Taming the difficult patient

Your colleagues share their secrets for defusing hostility, coaxing compliance, and allaying anxiety.

By Gail Garfinkel Weiss
Senior Editor

You were warned about them in med school: the patients who make threatening noises about lawsuits at the slightest provocation. The folks who know exactly what's wrong with them and how you should treat it. People who make you wonder why you didn't listen to Uncle Fred and become an actuary.

Yes—disagreeable, noncompliant, arrogant, and anxious patients come with the territory. But that doesn't mean you have to grit your teeth and put up with them. Most veteran physicians have developed ways of handling troublesome patients—although "handling" sometimes means showing hard-core irritants the door. So the next time you're on the receiving end of a patient's diatribe, don't get angry—get serious about determining what the trouble is and taking corrective action.

Here's a look at four patient "types" every primary care doctor will recognize, along with tips from your colleagues on how to deal with them.

The sour apple

Urologist Stephen Leslie of Lorain, OH, once sparred with a 65-year-old man who wanted a testosterone gel that had just been approved by the FDA. Leslie demurred, because he hadn't received official prescribing information, and no local pharmacy had the gel in stock anyway. With that, the patient erupted.

"He ranted and raved in the exam room and out in the hall," Leslie says. "He accused me of malpractice and threatened me with legal action, including letters to the state medical board and anywhere else he could think of. This was the only time in 19 years of practice that I had to call the police about an unruly patient. Fortunately, the man left before they arrived."

As Leslie acknowledges, experiences like the one he describes are atypical. Most irascible patients are open to reason, and will come around if you push the right buttons. For example, neurosurgeon Michael-Gerard Moncman of Altoona, PA, turned a cantankerous fellow into an ally by getting a staffer to run interference.

"He gave me a particular history, I operated on him, then he changed his history and sought care elsewhere while continuing to see me," Moncman says. "I learned that in treating this man and people like him, sometimes the best strategy is to figure out who in the office they best interact with and use that person as a buffer."

"So whenever this man called, we put his favorite staff member on the phone. That way, some of his hostility got defused and we were able to get through the situation very nicely. When all was said and done he admitted, grudgingly, that we had treated him well."

How is the intermediary selected? "Sometimes patients pick them for us," Moncman explains. "They'll call specifically to speak with a certain individual, or they'll express disappointment if someone is out of the office that day. When the intermediary isn't obvious, I may bring up a problem patient during a staff meeting and ask, 'Does anyone have a good relationship with this guy and can reach out and touch him better than I can?' Obviously, I bear ultimate responsibility for the relationship, but if I have someone who can intercede for me it's a big help."

E. Gene Burns Jr., a family practitioner in LaPlace, LA, sometimes wins over quarrelsome patients by agreeing with them on some point. One of Burns' patients was frustrated about having a procedure denied by an HMO. "Most patients in this position initially show their anger to the physician instead of the HMO," Burns says. "This man, however, was stunned and apologetic when I gave him a copy of a letter I had already sent to the HMO on his behalf."

The refusenik

San Francisco internist Gary G. Kardos remembers a 55-year-old auto mechanic who, upon meeting the doctor, barked, "Just give me a checkup so my wife will get off my back!" Kardos performed a complete physical, then referred the man for several screening tests.

"Two weeks later, I wrote him a letter reminding him to get the tests done," Kardos recalls. "He phoned to say he had no intention of comply ing because he felt fine. I countered that just as cars routinely get lube jobs and oil changes, people require preventive maintenance. Ultimately, he got the tests, which revealed a very high cholesterol level. It took me three months to get him to come in and discuss the matter, and another three months to convince him to change his diet, lose weight, and take medication.

"When he began treatment, I congratulated myself on finally getting through to him. But I must admit that I had some help: His wife threatened to divorce him if he didn't cooperate with me."

General practitioner Patricia L. Elliott of Rapidan, VA, brings resistant patients to heel by firmly cajoling them through procedures. For instance, when a brawny man balked at letting Elliott's nurses draw his blood because it "hurt too much," the doctor took over. "As I drew his blood, I did a lot of talking: exaggerated sympathy, exhortation, gentle kidding about how terrible it was, and the direct advice to stop complaining."

The know-it-all

The sign in Pottsville, PA, general practitioner Carl J. Forster's office reads, "A doctor's job is to give you what you need, not what you want."

Forster lives by that wisdom. When a 52-year-old, generally noncompliant, Type 2 diabetic wanted a cortisone injection to relieve hip pain, Forster said No. "I told him that routine cortisone injections might lead to destruction of the joint and the eventual need for hip replacement. After tests revealed mild arthritis, I recommen-ded physical therapy. But he still wanted cortisone.

