Friday, April 6, 2007

Difficult doctors, difficult patients

Most professions have their share of built in code-speak, and medicine is no exception. Those little phrases that sound like one thing but mean another, if you linger in the hallways of a medical office or hospital for any length of time you'll hear them floating down the corridor. One of the most fascinating phrases in medical code-speak is the 'difficult patient'. The medical noviate might easily be excused for thinking a difficult patient would be one with multiple complex diseases. Indeed, while that patient may indeed be complicated, they are usually not what medical jargon would describe as difficult.

I first encountered the term as a medical trainee. Dr. J., my preceptor of the day would say, be careful in there. This one's a difficult patient. With the sage words of warning in hand, I'd cautiously open the door to the exam room and peek inside. Even though I'd been warned, I never knew what I'd encounter on the other side. Sometimes the patient on the other side was angry, sometimes demanding, sometimes threatening to sue. Sometimes, however, it was hard to figure out why the patient was supposed to be difficult at all. The term difficult patient seemed to me to lack precision, so I started thinking about what it actually meant.

Patients who demand narcotics often obtain a label of difficult (often in bold red letters on the front of a chart), and these patients comprised much of my early exposure to the 'difficult' crowd. At first I thought the term might mean 'any patient who makes me angry', and many of the so described patients did seem to push the buttons of the people applying the descriptor.

As I progressed in my training I ran into other groups of 'difficult patients'. One group had the special code name 'non-compliant'. Sometimes I would peek around the door to see a nice little old lady with diabetes. How are your sugars?, I'd ask. Oh they're fine, don't worry too much about me. I brought you all some cookies today!, she'd reply. Are you doing okay with your pills? Well, I don't always take them because I feel good most of the time. Pleasent as apple pie, and not taking any of her doctors advice, I was forced to expand the definition to 'any patient who makes me angry or doesn't do what I say'.

Still, there were more 'difficult patients' to come. In fact there was a whole othe group of patients who were perportedly difficult, and required forewarning. For this group of patients the preceptor of the day would pull me aside and say This is a difficult one! They have such and such diagnosis, and we've tried everything. The diagnoses in question were a short list: Chronic pain syndrome, fibromyalgia, irritible bowel syndrome, dysthymia and chronic fatigue syndrome some of the most common. And so, the definition expanded again to 'any patient who makes me angry or doesn't do what I say, or who I can't fix'.

The final group of 'difficult' patients the group many of my preceptors seemed to fear the most. These were the patients in whom the presenting complaint was vague enough or subjective enough that there was no clear path of medical action. And the definition expanded again.

By the end of my medical training 'difficult patient' had come to mean 'any patient who makes me angry or doesn't do what I say, or who I can't fix, or who I don't even know what to do with'. As you might imagine such a wide definition lead to a lot of difficult patients, and a lot of stressed out doctors. As a resident some of the offices I worked in seemed to have labled half of their patients as difficult in some way or another, and the doctors working in them seemed to be nearly pulling their hair out with the stress of it.

Now I'll admit up front that for whatever reason I have a certain fondness for some of these 'difficult' folks, but as I finished up residency I gave some serious thought to why these patients were considered difficult, and what I could do in my own practice to preserve my own (already thinning) hair. If you boil it all down to it's essence it seems that all of these so called difficult patients fall into 2 groups: patients who are in some form of conflict with their doctor, and patients for whom the doctor has no idea what to do with. For each of these situations I've tried to use a few simple stratagies to keep from getting stressed out.

Some degree of conflict is unavoidable, but conflict itself is manageble (although doctors tend to be a highly conflict averse group...that could take up a whole other post). The most important point in conflict management is that it takes 2 sides to really have any conflict worth writing home about. So if an issue is really not that important I don't join the conflict at all. I've found that there are a few easy things that I can do to make almost all of my encounters with so called 'difficult patients' actually very pleasent.
  • Let the patient have their say. If I think a patient is angry because they feel unheard I try (and it's hard) to keep my mouth shut for 5 minutes and listen to their story. Usually the story is over in 2 minutes, and the frustration on both sides decreases.
  • I give my best treatment options to the patient, but I don't take it personally if my patients choose a different path.
  • I apologize when I have inconvinienced my patients, and I empathize when my patients are inconvinienced by things beyond my control.
  • When I don't know the answer I say "I don't know the answer".
  • I try to have a non-medical conversation with my patients on the way to and from the waiting room.

In the end I think some of my patients probably think I am a little simple, but for the most part I seem to have avoided much of the stress in practice that seemed so ubiquitous to me as a medical trainee. Sure my hair is a little thinner than it used to be, but I think that's mostly a matter of genetics, and I'm back to thinking of 'difficult patients' as the ones with 10 different diseases at the same time.


Professor Howdy said...


If I could speak in any
language in heaven or
on earth but didn't love
others, I would only be
making meaningless noise
like a loud gong or a
clanging cymbal. If I
had the gift of prophecy,
and if I knew all the
mysteries of the future
and knew everything
about everything, but
didn't love others, what
good would I be? And
if I had the gift of faith
so that I could speak
to a mountain and make
it move, without love
I would be no good to
anybody. If I gave
everything I have to
the poor and even
sacrificed my body,
I could boast about it;
but if I didn't love others,
I would be of no value
whatsoever. Love is
patient and kind. Love
is not jealous or boastful
or proud or rude. Love
does not demand its
own way. Love is not
irritable, and it keeps
no record of when it
has been wronged.
It is never glad about
injustice but rejoices
whenever the truth
wins out. Love never
gives up, never loses
faith, is always hopeful,
and endures through
every circumstance.

May You Always
Experience This
Kind Of Love,
Dr. Howdy

Nancy said...

Hey, I hope you do a post sometime about doctors being conflict adverse! As a nurse, it has driven me crazy thru the years when a doctor firmly, adamantly, insists up and down that we have to follow a certain approach with a patient, the nurses go in and do battle as directed (within ethical and consent limits of course), but if the patient ever says something to the doc directly, they usually meekly say "oh, OK then" and does whatever the patient wanted in the first place.

I'll be interested to hear what you have to say about Inuvik, I've never been there but will be in one of the Beaufort-Delta communities in late May. The weather up that way is better that time of year than it is in Baffin, I'm looking forward to it.

Xavier Emmanuelle said...

Interesting post. Where I used to work the "difficult clients" (and the ones that were often the hardest to manage) were the hypochondriacs who were in the office weekly (or so it seemed).

Dr. J. said...

Xavier: I agree that that is also a difficult problem. One line I like to use with these folks is 'It seems like you have been through a lot of medical tests and procedures, but they haven't helped much. Do you think we should be approaching things from a different angle?'
Sometimes that helps shift focus, sometimes it really backfires. I think many times these over-medicalized folks are part of a cultural shift to FAST, EASY, and CHEAP cures for all that ails you...often with no real benefit.
Another issue I see frequently in family practice are folks walking around with bad diagnoses....the issue of undiagnosis is challenging and not for the faint hearted!
...perhaps more in a later post...

Faustino Perez said...

I am very interested in heartsink patients (and heartsink doctors too). In fact, I am Spanish Gynecologist and I will do a presentation at the next Spanish Congress of Gynecology in Granada. Your views about medicine are very peculiar and I included your blog in our GineBlog links (

Best regards