(This is a digest of an article written by Internist Titus Abraham, MD that was originally published in September 2005 by Medical Economics.)
Having treated more than his fair share of tough patients, the author came up with 5 rules to effectively manage difficult patients:
1. Know Yourself. No one wins in a battle of wills and wits between doctor and patient. Understand your limitations and personality in order to manage your emotions. Calm professionalism is critical, regardless of the patient's actions and words. Granted you need emotion to empathize with the patient and create a therapeutic relationship, but avoid emotions that cloud your judgment and over-personalize your relationship with the patient.
2. Know the Patient. This goes beyond medical and psychiatric history to understanding past patterns and behaviors. Most difficult patients fit into one of the following personality types:
3. Someone with underlying personality disorders that lead to non-compliance or self-destructive behavior (alcohol/drug abuse).
"A malingerer who is seeking narcotics or some form of secondary gain in the form of increased attention.
" Someone with a somitization disorder, ranging from one-time chest pain admission to chronic headache patient. Once organic conditions have been ruled out, an underlying psychosocial problem usually needs to be addressed by a psychiatrist or chronic pain specialist.
"Someone with a strong need to control (or someone who has a family member with such a need). In order to avoid conflict over continual demands on treatment specifics, you have to try to build trust early on. Present yourself as a "partner" in their care, emphasizing that you are a trained professional with specific skills and expertise. Always avoid any appearance on condescension. Be thorough in explanations and utilize brochures and handouts.
1. Focus on the Big Picture. Having "lost control" by being ill, patients may try to regain control by refusing treatment, testing or medication. You must be patient enough to repeat your explanations about necessity of treatment or test. Be willing to forgo a test or medication, if it won't adversely affect care, in order to win cooperation. If a patient continues to refuse (and is of sound mind), document the refusal and move on. If the patient is not of sound mind, you must weigh the long-term consequences and perhaps solicit family members and colleagues in arriving at a practical decision.
2. Have Compassion. Demonstrate your compassion by listening attentively and interrupting only when the conversation loses focus. A discreet tough on the shoulder or hand can often comfort an anxious, but difficult patient. Let them know you are concerned.
3. Set Limits. A patient's demand for a certain test or treatment does not obligate you to provide it. However, sometimes the patient is right, so evaluate all such requests objectively.
4. Don't Accept Insults. No one has the right to insult you. If you become the target of insults, turn the care over to another physician after providing adequate notice to the patient.
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