Jul-Aug 2000 Table of Contents

‘Problem Patients’: A Fresh Look at an Old Vexation



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Every practice has at least one. Here's how to reduce irritation and improve outcomes.

Fam Pract Manag. 2000 Jul-Aug;7(7):57-62.

This content conforms to AAFP CME criteria. See FPM CME Quiz.

It was my good fortune to grow up with a father who was an old-school physician in the best sense of the word. Although he had many emotionally needful patients in his practice, I don't recall that he considered them “problem patients.” A small incident that occurred while I was growing up explains a lot about how my father approached patient care.

It is Sunday afternoon, and Dad and I are sitting in the living room. We hear a car in the driveway, a knock at the back door and then the voice of a neighbor conversing with my mother in the kitchen. The visitor's voice gets louder and more shrill as she talks about our cocker spaniel, saying how darling she is and how she just adores dogs. Dad listens for a minute, and then softly says, “She's afraid of dogs. Go put Greta in the basement.” I do so, and immediately the visitor's voice becomes softer and more relaxed.

My father was listening not only to what the woman was saying, but also to how she was saying it. Perceptive listening and insight into human nature are powerful tools that can help us understand our patients better and address their problems more effectively. This in turn makes patient care more pleasant and professionally rewarding.

KEY POINTS:

  • Problem patients often have special needs. Insight into human nature, perceptive listening skills and patience will aid physicians who care for them.

  • Problem patients' illnesses aren't curable in the traditional sense, so physicians shouldn't feel frustrated if, despite their best efforts, these patients make only limited improvement.

  • Visits that are short, frequent and focused will make problem patients feel cared for and understood and will help minimize the risk of burnout for physicians.

Understanding problem patients

Two basic concepts underlie our understanding of so-called problem patients. First, all humans have uncomfortable feelings. Our ability to tolerate them is influenced by our beliefs, emotional needs and external stressors. Somatic symptoms are more tolerable and have less impact when negative factors are under control and life is going well.

Second, some people perceive (usually unconsciously) that having symptoms serves a useful purpose for them. Such situations are seldom curable in the usual sense, since most problem patients are highly resistant to any form of insight-oriented counseling. Physicians should take a palliative approach and should not feel frustrated or guilty when their efforts fail to achieve a full recovery.

There are many terms used to identify a problem patient. “Difficult patient,” “thick-chart patient,” “hateful patient” and older pejorative terms such as “crock” and “gomer” are just a few examples. At the most superficial level, problem patients are defined by the feelings physicians have when they work with them. Frustration, uncertainty, anger and a feeling of being manipulated or controlled by the patient are common.

Another way to identify problem patients is by their behavior (see below). These patients also tend to be associated with a highly controversial and changing cluster of diagnoses that currently includes multiple chemical sensitivity and Gulf War syndrome.1

Typical problem-patient behaviors

Multiple symptoms involving multiple body systems

Vague and shifting complaints

Dependent, clinging behavior

Undue concern bout minor symptoms

Excessive preoccupation with physical disease

Poor response to usual methods of treatment

Hostile, demanding, dissatisfied

High utilization of health care services

Manipulative, exploitative, controlling

Seductive, sexually or otherwise

Unrealistic expectations of cure

Raises new problems as visit ends

Resistant to physician's recommendations

Noncompliant with treatment program

Difficult to communicate with

Rambling, unfocused

Self-destructive

A substantial body of research has linked problem-patient behavior to the psychological and social factors listed below. Some patients may require consultation with a mental health professional and psychometric testing. While a specific behavioral diagnosis can be helpful in guiding treatment (especially when deciding whether to aim for improved functioning or simple palliation), it's not necessary or practical in every situation.

Underlying psychological and social factors

Feelings of guilt, worthlessness, incompetence, shame

Loneliness, social isolation

Fear of abandonment

Life stress

Concern about personal safety: at home, on the street, other

Survivors of childhood abuse, sexual or other

Rational need for medical information or treatment

Somatoform disorders

Hypochondriasis

Personality disorders: dependent, obsessive or paranoid

Mood disorders: anxiety, panic, depression

Borderline personality disorder

Involvement with tort law or workers' compensation system

The other side of the coin

Evidence suggests that the “problems” do not lie exclusively with the patient. The American medical education system teaches a linear model of disease in which there is a sequence from symptoms to objective data to diagnosis to treatment and then to cure. Physicians who are educated in this system sometimes feel frustrated or guilty when this sequence breaks down, as it surely will when dealing with patients who don't want to get well.

The highly structured, often impersonal character of our medical facilities also tends to hinder the care of problem patients. Physicians in teaching clinics (as opposed to continuity-oriented primary care teaching practices) seldom have ongoing contact with patients, and increasing time pressures make it ever more difficult for the unhurried dialogue that's necessary to get to know patients as people. The inevitable result is that physicians trained in this milieu and new to practice are the ones most likely to perceive patients as “problems and to develop feelings of inadequacy and despondency when required to address multiple vague symptoms.”2 As they gain experience and confidence, they become more tolerant of people who do not meet their standard of rationality, and they also become more adept at persuading patients to forgo needless tests, consultations and treatments.

A practical approach for managing problem patients

The comprehensive strategy suggested in the following paragraphs may seem unduly burdensome, but experience has shown that it will save time, money and aggravation in the long term. Because each situation is unique, physicians must remain flexible; however, this approach will usually help produce favorable outcomes for patients.

