What to do with the difficult patient

These thoughts were inspired by “The Burden of Difficult Encounters in Primary Care” in the February 23rd Archives of Internal Medicine.

Since the subject surfaced in the 1990s, it has been repeatedly demonstrated that physicians of all specialties find 1 in 6 patient visits to be “difficult” (synonyms: “heartsink” and “black hole” in British literature, and “problem,” “disliked,” “frustrating,” “troublesome” or “hateful” in America).

But you know the type.

Over the years it has increasingly been recognized that this is not all the patient’s fault. The doctor plays a role, too. This article indicates that it’s a pretty big role. That’s good news, because there’s not much we can do to change anyone except ourselves.

Subspecialists have a much higher percentage of difficult encounters than general internists or family physicians. No surprise there. If you can’t handle long-term relationships, with all the attendant conflicts, choose work at the other end of a colonoscope.

The interesting thing about this survey of 423 primary care physicians is how they stratify. For instance, 41 “low difficulty” physicians were characterized by “an almost complete and unanimous indication of no perceived difficulty with patients they saw.”

On the other end, 113 “high difficulty” docs “had  almost complete and unanimous indication of working with difficult patients.”  

Obviously, it’s not the patients.

When I read the accompanying editorial, and before finding that 10 percent of primary care physicians experienced virtually no obnoxious patients, I was thinking, “I am either in denial or really weird.”  Now I know that I have a little company.

The question is, can “we few, we happy few, we band of brothers” recruit converts from the rest of the profession?

Hints: We happy few averaged 46 years of age, while les miserables averaged 41. So hang in there another five years; there’s hope. And 50 percent of les miserables were women, compared to 27 percent in the “low difficulty” group. Somehow I don’t think a sex change operation would solve this problem.

Ethnic/racial and work status (full- or part-time) didn’t seem to make a difference. High-difficulty docs are 12 times more likely to experience burnout than low-difficulty types. No surprise there, either.

The authors duck hypotheses for the dramatic gender differences but offer two explanations for the effects of experience, one of which seems reasonable to me.

One is that older physicians have developed coping mechanisms to mitigate the difficulty. For me, one of these mechanisms is simply “tincture of time.”

I have so few perceived difficult patients in my practice that they come immediately to mind. One is a distinguished looking lady who is never, ever satisfied with the care she receives; yet she comes back for more. Recently I received the usual humane and thorough referral letter from the Mayo Clinic, which is my Golden Turf. The office staff laughed out loud as we read the author’s exquisitely phrased note, which said, between the lines, “Boy, I’m glad she’s going back to Kansas! She wore me out.”

That makes me feel better. Mayo can’t stand her, either. So we’ll just hang on and do our duty.

Another is a woman so severe-looking, with every facial line pointing toward her toes and a voice to match, that she invokes Alexander Theroux’s classic description: “Her piss would etch glass.”  Since I found a huge ovarian tumor on a database physical visit she had long resisted, we have achieved rapprochement. In repayment for saving her life, she occasionally blesses us with a smile.

A smile from her is better than a slap on the back from anyone else.

Another effect of time is that the better I know a patient, the easier each encounter becomes – both professionally and personally. My world-class hypochondriac, after 20 years of relationship, now opens every encounter with, “I know you’re going to think I’m crazy, but … .” And I do, and she knows I do, and we get along just fine. She now believes my reassurances, sort of.

A second factor raised by the authors is “self-selection” on the part of patients. This doesn’t make any sense, unless they mean that disagreeable patients seek out disagreeable doctors. Here’s what does make sense: If I kindly but persistently refuse to meet the unreasonable demands of a difficult patient, either he will learn to behave or leave my practice. This is a win-win for me, and a win-lose for him. Three out of four ain’t bad.

Or it could mean this: I once gave one of my best friends the heave-ho from my practice. He was sweet as pie to me, but an absolute jerk to my staff. I don’t like “respecters of persons,” to quote St. Paul. After two warnings, he got walking papers. My staff learned that I stood behind them, even when it cost me personal pain.

My advice for all you whippersnappers is to give private practice at least a decade before throwing in the towel. But you’ve got to work at it. If you don’t, at some level, love the knuckleheads in your practice, bail early. I’d suggest anesthesia or pathology.

The authors suggest additional training in the biopsychosocial arts, or counseling, but I’m not sanguine about those. Part of it is having the right personality (maybe part of that is having the right religion), and the other part is motivation and will to fix what’s wrong in your attitude and your practice. That comes from within, not without.

Posted at 11:31AM Jul 20, 2009 by Doug Iliff  |  Comments[1]