Dealing With Problem Patients

Every doctor has a "problem patient" war story, but primary-care physician Anne Biedel's will knock your socks off.

A retired schoolteacher began coming to her practice frequently, often for medically dubious reasons. The schoolteacher made Biedel's staff uneasy with her pushy and overbearing nature; sometimes she would just barge beyond the reception area, near the exam rooms, as if she worked there.

Moreover, she took an unhealthy interest in Biedel personally, and knew more about her private life than the doctor was comfortable with, even in a small town. And her attitude toward Biedel and her staff unnerved them - she was seemingly friendly, yet also vaguely menacing.

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"She knew where I lived and where my daughter went to school, and at first she approached me as kind of, 'Hey, you know, I'd like to get to know you,'" Biedel recalls. "But hers was an unwelcome, uneasy presence in the office. ... She had almost like a stalking behavior. One day I came out of an exam room and found my nurse hiding under the desk. I said, 'What the heck are you doing under there?' And she said, 'Guess who's out there?'" 

The last straw was when she appeared in the office on Biedel's birthday, eager to show her staff the "surprise" she'd cooked up for the doctor: she'd written "Happy Birthday" on her thighs.

Apparently the schoolteacher's feelings for her physician were more than professional, and more than friendly.

Patients as troubled as this are rare, but not unheard of. Doctors and their staffs can be magnets for the lonesome and the delusional. The quasi-personal nature of the physician-patient relationship and the casual, family atmosphere of most physician offices can be confusing to patients yearning for warm human contact.

"I'm a warm person by nature," says Aletha Tippett, a solo primary-care physician in Cincinnati, who had an experience years ago eerily similar to Biedel's. "I touch my patients. I get involved in their lives; I'm very close to my patients."

One patient who tried to get too involved haunts Tippett to this day. The woman was not satisfied with regularly scheduled appointments; she began trying to ingratiate herself into the day-to-day lives of the doctor and her staff. She would call daily, just to chat, or show up at the office with trays of fresh-baked goodies. Moreover, she was often rude to the staff, presumably viewing them as barriers to Tippett. They felt bad for the woman; they assumed she was simply lonely. But they did not have time for her incessant pestering and they tried gently to discourage her.

"I would tell her, 'You have to stop bringing us fudge,'" Tippett recalls. "'You have to stop calling. You can't show up here every day.' I wound up having her evaluated by a psychiatrist, and the psychiatrist said, 'You know, she's in love with you.'"

Both physicians knew that they would have to end their relationships with their lovelorn patients, and did so. Tippett's former patient still hasn't gone away completely.

"It's been seven years," she says, "and I still get letters from her sometimes. She'll say, 'I just wanted to check in to see how things are going.'"

The schoolteacher in Biedel's practice was even less cooperative. Although Biedel, who was in the process of leaving her group for a solo practice, had written the patient a letter informing her of the decision and offering her urgent care for 30 days at her former group, the schoolteacher showed up at Biedel's new office demanding to be seen. When she was firmly rebuffed, she stormed out of the office, seething.

Then she found a lawyer and sued. Because she had no legitimate malpractice claim, her action came under Washington state's obscure "tort of outrage."

"It was for this outrageous behavior I had supposedly showed her," Biedel says.

The suit was disposed of, but the memory of the frustration remains.

No small problem

Perhaps you've never had such an unnerving experience. But if you're like most physicians - and especially if you're in primary care - you've dealt with plenty of so-called problem patients. About 5 percent to 10 percent of patients in a typical primary-care practice are considered difficult to deal with by their doctor, meaning high-volume doctors might see several such patients every day.

This is a problem for your practice on several fronts. In the first place, unhappy patients are more likely to sue. Second, they take considerably more time to handle than others, even when they are handled efficiently, meaning they are costing you money.

And perhaps most glaringly, difficult patients are a huge drain on job satisfaction for everyone in your office. After all, most of you got into healthcare because you like helping people. What could be more offensive than a person who comes to you for help, then doesn't appreciate it? Poor management of problem patients can increase your staff turnover. And as for you, one difficult encounter can ruin your whole day.

