Patient Relations: Who’ll Stop the Rain?

It was 6 a.m. when the phone rang at the home of internist Robert Centor. A patient, eager to discuss her condition, had discovered that daybreak was a surefire time to reach him. “Patients who feel entitled to you at all hours are particularly difficult,” says Centor, a past president of the Society of General Internal Medicine. “I was in the shower when this patient woke my wife up. [The patient] obviously didn’t understand social boundaries, but she did understand what my wife said to her.”

Difficult patients, who can vex even the most mild-mannered physicians, span the spectrum of challenging behavior. Some specialize in self-diagnosis, demanding unnecessary tests and medication. Others monopolize your time and energy. Still others refuse to pay their bills, or they verbally abuse your staff. Amid the many in your patient population who are gratifying to treat, these few rabble-rousers can make you wonder why you ever got into the business of healing.

Fear not. With the right communication tools, a little sensitivity, and a hefty dose of patience, you can learn to work with your challenging charges, but you may also discover how to better treat their emotional - as well as their physical - needs.

A universal pain

“These patients do take a lot of time and energy and we can end up exacerbating the whole thing by our response,” says Andrew Wolf, a general internist and associate professor at the University of Virginia School of Medicine, who holds regular seminars on dealing with tough patients. “One really does need to work on becoming an expert at treating these patients. They’re not going away.”

The first step, says Shakaib Rehman, associate professor of medicine at Ralph H. Johnson V.A. Medical Center at Medical University of South Carolina, is to recognize that it’s not necessarily the patient who is difficult; rather, the situation makes them so. A large number of patients who express anger, for example, have not been given the right information at the right time. “Most experienced physicians realize that difficult patients are not the same as say, someone with diabetes or hypertension,” says Rehman, who delivers workshops on doctor-patient communication. “You yourself can have a difficult conversation with the phone company, and suddenly, it’s you who are difficult.”

The fearful patient

The underlying cause of your patient’s irksome behavior may not in fact be what you think. Often, for example, it’s fear, which can drive an otherwise reasonable person to become overly emotional, quick-tempered, or disagreeable. “Patients don’t always feel in control in the doctor’s office,” says James Welters, a family practitioner and chief medical officer with Northwest Family Physicians, an 18-physician practice in Minneapolis. “They may be scared because of a previous interaction with a physician or something a family member experienced. Certainly, when you’re ill, you feel more vulnerable.”

When interviewing patients during exams, he says, it sometimes helps to simply ask them to describe their worst health concerns. “Sometimes their fear is something that wouldn’t even cross my mind, like a patient with a persistent cold who immediately thinks lung cancer,” says Welters. “Just telling them, ‘No, I don’t think that’s what it is,’ can put their mind at ease.”

You can also help allay fears by improving your communication skills. That means focusing on your patient’s verbal and nonverbal cues (e.g., facial expressions, uncomfortable shifting). Allow them to speak without interruption while you maintain eye contact. Ask open-ended questions that encourage patients to provide more detail. “And how is this affecting your personal life?” can throw wide the gate of communication.

Empathy is equally important, but it must be sincere. “Don’t say things like ‘I understand,’ because you really don’t know what they’re feeling,” says Welters. “It comes across as false. Instead, use phrases such as, ‘I understand from other patients who have had this condition that these are the things you might be feeling.’”

The drug seeker

Some patients are difficult to manage because they’ve become dependent on pain medication or another controlled substance. Often, these patients have a legitimate medical condition and are experiencing discomfort. Unfortunately, they become relentless in their pursuit of stronger drugs.

“Some patients will go to great lengths to get them from you and others,” says Welters. “I had one patient who went from hospital to hospital saying she wasn’t getting pain medication or anti-anxiety medication or sleeping pills from her physician. Ultimately, she started forging her own prescriptions.”

At his office, Welters asks all patients who are on controlled substances for more than two months to sign a contract saying they won’t solicit medication elsewhere and if they do, they must agree to let his office know.

The angry patient

If you’ve been in practice for any amount of time, you’ve no doubt experienced the angry patient who walks in with a chip on her shoulder and untenable expectations on her mind. She finds fault with the medical profession in general and, often, with you, personally. “It’s important to keep your cool under any circumstance, but these are the ones who really test that,” says Wolf. “They say things like, ‘You’re late. What kind of care is this? I don’t know why I’m here; you can’t fix me anyway.’”

What works? Let the person vent - briefly. Then follow up with a comment, such as, “I can see you’re very angry.” This sort of reflective response counts with these patients because it legitimizes their feelings. Often, adds Wolf, these are patients who feel impotent either in life or in the doctor-patient relationship. You can help to re-empower them. “Tell them [that] what you really want to do is work together to address their health concern,” says Wolf. “Let them know that they’re the one who ultimately makes the call on whether or not they choose to get that MRI or take the medication you prescribe. If you allow them to choose it on their own, they’ll choose it.”

All in the family

It’s not always the patient who causes problems, of course; sometimes it’s the spouse or adult children. “When you have a patient who is terminally ill, in particular, it’s usually the family who has the more unrealistic expectation of what can be done,” says Centor. “That’s a very difficult situation, partly because of the angst you feel when they demand unnecessary tests for a patient that you know will only cause suffering and not do any good. It eats at your heart. You don’t want to get angry at the family, but you are angry at the family.”

