A Patient Can Never Be Difficult

“There are no difficult patients; only patients with difficult problems.” I learned this mantra from a colleague and have used it to help shape my practice for quite some time now.

A few recent comments online about “difficult patients” have bothered me. When I tweeted a similar quote the other day, one person on Twitter insinuated that I was naive to say this.  One medical website even has a subsection under “Patient Relations” called “Difficult Patients”. Kevin Pho blogged about a similar issue recently, as has Dr. Maria Yang.  My take is somewhat different, but the basic premise is the same.

This is by no means a naive philosophy.  The simple statement can be applied in every situation.  The concept of a “difficult” patient is, well, difficult to comprehend.  In whose mind is the patient difficult?  Invariably, in the treating physician’s mind, but like many things in medicine, the concept can have different meanings for different observers.

Kevin Pho’s post referred to a study by Hinchey and Jackson published this month in Journal of General Internal Medicine, that explored both patient and physician factors in situations where patients are considered “difficult”.  You may have your own ideas of what makes a patient “difficult” that are not addressed exactly in this article.

Instead of considering the patient “difficult” in the first place, I would suggest another approach when faced with such a patient:

Try to understand what is driving the behavior or the situation that makes the patient seem difficult.

I couldn’t possibly list all of the possible reasons that might make a patient seem difficult, but here are a few options to consider:

  • The behavior that you consider difficult is patterned from early life experiences
  • The patient is worried about a serious problem but hasn’t told you
  • The patient doesn’t feel “listened to” by the healthcare system or other doctors (or you!)

There are innumerable other reasons I’m sure you could come up with. However, ultimately the underlying reasons for the “difficulty” are usually not things that the patient can control without external assistance.  Even in the unusual situation of Munchausen syndrome, in which patients harm themselves for secondary gain, there is a significant underlying disorder that warrants discussion and treatment.

Next time you are faced with a patient you find “difficult”, try considering why you are feeling that way, and explore what the driving force behind the patient’s situation might be.  You will open up the relationship with your patient and hopefully improve your patient’s outcome.

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About Ryan Madanick, MD

I am a gastroenterologist at the University of North Carolina School of Medicine, and the Vice-Chief for education in the Division of GI & Hepatology . I specialize in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD. I can be followed on Twitter: @RyanMadanickMD (he/him)
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12 Responses to A Patient Can Never Be Difficult

  1. Great points about a touchy subject for many physicians. Early in training and practice, one may identify lots of difficult patients. Later in one’s career, they seem to disappear, because the physician has expanded their skills and knowledge. The master knows more dance steps than the neophyte.
    Thanks for a timely eye opener to your profession. Blog On!
    Pat Jonas, MD, ABFM

  2. Brenda says:

    As one of those “difficult patients” — and for physicians in the hospital where you work, no less! — I very much appreciate your message, here. In particular, your observation that some patient behaviors may be patterned from early life experiences is spot on. In my case, I have a whopping case of medical PTSD stemming from a traumatic six-week medical encounter when I was 5 years old.

    I’d like to see you say more about how physicians can cope in such circumstances. Medical trauma, when it is uncovered and recognized, takes quite a bit of time for the patient to try to resolve. What is a physician to do, in the meantime, when on-going doctor-patient engagements are a must? Aren’t such patients too time-consuming? And don’t you, as a physician, get tired of having to constantly try to understand and work around the patient’s fears and inabilitly to just relax and trust all to you?

    Yes. I am getting help to try to overcome my PTSD. But that’s *my* long-term process. Insofar as I need quite a bit of on-going medical attention from physicians, now, it becomes my doctors’ long-term process, too. How can they cope, without throwing their hands up in the air and walking away?

    Identifying the problem is one thing. Knowing how to address it on a long-term basis is another. What works for you?

    • Brenda, perhaps you have hit on the biggest issue of them all, which ultimately gets at why physicians tend to call certain patients “difficult”: because we do not have the background and expertise to deal with their problems.

      In such situations, if it is beyond my expertise to deal with, I ask for assistance and consultation with someone who has a better understanding of how to deal with patients who have the difficult issue.

      IMHO, the key to addressing the issues ultimately stems from open communication and empathy. Listen to the patient; listen to what they are saying, and more importantly, what they are not.

      • Brenda says:

        That communication thing is a tall, tall order. But I’m sure you are correct. May I offer an observation about communication and empathy, from a patient point of view?