"Physicians are highly oriented toward success - that's the culture and their training," says Gregory Carroll, a psychologist who directs the Bayer Institute for Health Care Communication, a research, education, and advocacy organization based in West Haven, Conn. "So part of it is the actual time spent, and part of it is the perception of time, which is quite subjective. When you ask doctors how much time they spend on these patients, they would probably vastly overestimate it. But they clearly spend a disproportionate amount of time feeling upset and frustrated, and in some ways, feeling unsuccessful."

Are you taking these encounters home with you? Do they dominate your thoughts on your evening commute, affect your personal relationships, keep you up at night? It doesn't have to be that way. While you'll never get rid of difficult patients entirely, you can learn to handle them better by developing a few simple techniques.

Who are you dealing with?

The garden-variety problem patient may not stalk you or fall in love with you, but he is quick to anger, complains incessantly, verbally abuses staff, causes scenes in reception rooms, and expects everything his way. And that's just the angry patient - only one of several difficult types. Others include the manipulator/drug-seeker, the sad patient, the patient in denial, and the "fix-me" patient, who takes no responsibility for his own care.

You'll need to determine what sort of problem patient you're dealing with - not because the actions you'll take are dramatically type-dependent (on the contrary, your responses to each are roughly the same) - but because you probably do better with some types than with others. That's human nature.

"There is no one-size-fits-all difficult patient," says Gary Glober, a gastroenterologist who spent 20 years in private practice and now conducts relationship-building workshops for healthcare professionals. "What might be a difficult patient for one doctor is no problem for another. ... Difficulty can come in various packages, and what's interesting is that what makes a patient appear difficult is not inherent in that individual. It's the inability of the person with whom they are interacting to handle that situation."

Chances are you can distinguish between these types (and can name some others) without much trouble. It's important, though, to make the distinction with each difficult patient individually, rather than simply lumping them all together as problems.

Carroll argues that physicians should drop the whole notion of "the difficult patient" altogether because it is the relationship, not the patient, that's challenging. In the Bayer Institute's extensive workshop on the subject, physicians are shown short video clips of actors playing out typical examples of strained patient encounters. Participants are then asked to rate which of the scenarios strikes them as the most painful.

Rarely do the physicians in the workshop reach consensus, says Carroll. A doctor in private practice may recoil at an enraged patient, but emergency room physicians deal with so many angry patients that they are barely fazed by them. Instead, the fix-me patient who shows up expecting easy solutions is what pushes an ER doc's buttons.

The Bayer Institute describes its process of fixing difficult patient relationships with an acronym, ADOBE.

Acknowledging the existence of a strained relationship (the A in ADOBE) and vowing not to let it eat you up inside are the first steps in handling the problem patient. Carroll says you can be pretty sure trouble's brewing when the relationship meets one of these criteria:

• You can predict, based on your experience with patients like this one, that you probably won't have clinical success. (Remember, this judgment should be based on your relationship with the patient.)
• The patient's expectations and yours concerning the likely clinical outcome are significantly misaligned.
• For one reason or another, the patient's needs are well outside of your comfort zone, or outside of the practice or communication style that you're used to.

When a patient relationship falls into one of these categories, it's a sign you'll need to take extra measures, or, in extreme cases, refer the patient elsewhere.

Responding to denial

Denial among patients and their families is a hot button issue for Rey Patterson, a family physician in Fishersville, Va., and the assistant director of the Hospice of the Shenandoah. There was the man whose elderly mother was "terribly sick ... and had been diagnosed with Alzheimer's for 14 years," yet he "still wants aggressive care - he wants her to be a code blue," Patterson says.

And there was the woman who insisted on caring for her brother on her own after his second stroke, even though he couldn't speak, was virtually immobile, and needed full-time care.

"Many, many people have unrealistic expectations about their life and times," says Patterson. "Day in, day out, I find myself having to gently - even covertly - move people to a different understanding of what they can do and what we can do for them. Some of the most disgruntled patients are examples of doctors having succeeded far too well in our job, because we've given society the expectation that there is nothing untreatable."

