5 rules for managing tough patients

Ms. Ferrell was a difficult patient.

I took a deep breath as I entered her room. She'd been admitted for abdominal pain and vomiting, but the workup over the past two days had been negative. By now, I doubted there was any point in keeping her in the hospital. But I knew she would resist leaving. Her history was littered with ED visits for similar complaints. She had even been admitted a month ago for the same complaint; the workup had been negative then, too.

So I walked into the room with the biggest smile I could muster. After I greeted her and explained that we'd found nothing during the workup, I stopped and listened. Ms. Ferrell told me that she did have pain, especially after eating. She had even vomited her breakfast. Then, the patient-who seemed the picture of rationality and intelligence-went on to describe "parasites" under her skin that came out at night to leave trails on her. I did nothing to dissuade this apparent delusion. "Something is wrong with me!" she insisted, and I agreed.

I had no evidence that Ms. Ferrell was malingering; she probably had a somatization disorder. By this time, I had talked to the social worker who detailed utter chaos in the patient's personal life. Apparently, her last admission had come on the heels of an acute problem at home. This admission seemed to be following the same pattern.

I sent her home with recommendations to see her primary doctor and to seek a chronic pain specialist.

Difficult patients are difficult not because they're a medical mystery, but because they challenge our psychic defenses, stretch our tolerance and patience, or demand much more of our time than we can give. But it is possible to care for these challenging patients-if you know how. Here are the five rules I've developed:

RULE 1

Know yourself. Taking on a difficult patient can spiral into a battle of wills and wits that you're destined to lose. That's why it's necessary to understand your own limitations and personality. You have to manage your emotions: Be as professional and calm as possible, regardless of what your patient says or does.

This isn't to suggest that emotion is bad; it's necessary to care for the human being in front of you and to create a therapeutic relationship. But you need to avoid emotion that clouds your judgment and over-personalizes your interaction with the patient. This takes practice and a willingness to learn from mistakes.

RULE 2

Know the patient. Knowing the medical and psychiatric history of the patient is the bare minimum. You have to understand the patient's past patterns of behavior in order to ascertain future behavior.

Most difficult patients fit one or more of the following personality types:

These complaints need to be addressed head-on once organic conditions have been ruled out. Multiple ED visits for headache, chest pain, or abdominal pain may signal an underlying psychosocial problem that can be best addressed with the help of a psychiatric professional or chronic pain specialist.