        You doctors and nurses inhabit a different cognitive world than we patients do. Through long years of training and then more years of clinical practice, you come to understand reality differently. The result is that certain things come to seem normal to you and define reality for you — things that you take for granted as true or obvious and never blink an eyelash over. They are as taken-for-granted by you as the air you breathe.

        However, these things are not at all normal, true or obvious within the context of a patient’s non-medical reality. When we become patients, especially if our health conditions are very serious and involved, we are thrust into your reality, ready or not, like it or not. It is disorienting in the extreme. Frightening. It’s like waking up on Mars and having to try to figure out really quickly how to get along there, because your welfare (maybe even your life) depends upon it.

        It would be very helpful to patients — especially the difficult ones! — if doctors could learn how to walk out of the medical reality they know so well and join the patient in his or her own reality, sit with the patient in their reality, acknowledge their reality, honor and value it, and then, all in good time, gently take the patient’s hand and help them walk more carefully and surely into the frightening new medical reality that they must now live within.

        Don’t expect the difficult patient to jump quickly into your reality and figure it out with the benefit of a few pro-forma reassurances from you, sitting on high within your medical specialty. They are too disoriented and sometimes too frightened. They don’t know which way to turn. You must go to them, join them in their reality, cry with them, rant and rave with them, honor their fears, and then gently lead them to the cognitive and emotional place where you know they need to be in order for treatment to move forward.

        The words you use will be important, in trying to do this. You have to realize that even though you and the patient may appear to speak the same language because you use the same words…often you don’t speak the same language at all. You have probably forgotten this, but when you were trained in how to work in the medical reality, you were taught to use common words in new and unique ways. Ways that may sound like gibberish or double-talk to the patient.

        For instance, “survival” in everyday parlance and “survival” in medical-speak don’t mean the same thing or have the same connotations. So before you have a discussion with a patient who asks about their survival, you might want to check into what the patient means by “survival” and compare that to how the term is usually used in the medical reality. Otherwise, the two of you are more likely to miscommunicate than you are to reach mutual understanding and have a shared framework for decision-making.

        In the end, it’s the human touch that matters the most. I treasure the memory of the medical student who cried with me, the nurse who took the time to get me a sandwich rather than letting me go hungry or sending a subordinate to do it, the physician who tried to answer my many questions and finally said, “Look, Brenda, I’m really sorry this has happened to you.” When he said that, it’s like all of my questions and anxieties just dissolved into a little puddle at my feet.

        Speaking for all difficult patients out there, I’m really sorry that we can be so high-demand. (Sometimes it’s not much fun for us, either.) But I’m really grateful for the caregivers who rise to the occasion, again and again, to try to help us, despite it all.

  3. Ryan, you definitely touch on a pet peave of mine as well. In my research I found that most of the “difficult patients” are patients who have been through significant, and oftentimes unpleasant, journeys of finding the healthcare information they seek. There is a substantial amount of misinformation about diseases, treatments available, and how to find the most qualified physicians in specific treatment algorithms.

    Most of my colleagues spend considerable time every day answering questions patients have about the advertisements they see on TV, the information they get from forums where patients share their experiences, and from health information articles written by non-medical personnel.

    I definitely think it’s time for physicians to regain their reputations as the primary, most reliable, and most trustworthy source of information – but unless doctors establish their online presence, the amount of misinformation will keep growing and they will continue to see more of the “difficult patients.”

    In the meantime, listen to Ryan’s advice – “explore what the driving force behind the patient’s situation might be. You will open up the relationship with your patient and hopefully improve your patient’s outcome. “

  4. I’ve caring for an elderly family member who recently underwent surgery to replace a stenoic aortic valve. He was “promised” by his PCP of 30 yrs and cardiologist of 10 years “oh, this surgery is routine now. 5 days and you are back at home.” My gut feeling was this kind of language was misleading at best. The technical aspects of this surgery are quite well worked out; the recovery aspects are not, and recovery of this 83-year-old patient has been anything but smooth. Nobody told him that he was “high-risk” merely because of his age. That should have been brought up in conversations about the surgery; and the possible consequences of being a high-risk patient should have been addressed. Four months after surgery we are just now, tenuously, off the vent. My relative has expressed a deep sense of abandonment by his PCP and cardiologist. He wants to know why those doctors who so glibly recommended this surgery are nowhere to be found now–not so much as a visit. And secondly more frustrating to me, I have seen undergraduates in my 8:00 am genetics class show more initiative, intellectual curiosity, and motivation after a night of drunken debauchery than some of the doctors and nurses at the various facilities to which we have been shipped during this process–all of which market themselves as the places to be for high-quality, patient center healthcare. Perhaps it’s not the patients (or the family members), or even the doctors and nurses, who are difficult. Perhaps it’s a system that relies on contract labor to deliver something we call healthcare, that in many ways completely lacks an ethic of care and doesn’t seem to be geared toward promoting physical, mental or emotional health. Perhaps that’s what is really difficult.