"My response was that my recommendation is based on my evaluation and what I think is best for him, and if he feels I'm not meeting his needs, he can just let me know where he wants his medical records transferred" (see "To dismiss or not to dismiss?").

Baltimore FP Jeffrey Schultz also uses the "this is what I think is best" tool. According to Schultz, "It reframes the discussion into why I consider a course of action preferable—and finesses peripheral issues such as what the HMO will pay for or what the patient thought should happen."

Michael-Gerard Moncman offers this advice regarding patients who have their own ideas about their treatment: "Document, document, document." In the case of one noncompliant patient, Moncman instructed his staff to make a note of every contact they had with the man. "If, say, my staff spoke to him on the telephone," Moncman explains, "they would type a dated note: 'Spoke to Mr. So-and-so today at such and such time regarding these complaints.'

"If they had a discussion about this patient with me or if we took any action, that was added to the notes. Later, when he tried to sue me, the case got nowhere. I'm sure my documentation saved us."

The anxiety-ridden

"I have learned that, in almost every case, by demonstrating a willingness to listen and to let the patient talk, we can work out whatever it is he's concerned about," says radiation oncologist Dale E. Fuller of Dallas. "Humor helps, too," he adds.

Indeed, experts in patient relations maintain that one of the main reasons patients—particularly apprehensive patients—become unmanageable is that they feel they're not being heard. One way to turn things around, the experts recommend, is to give these patients regular appointments, whether they're sick or not. In many cases, just knowing they'll have talk time with you is therapeutic.

That's exactly what FP Scott Helmers of Sibley, IA, did when he treated a woman who had multiple physical complaints for which no organic cause could be found. "She came in every two weeks," he says. "I learned that if she got a chance to go through her list of symptoms, she'd be reassured and wouldn't feel the need to call the office quite so often or make more-frequent appointments."

Johnson City, TN, family physician Forrest Lang, who conducts CME courses on "Reaching common ground in difficult situations," insists that it's worth taking the time to find out how a disgruntled patient got that way. If, for instance, the patient says he's upset about having to sit a long time in the waiting room, Lang suggests that you apologize, offer a brief explanation, and move on: "I'm sorry we kept you waiting. An unexpected problem came up. But now you have my full attention. How can I help you today?"

In a best-case scenario, the patient who once made everyone cringe will become an office favorite—as happened with Scott Helmers' somatization syndrome patient. The woman continued to see Helmers for some 14 years, and when she died Helmers honored the last request she made of him: He sang at her funeral.

To dismiss or not to dismiss?

"It's absurd to expect a physician to relate positively to every patient, and it's futile to try. Therefore, when I started practicing, I reserved the right to 'fire' difficult patients, and gladly gave every patient the right to fire me. This has worked perfectly for more than 25 years," says Raleigh, NC, ophthalmologist David H. Jones.

FP Forrest Lang of Johnson, City, TN, has a different view. "When doctors dismiss somebody, it's usually because they haven't understood why the patient won't cooperate," he says. "The only patient I dismissed in the last 10 years was a man who lied to me. He took my prescription and altered it. So I realized I couldn't trust him. But that's different from dismissing someone for, say, not keeping appointments or not taking medication. To me, the physician's job is to help patients be compliant."

Internist Jeffrey M. Kagan of Newington, CT, tries to do that by, in effect, putting a problem patient on probation. He's been treating "George," a middle-aged man whose physical problems include diabetes, congestive heart failure, and morbid obesity. Not only does George miss appointments, call the office frequently, and disturb other patients while he's in the waiting room by roaring into his cell phone—he has threatened to sue Kagan, and he rarely takes medications or goes for tests without an argument.

"I'm planning to give him a written list of expectations—mostly common courtesies expected of all patients—that he must follow if he wants to continue receiving primary care in our office," Kagan says. "I'm sure it would be easier just to discharge him, but I feel I would be letting him down if I didn't try to mold his behavior into something more acceptable. The list will serve as a contract, and he'll be told that a violation will result in formal dismissal."

If, as a last resort, you send a patient packing, be careful not to step in any legal minefields. You'll need to provide at least 30 days' notice (via certified mail, return receipt requested), refer the patient to the appropriate medical society or hospital to obtain a list of physicians, and offer emergency care as needed. If the patient's in a managed care plan, read the contract carefully to determine the plan's discharge policy.

For additional information, see "How to cut loose from a troublesome patient," April 10, 2000.

Gail Weiss. Taming the difficult patient.

Medical Economics

2002;5:100.