounters as difficult.”²

Diagnosis and treatment of psycho-social issues falls outside of the scope of practice of O&P clinicians. However, as healthcare professionals, we have the responsibility to understand our patients’ challenges sufficiently to work effectively with them. Whether the difficulty in an encounter is associated with psychiatric diagnoses and mental illness or not, it seems reasonable to conclude that beliefs such as those listed in the Physician Belief Scale interfere with successful navigation of many of the issues that cause our patients distress and negatively impact their O&P care. As an example, being unwilling or unable to address psychosocial issues puts us at a disadvantage when addressing nonadherence, which is tied more to a patient’s preferences, expectations, and motivation than his or her clinical understanding.

Failing to acknowledge emotional and psychological influencers of behavior is to miss opportunities to work constructively with patients. Family physician and family therapist John Launer, MD, states, “the real challenge is usually how to remedy the situation by the way you respond. This perspective is taken for granted in fields like counselling, mediation, social work, or therapy. In those settings, ‘difficult’ behavior is recognized as being a common result of adverse experiences or former encounters with authority, and as a consequence of feeling powerless. At root, it signifies suffering and frustration with the failure to relieve it.”⁸ It is equally true that our own reactions to difficult patient behaviors may indicate a deeper problem in ourselves and may signal the need for training to develop the skills necessary to respond more effectively in difficult encounters. According to Hahn and Kroenke, “by taking the doctor-patient relationship and their own response as the object of change (rather than the more traditional expectation that the patients’ ‘pathology’ is the target of intervention), physicians can make an effort to avoid reacting to uncertainty with insecurity, to abrasive personal styles with defensive retaliation, and to patients’ psychosocial needs with insistence on a narrowly defined biomedical agenda.”⁵

Closing Thoughts

That a minority of patient encounters are considered difficult is less surprising to me than that the majority of them are not. Many patients with serious health issues and other overwhelming life challenges deal with them more constructively than I do. The encounter described at the beginning of this article included relatively minor difficulties, which so far have been successfully navigated simply by listening to the patient. The challenges would undoubtedly have escalated had my response been different. Had that happened, it would have been easy to leave the encounter believing that the patient labelled as difficult had proven himself worthy of that label, and not that my response had contributed to the difficulty. Many difficult encounters are not so easily resolved and represent significant barriers to providing care. Considering our own contributions to difficulty, including unhelpful responses to difficulties that patients contribute, can help us deal with them more professionally and effectively. It can also significantly lower our stress and leave us with more emotional and cognitive reserves to devote to providing the best care despite those difficulties.

John T. Brinkmann, MA, CPO/L, FAAOP(D), is an associate professor at Northwestern University Prosthetics-Orthotics Center. He has over 30 years of experience in patient care and education.

References

1. Jackson, J. L., and K. Kroenke. 1999. Difficult patient encounters in the ambulatory clinic: Clinical predictors and outcomes. Archives of Internal Medicine 159(10):1069-75.
2. Lande, R. G. 2023. Managing difficult encounters. Osteopathic Family Physician 15(2): 19-23.
3. Roter, D. L., J. A. Hall, D. E. Kern, L. R. Barker, K. A. Cole, and R. P. Roca. 1995. Improving physicians’ interviewing skills and reducing patients’ emotional distress: A randomized clinical trial. Archives of Internal Medicine 155(17): 1877-84.
4. Stein, T. S., and J. Kwan. 1999. Thriving in a busy practice: Physician-patient communication training. Effective Clinical Practice: ECP 2(2): 63-70.
5. Hahn, S, R., K. Kroenke, and R. L. Spitzer, et al. 1996. The difficult patient: Prevalence, psychopathology, and functional impairment. Journal of General Internal Medicine 11(1):1-8.
6. Groves, J. E. 1978. Taking care of the hateful patient. The New England Journal of Medicine 298(16):883–7.
7. Ashworth, C. D., P. Williamson, and D. Montano. 1984. A scale to measure physician beliefs about psychosocial aspects of patient care. Social Science & Medicine 19(11):1235-8.
8. Launer, John, ed. 2022. Dealing with difficult patients–by dealing with difficult doctors. Postgraduate Medical Journal 98(1162):649-50.

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