The best way to handle such patients is to calmly explain their options and let them decide what they'd like to do, making sure they understand the consequences of their choice, Patterson says.
For example, Patterson couldn't medically justify admitting the elderly woman to the hospital, so he told her son he'd admit her only with a signed Medicare waiver. The son didn't like that very much, but eventually they reached an uneasy understanding. As for the stroke patient's sister, Patterson at this writing was getting her involved in much of his inpatient care, as a way of showing her the difficult job that lay ahead.

In both cases, Patterson's actions were the result of his first coming to an understanding about what the difficult individual's problem really was. The son simply did not want to let his mother go. The sister believed firmly that no one knew her brother like she did, so anyone whose views differed from hers on the subject of his care was simply mistaken.

Reaching this understanding is what the Bayer Institute calls discovering the meaning (the D in its ADOBE acronym).
"It's nothing new, but the first thing is to shut up and listen to the patient," advises Patterson. "Listen for the root of their discontent. If you can find the thing that's gotten them to that point to be confrontational or argumentative, you can say, 'You know, what I'm hearing is 'this.' Can you tell me if I'm right?' You're asking their opinion. Then you can say, 'I can't argue with how you feel.' If you validate them after you've listened, they feel legitimized, and at that point you can say, 'What I'd really like to do is stop arguing and talk about what we can offer.' You need to get to a point where the cudgel is not raised."

Demonstrate compassion

Let's face it: It's hard to feel compassion for some types of people. Those who have created their own problems, and those who aren't nice to the people trying to help them, can strain anyone's inner Florence Nightingale. Yet demonstrating compassion, even through small, symbolic gestures, is not only part of the physician's job, it's also very much in your own best interest in defusing difficult encounters.

One of the videos shown to physicians participating in the Bayer Institute workshop depicts a woman who's recently had a hysterectomy. She's furious with her physician, even irrational.
"When she comes across in this 30-second video as being negative, nasty, mean, and she's shaking her fist at you and says, 'I just can't believe the way you're acting; you just don't care!' - the people in the room roll back in their chairs and are almost heading for the exits," reports Carroll. "But when you understand the meaning of this experience she's been through, [you realize how she gets] this impression of the doctor not understanding, not empathizing, not at all grasping the severe impact on her."

In other words, understanding where someone's coming from is a key to mustering compassion for her, even when she seems unworthy of it. "If you ever appear cold or unfeeling, forget it," says Patterson.

Which brings us to the O in ADOBE - finding opportunities for compassion. What's involved in that? In a brief patient encounter, strikingly little: Try sitting down with the patient instead of hovering over him. Listen carefully. Let him know he's been heard by repeating his main points back to him. Say something like, "Mr. Johnson, I understand how you feel."

Sometimes patients have legitimate reasons to be angry. Hear them out. Don't get defensive.

"I think the real key is not blaming the patient - not assuming that it's the patient's fault," says Tippett. "Instead, just say, 'We have a problem. How can we solve it?' You have to get them into an alliance with you."

Janice Smith, a staff member at Springer Clinic, a multispecialty group in Tulsa, Okla., has acquired a reputation for handling people complaining about one of the most common sources of patient discontent: their bills.

"I don't take things they say to me personally," she says. "I let them yell at me, and say whatever they want to say, and get out whatever they need to get off their chest, and then we try to move on and I tell them what I can do for them."

Smith says she gained a heightened sense of compassion during her many years as an aide in hospice care. And besides, she adds, "I've been on the other end - I've called and yelled at a few people, too, when I feel like they're not doing what they're supposed to do, or they're not listening to me."

Set boundaries

Then again, many patients are just irrational. Some have a whopping sense of entitlement. A few think of your staff as "the help," and see nothing wrong with verbally assaulting them. They might think of you as a member of their "staff," available to them at any time for any reason.

For your own sanity and the protection of your staff, you must set and enforce boundaries, the B in Bayer's ADOBE.

