Navigating Difficult Patient Encounters

It's your last appointment of the day and you see that a patient has scheduled to be seen for sinusitis. You sigh, because you know this patient well. You know that a simple sinusitis is far from what you will encounter. You know that there will also be four or five other somatic complaints, the social history will reveal a new drama, the patient will admit noncompliance to recommendations from the last appointments. Finally, you know he will expect you to fix each of his new and old problems by the end of the 20-minute appointment. Every clinician has, no doubt, run into difficult patients. Here are 10 simple tips that may help you manage these challenging appointments while maintaining your professional integrity:

1. Remember, you are not the problem. It is easy to let the patient suck you into her perception that  you are the problem - because you won't prescribe the requested medication or meet some other unreasonable patient demand. Keep your professional perspective and realize that your decisions are in the patient's best interest.

2. Examine your own response to noncompliance. Many years ago, I realized it was my job to make sure patients understand the most current recommendations regarding lifestyle changes and medicines to control their various diseases. Whether they comply with the recommendations, on the other hand, is out of my control. I give kudos to patients who comply and partner with those who can't to figure out solutions to situations that prevent compliance, but I don't take it personally.

3. Be consistent. In the physician-patient power differential, your reactions to a patient's behaviors must follow a routine. If you disregard your own rules once, the patient will expect it every time. For example, if you never prescribe diet pills or short-acting benzodiazepines, don't give in to a patient's plea for "just this once."

4. Use active listening skills and resist your impulse to interrupt. If the patient feels that you really hear her, she is less likely to leave the visit feeling dissatisfied.

5. Consider underlying depression, anxiety, or substance abuse as a contributing diagnosis. Patients with a large number of somatic complaints might have an underlying psychiatric disorder, even though they are able to function well at work and home. If your patient meets screening criteria, might he benefit from pharmacologic treatment or counseling?

6. Find a trusted sounding board. Physicians are human, after all, and difficult patients can be frustrating. Another healthcare professional might be able to offer suggestions for coping with a specific patient behavior you find challenging.

7. Partner with your office manager to determine the amount of time you need for known difficult patients. Schedule challenging appointments realistically; giving yourself extra time. Remember, if you spend more time with the patient, you can bill a higher level E&M, which might ease the discomfort of the patient's neediness.

8. Above all, stay safe. If a patient is volatile, she might pose a danger to you or your staff. It is perfectly appropriate to call security or police if you feel the patient represents an imminent danger to anyone in your clinic.

9. Consider confronting the behavior. Sometimes a professional confrontation can be therapeutic. Before doing this, however, you may wish to refer the patient for counseling and you must ensure he is emotionally stable.

10. If you consistently "attract" difficult patients, you may wish to seek counseling for yourself. Transference and counter-transference can occur in all professional relationships, but if you experience more than your share then you might need to figure out why.

Sarah Parrott, DO, is an assistant professor of family medicine and division coordinator for communications at Kansas City University of Medicine and Biosciences in Kansas City, MO. She can be reached at sparrott@kcumb.edu.