  5. Stephan says:

    Hey I recognize that comment. One thing I’ll add is that viewing the problem as difficult instead of the patient gives both physician and patient common ground to tackle. It sets the stage for collaborative rather than combative helping.
    Great post Dr. M. It’s a message that isn’t out there enough.

  6. As one of the people who was using the term “difficult” (and being a patient who represents patients, no less!) I’ll have an alternative viewpoint.

    First – I agree with most of your post, Ryan. I laud you for your perspective and your suggestions. If you read the articles I wrote at Physician’s Practice about dealing with difficult patients, then you know that you and I share a point of view on this, even if you don’t like how the word “difficult” was being used.

    However – I think there is “difficult” – and then there is “difficult.”

    It’s entirely possible that when your mentor told you, “There are no difficult patients; only patients with difficult problems” he was not referring to behavior problems. He was talking about dealing with mysterious symptoms or dire diagnoses or strange side effects.

    That’s very different from difficult behavior problems – and no matter what the reasons, no matter how understanding you might be, I believe patients CAN be difficult. When they are upset and make a scene in your waiting room — no matter WHAT the reason – they are being difficult. When they won’t comply with an agreed-upon treatment for no good reason, but still expect you to somehow magically fix things for them, then they are being difficult! They are difficult when they don’t take responsibility and expect you to take up the slack.

    That’s certainly not intended to discount the merits of figuring out what the problems are that make them behave in ways that create problems – it’s just a recognition of behavioral reality. In all these cases, the term “difficult” is an adjective that is entirely accurate. To your point, in all these cases, it’s worthwhile figuring out what makes them difficult then agreeing together on steps that can be taken to improve the situation. But it’s not always about figuring out what the underlying problem is with the patient.

    Some of us patients use the ability to be difficult to get what we need. It’s intentional. When I was left waiting in my PCP’s waiting room for 97 minutes, you can believe that I made myself intentionally difficult – otherwise I would likely still be sitting there. That has nothing to do with my life experience or unrecognized medical problems or not feeling listened to. It has to do with disrespect of my time. it can’t be fixed by understanding me better. I am sure you already understand that I don’t want to have to wait 97 minutes. It’s only going to be fixed by improving your appointment system.

    And until it’s fixed – I will remain difficult. That makes me (and other patients who feel disrespected) a difficult patient.

    • Thanks for your comment, Trisha.

      Believe it or not, his comment was actually directed specifically at the behaviors that physicians often call difficult. His point was to make sure I (as well as our trainees and colleagues) attempt to understand the reason that the perceived difficulty was occurring. In your situation, some docs could call you difficult because you were angry (rightfully). I would take the opposite approach, and say that the situation was difficult (long delay, plus your reaction to it, which is the way many people react, although some do not). Those of us who see you as difficult because you did that have lost the opportunity to address other issues. Some people that are considered really “difficult” are actually not understood fully, usually psychologically. I find it is more important to try to understand motivation than to label someone as difficult.

  7. This post reminded me of the other phrase frequently used when presenting the history: “The patient was uncooperative.” I know I’ve mentioned this to you before, Ryan; but for your blog readers, I’ll share again what my former chair Paul McHugh said to any psychiatry resident who used that phrase: “You mean, you were unable to win the patient’s cooperation.” Puts the onus of developing a therapeutic relationship back on the clinician, where it should be.

  8. Also, just remembered what a GI doc (sorry!) once described my husband in his outpatient medical record “Chronically-ill appearing man.” Actually, my husband is quite fit, he was just kept waiting TWO hours for his appointment and so was frustrated and tired!

  9. Kevin Nasky says:

    Lots of great points made both by post’s author and subsequent comments. However, difficult patients do exist. This might be a worthy read: http://www.psychresidentonline.com/NEJM%20Taking%20Care%20of%20the%20Hateful%20Patient.html

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