"In my practice, we're a team, a family," says Tippett. "I tell patients, 'You have to treat my staff with the same respect and courtesy you treat me, and if you can't [do that] you can't come here anymore.'"

Marty Sturtz, business manager of The Betty Seinfeld Breast Center in Boynton Beach, Fla., has become a reluctantly rigid enforcer of practice boundaries regarding patient behavior, employing a system known around the practice as "The Marty Test" - in essence, a series of questions asked by staff to determine whether the practice is willing to accept a patient. The staff uses the Marty Test with mostly angry patients who aren't calming down.

"The biggest question is, 'Do you understand that if you continue in the manner that you're continuing, we will not see you in this office today? Because you're acting out and we're not comfortable with this,'" she says. "That either calms them down or accelerates them, and if they accelerate a notch or two, then we say, 'OK, you've been noticed, so we're not seeing you today.'"

If that sounds a lot like how you discipline a child, Sturtz agrees it's not a coincidence; patient misbehavior is often remarkably juvenile, she says, and the best defense is to "nip it in the bud." Long-time patients and employees appreciate the practice's firm insistence on decorum. In fact, the Marty Test has become so well known in South Florida that physicians in other practices sometimes call Sturtz in the midst of their own patient battles.

"They'll say, 'I've got a patient in my waiting room yelling and screaming. What do we do? How do they pass the Marty Test?'" she says. "I end up getting on the phone with their office managers."

Most physicians have from time to time dropped patients for behavioral reasons. You shouldn't feel guilty about that as long as you've made an honest attempt to make the relationship work, have followed the rules concerning patient-dropping  and have judged the patient fairly, using your own Marty Test.

Get some help

Just as you would never deny a sick patient access to the appropriate medical care, you shouldn't forget the vast resources usually available to you in managing a difficult patient. You can and should enlist the aid of others; doing so is the Bayer Institute's idea of extending the system, the E in its ADOBE.

Once you've come to an understanding about the nature of their problem, you should have a pretty good sense of which parties are most appropriate to call upon. It might be a family member, a social worker, a substance abuse center, or another physician.

It may even be law enforcement.

When Rey Patterson and his colleagues struggled to understand what was wrong with a baby whose parents reported episodic dyspnea, the child's father threatened Patterson with violence: "He said if anything happened to his kid, he'd find me and whale me with a tire iron or worse."

By the time of the confrontation, Patterson had already contacted child protective services - the parents had brought the child in several times, each time saying he'd stopped breathing and had turned blue, yet when the doctors examined him they could find nothing wrong; they had no choice but to consider the possibility of abuse - so Patterson's relationship with the father was already strained.

Nevertheless, he was able to talk the father down, and the child's ailment was discovered shortly thereafter - he was missing part of three tracheal rings, for which he had surgery - so it ended well. But in a similar situation, you might be wise to call the police.

Give yourself a break

The corollary to some patients' delusion that doctors can fix anything with a prescription is the physician's own conceit that any patient whose medical condition isn't particularly serious can be "fixed." Some patients' personality traits are such that the ADOBE steps will take you only so far. They will always be difficult; the best you can do is manage them. Don't beat yourself up over that.
What are such people really looking for?

"If I had to use one word, I'd say 'magic,'" says Robert Gillette, a semiretired family physician in Rootstown, Ohio, and a professor at the Northeast Ohio Universities College of Medicine. "They're looking for something that isn't going to happen. One wants to get her mother-in-law off her back, another wants to get her daughter unpregnant, and yet another wants to get out from under a lifelong sense of inadequacy.

"Physicians are accustomed to solving problems, but in this case the problem may be something you can't solve. And so you have to recognize early on that you aren't going to make everyone happy, and some of them are going to go elsewhere, and some of them are going to tell their friends what a bad doctor you are. ... A lot of physicians think their job is to please people, and you have to recognize that you can't please everybody."

Bob Keaveney, editor for Physicians Practice, can be reached at bkeaveney@physicianspractice.com.

This article originally appeared in the February 2004 issue of Physicians Practice.