His strategy for dealing with unruly families? Suggest they seek a second opinion. “Life and death situations are very emotional for families and for physicians,” says Centor. “It’s healthy to bring in another doctor who can back up what you are saying, which helps the family accept what you’ve already told them.” In a hospital setting, you might also obtain written confirmation from the ethics committee that they agree with your prescribed course of treatment.

The no-can-do-er

Though not actively combative, the noncompliant patient can be equally frustrating. Patients ignore healthcare advice for a variety of reasons, including fear of possible side effects, cost concerns, a belief that the treatment will be ineffective, and language or cultural barriers, to name a few. You can help your patients stick with a treatment plan, however, by taking the time to explain the reason for the test or medication you’ve prescribed and the consequences of failing to follow through. Where possible, use visual aids - heart scans, blood pressure results - to help drive the point home.

Here’s one more reason: Many people simply forget most of what you’ve told them. If they can’t remember, they can’t comply. At the end of each visit, ask your patient if she has any questions or concerns. Then ask her to repeat back your instructions. Even better: Provide a written summary of the diagnosis, recommended treatment plan, alternative options, and the potential risks and benefits. Everyone, from sleep-deprived new moms to career-centric yuppies to easily flustered senior citizens, will appreciate this.

Emotionally needy

There is also, of course, the dependent or emotionally needy patient. “These patients want your attention all the time until it becomes suffocating,” says Centor. “They feel they’re the most important person in the world. They go from doctor to doctor until they find you and they eventually leave you, too, when you can’t be there for them all the time.”

You’ve likely dealt with such somatizing patients, who present with a mix of physical ailments for which there is no medical explanation. “This is very challenging for all of us,” says Wolf. He says that some studies suggest half of all patients have at least one complaint with no biomedical basis. “I think doctors get frustrated and a lot of us resort to testing as a way of not dealing with that patient - perhaps not consciously, but we really don’t know what else to do.”

Instead, try judicious, limited testing. Instead of an MRI, for example, opt for an X-ray. “When you’re dealing with these patients for the first time, there’s inevitably some diagnostic testing that needs to be done to make sure we’re not missing something, but eventually, for patterns of physical symptoms that don’t have a strong biological basis, try the lower cost, less risky treatment instead - especially if it’s done for symbolic reasons,” says Wolf.

Centor agrees. “I had one patient who had had 18 previous HIV tests [but had] done nothing in the interim to put himself at risk,” he says. “Every time I saw him he wanted a new test. Sometimes a request for a test is reasonable, but when it’s expensive, dangerous, or totally unnecessary, you have to explain to the patient why you’re not going to do that and you have to be willing to get fired for it.”

It may seem counterintuitive, but you might also try seeing somatizing patients more often. “I try to bring them back more frequently than they can come up with complaints,” says Wolf. Depending on the severity of symptoms, he will usually recommend visits every two weeks to three months. This seeming “visit overkill” can actually reassure such patients, telling them that you’re available to help them, no matter what.

“Eventually, the focus of the interview moves away from how bad these symptoms are to how things are going in their life,” says Wolf. “This works incredibly well and office visits are a relatively cheap way to treat people, versus MRIs or having them visit the emergency room.”

The non-payers

For patients who fail to pay their bills, recognize that they’re not necessarily trying to wreak havoc on your accounts receivable. They may be working with their insurance company to resolve a claim dispute. Or, more likely, they may be having financial trouble at home. Ask late payers what your office can do to help - write a letter to the patient’s insurer? Set up a payment plan? If the patient is truly struggling financially, your office may also choose to reduce its rate for services rendered, or work with hospitals and specialists to negotiate lower rates. “It’s like any business,” say Welters. “You have to negotiate with patients who can’t pay their whole bill, but can pay part of it. We sometimes reduce our fees for procedures performed.”

Enough’s enough

If, despite all your best efforts, a patient continues to behave poorly, then you’ve got a responsibility to your practice to cut that person loose. “It probably should happen more often than it does,” says Welters. “I had one patient who called four or five times a day and spent an hour on the phone with our staff. I told her this is really interfering with our ability to care for other people.”

Centor agrees. During his 20-year career in outpatient practice, he has “fired” only three patients. “For me, the most difficult patient is the one who is verbally abusive to my staff,” he says. “I can handle verbal abuse directed at me, but when they’re rude to my staff, that’s when I fire patients. If you make my nurse or clerk cry, you’re out.”

Hopefully, this final-straw scenario is a rare happening for you, too. It should be. Most people stop acting out as soon as they’re confronted with their shenanigans. Just make sure you take time to search for the underlying reasons before just showing your patient the door. You’ll both learn from the experience: Your patient will get a refresher course on playing well with others, and you’ll hone your communication skills. Both results will lead, in turn, to more gratifying experiences for everyone in your practice.

Shelly K. Schwartz, is a freelance writer in Maplewood, N.J., who has covered personal finance, technology, and healthcare for 12 years. Her work has appeared on CNNMoney.com, Bankrate.com, and in Healthy Family magazine. She can be reached via editor@physicianspractice.com.

This article originally appeared in the July/August 2008 issue of Physicians Practice.