Difficult Patients

Dr Faisal Al HadadConsultant of Family Medicine

&Occupational Health

PSMMC

Introduction

Difficult patient: the one with whom the physician has trouble forming an effective working relationship.

This term has become politically incorrect.

In one study, American doctors rated 15% of primary care patients as 'difficult'.

Types of Difficult Patients

Somatizing patient: patients who express personal distress in the form of somatic symptoms and refuse to believe that no organic disease is present.

Dependent clingers: are excessively dependent on the doctor, desperate for reassurance but will return continually with a new array of symptoms.

e.g. "Thank you, my back's much better but I've got chest pain now."

Types of difficult patients

Entitled demanders: Patients who make excessive demands by frequent visits, pressure for tests, medications or referrals. They are frequently complaining when every request is not met.

e.g. "I must see a specialist for my ingrowing toenail right now!"

Manipulative help-rejectors: continually return to the surgery to report that treatment failed. Where any symptom is relieved, it is rapidly replaced by another.

e.g. "None of the painkillers have helped my back, I'm allergic to

those other pills, Pain Clinic did nothing. You've got to help me!"

Types of difficult patients

Self-destructive deniers: whilst suffering from a potentially serious condition, will make no effort to alter their self-destructive behaviours.

Angry Patients

Seductive Patients

Grieving Patient

Risk factors

Risk factors related to the doctor:

Perception of high workload

Poor job satisfaction

Poorer postgraduate qualifications

lack of training in counseling and communication skills

Risk factors

Risk factors related to the patient:

Psychiatric disorders (particularly somatoform disorder, panic disorder, dysthymia, GAD, MDD and probable alcohol abuse or dependence)

Functional impairments

High use of health care

Lower satisfaction with care

Cues indicating difficult patient

A new patient who comes after leaving another physician and extravagant in his praise for you while expressing great hostility toward the former doctor ?Demander

Frequent visits for problems that never respond to treatment; persistent complaints of symptoms with repeatedly negative tests and unhelpful consultation ?Somatising

Disagreement over prescription drugs. The relationship with the doctor is good as long as they receive their prescription. The medications may be taken for a spurious diagnosis ?Dependent

Cues indicating difficult patient

Cues from our own feelings. When a patient evokes a feeling of anxiety, pressure, boredom, or frustration; or when we particularly want to please and impress a patient.

Breaking Bad News (BBN)

Dr Faisal Al Hadad

Case Discussion

Abdullah is a patient of yours who comes to see you one day with his wife Sharefa. Sharefa is also a patient of yours who was admitted to hospital for investigations for liver. The results of the liver biopsy showed a well differentiated hepatocellular carcinoma. This result had been disclosed to Abdullah only. He has come to you today asking for your assistance in telling his wife the results of her investigations.

How would you handle this situation?

Before Consultation

Ensure appropriate physical setting (quite and private consultation room)

Avoid interruptions during the consultation

Ensure enough time for the consultation

Be aware of the details of the patient and all necessary information

What information is to be conveyed and in what order?

Ensure family support during consultation

During consultation

Fire a warning shot then pause before going on

Find out how much the patient knows

Find out how much the patient wants to know

Clarify the information you are giving and check understanding.

Elicit the patient's concern

Honestly and accurately

During consultation

Effective communication skills: Clear language Eye contact Empathy Attentive listening Unhurried manner Body language Appropriate touch Appropriate use of silences Encourage patient to ask questions Summarizing

During consultation

Explanatory leaflets

Avoid unnecessary distress

Avoid overload patient with information

Leave the patient with an early follow-up plan and a realistic hope.

After consultation

Roger Neighbour (1987)Inner Consultation

Connecting 

Summarizing

Handing Over

Safety Netting

House Keeping

Thank you