How to Work with Difficult Patients

By Brian Wu, MD, PhD

Difficult patients are an inevitable part of medical practice, but knowing what to expect can help make these interactions more productive and positive.

As a doctor, you know that the potential challenges standing between you and positive outcomes for your patients are many. You also know that sometimes one of those challenges is your patients themselves, especially when they behave in ways that make your interactions difficult.

A study published in Academic Medicine found that students, residents and new physicians were most likely to identify patients as “difficult.” The researchers concluded that this is because certain patients and situations present particular challenges to those still learning. Specifically, so-called difficult patients may:

• Hinder your ability to perform well, especially in front of others
• Frustrate your expectations about patient care
• Require tools or authority you don’t yet have

Even if you’re further along in your career and these factors don’t apply, challenging patients are an inevitable part of medical practice, which means it’s important to know how to approach and mitigate these encounters. Here’s a look at the types of difficult patients you’re likely to come across in residency and beyond, as well as some advice for making the time you spend with them more productive.

4 Kinds of Difficult Patients

Among the various patient types described by a paper in Psychosomatic Medicine and General Practice (PMGP), it’s wise to prepare for the following four.

1. Angry Patients

What to Expect

Angry or combative patients are generally easy to spot: They frequently present nonverbal cues such as clenched fists, drawn eyebrows, crossed arms or altered breathing patterns. Verbally, these patients may be belittling, demanding or accusatory. They may feel angry due to internal factors, such as mental illness, depression or pain, or external factors, such as not receiving as much analgesic or as many services as they believe they are entitled to.

What to Do

Stay calm, but don’t hesitate to ask for assistance if you believe the patient may harm others or themselves. “Clinical Methods” recommends techniques such as reflection (communicating to the patient that you have heard them) and legitimation (communicating to the patient that you understand where they are coming from) to help you improve the doctor-patient encounter.

2. Manipulative Patients

What to Expect

Manipulative patients often play on your feelings of guilt or other emotions in order to get what they want. Specific behaviors may include threats of rage or of harm to themselves or others if their demands are not met. Manipulative behavior can sometimes be hard to distinguish from a personality disorder.

What to Do

Be aware of your own emotional state and weaknesses. Setting firm boundaries in the doctor-patient relationship and knowing how and when to say “no” is essential with this population.

3. Hypochondriacal Patients

What to Expect

Hypochondriacal patients may complain of chronic, vague symptoms without any definite diagnosis to explain them. The PMGP paper notes these patients may have a history of frequently changing doctors and of undergoing multiple diagnostic tests. Moreover, these patients may have comorbidities such as anxiety, depression or personality disorders. If the patient has anxiety, they may seem distracted, ill at ease, tense or difficult to communicate with.

What to Do

The PMGP paper advises that you address the issue of “doctor shopping” at the outset of the relationship. It can be helpful for you to make a plan with the patient to see them once a month or so for reassurance, but refrain from testing unless it becomes necessary. Managing the comorbidities often present in this particular population is also important.

4. Grieving Patients

What to Expect

Patients experiencing grief or sadness may present nonverbal signs such as a drawn facial expression, tears or emotional withdrawal or avoidance. They may feel this way for a number of reasons, such as a loss of health, independence or a loved one.

What to Do

Comforting a grieving patient can be challenging. “Clinical Methods” recommends reflection and legitimation as well as seeking partnership with the patient (working together as a team to help solve a particular problem) and showing respect for the patient (commenting on what they’re doing well).

General Advice for Challenging Patient Encounters

No matter what type of difficult patient you’re working with, developing the following three habits will help strengthen your relationship with them.

Show Empathy

Expressing empathy for your patients can defuse a situation before it gets out of hand. Let them know that you’re listening and that you respect their feelings (even if you don’t necessarily agree with them). This assurance alone can improve an encounter.

Give Support

While this may seem obvious, giving your patients emotional and not just medical support is an integral part of providing care. “Clinical Methods” suggests that you be explicit about this when communicating with patients. Saying something as simple as “I’m going to do what I can to try to help you” can greatly improve a patient’s experience.

Keep Your Patients’ History in Mind

There are many conditions, including psychiatric issues, dementia, traumatic brain injuries and substance use disorders, that can cause irrational or overly emotional behavior. It can help you to view patient behavior in light of a diagnosis rather than taking it personally.

While you can’t control how the next patient who walks in may feel or act, you can control how you handle the encounter. By thoughtfully listening to your patients’ concerns, showing that you understand and working together to find a solution, you can improve the experience for everyone involved.