1. Recognize problem behavior when it exists. An established patient may keep returning with ill-defined, fluctuating or otherwise problematic symptoms, or a new patient may offer a flood of complaints that suggest a behavioral cause. Either situation should alert the physician to the need for a comprehensive management approach.

2. Obtain the patient's perspective. There is often an understandable urge to cut a patient's “organ recital” short and finish the encounter as quickly as possible. Sometimes this is the only workable solution at an initial patient visit. If so, tell the patient that you want to spend more time evaluating him or her and ask your staff to schedule a follow-up appointment.

One way or another, there must be an opportunity for the patient to tell his or her story, with guidance and skillful questioning from the clinician. Ask about the illness and the patient's expectation about what should be done. Discuss what treatment has been prescribed in the past and the outcome. Ask the patient what he or she thinks is the cause of the illness, the prognosis and any perceived obstacles to improvement.

3. Take a structured history. This includes a general medical history and a psychosocial systems review. The latter is intended to elicit information about life stressors and the coping mechanisms and resources that the patient has available. Ask for the names of former physicians and the dates of and reasons for prior hospitalizations. A patient's reluctance to allow access to such reports may itself be a significant bit of data.

4. Do a routine physical examination and screening lab work. This will help to identify any coexisting biomedical problems and assure the patient that you care enough to do a thorough evaluation. Be sure to touch the part that hurts. It is usually unwise to start with a “megawork-up” to rule out any conceivable disease.

5. Complete any indicated testing promptly. Try to avoid falling into a pattern of ordering new tests and procedures each time the patient describes a new symptom.

6. Give the patient a timely report of your conclusions and plan. Acknowledge that the patient's symptoms are significant, and offer your willingness to work with him or her on a continuing basis. Give assurance (when you can with confidence) that the findings do not portend disability or represent a threat to life. Listen to be sure that the patient understands and accepts what you are saying.

7. Set limited objectives. Having symptoms may be an important part of a patient's life, and diligent efforts to abolish them can have unfortunate consequences such as depression, angry denial, hostile behavior toward physicians or others, self-destructive actions, or simply switching to another physician. A more gradual approach will minimize this risk and may gradually encourage patients to relinquish the role of sick patient.

8. Schedule regular visits. It may be necessary to schedule appointments as often as weekly at first, but the interval should gradually be extended to perhaps once a month. Patients who miss appointments should be called and asked to reschedule. Regular patient visits will accomplish the following objectives:

  • They make patients feel cared for and understood.

  • They address small concerns before they become overwhelming to the patient.

  • They may gradually (slowly!) lead the patient to more mature thought patterns.

  • They reduce or eliminate unnecessary telephone calls, tests, consultations, hospital admissions and visits to the emergency department.

9. Keep visits short and focused. Encourage your problem patients to write down their health concerns and bring their list to each visit. Have them mark with an asterisk the one or two items that concern them the most. Address these, and, unless you see one that concerns you, leave the others for another day. Your goal should be an average visit of no more than 10 minutes in length.

10. Touch the patient. Start the visit with a handshake. Do a brief heart and lung exam, even if you have done it a dozen times before. End the visit with a pat on the back and assurance that you want to see the patient again at the next scheduled time.

11. Give the patient something to do. Prescribe some form of regular exercise, even if it is only a daily 20-minute walk. You may want to suggest vitamins and dietary modifications. Encourage your patient to get involved in hobbies, religious activities, group trips and the like. Some hands-on therapies such as chiropractic or massotherapy can be tried, although there is little evidence that they have more than palliative value.

Having a pet can be therapeutic for people with limited social contact. A pet provides an emotional attachment and some purpose in life. A dog may be a good choice for people with adequate physical, mental and financial resources. A cat is quieter and needs less care than a dog, and may be preferable for some patients. Smaller pets such as gerbils, fish or birds have shorter life spans and offer less opportunity for emotional attachment. You may want to encourage your patient to consult with a veterinarian about selecting an animal of appropriate size and temperament.

12. Use medicines selectively. Pharmacotherapy is seldom central in the management of problem patients and should usually be de-emphasized; however, medication is often necessary for coexisting depression, panic disorder or other specific indications.

13. Work with family and friends. Ask family and friends for their views of the patient's problem. Listen for genuine concern that can be put to good use with some coaching. Listen for destructive attitudes that can undercut your best efforts, perpetuate invalidism, dependency or shame. Of course you should always get the patient's permission before approaching the family, and avoid any interaction that could be interpreted as going behind the patient's back.

14. Work with your colleagues and staff. Be sure they understand and support your philosophy and plan. They don't necessarily have to accede to all of the patient's requests, but they should be friendly and call the patient by name. Discourage the use of pejorative descriptors that can promote negative attitudes toward patients in your practice. Listen to the insights that your team members have after interacting with your patients. They may point out something you've overlooked. Let them share in the work of providing emotional support and the gratification that comes when effective care leads to healthier behavior. Finally, be sure that they understand and honor their absolute responsibility to respect the privacy of these patients.

Managing problem patients in urgent care settings

It will be nearly impossible for physicians who care for problem patients in emergency departments and urgent care settings to use the same approach as those in primary care offices. Typical obstacles in the urgent care setting include lack of focus on continuity or on psychosocial considerations, a perceived need for immediate ing, a strong focus on protection against medicolegal risks and a highly controlled, high-tech environment designed to meet the needs of seriously diseased and injured patients.

It is probably wise to recognize at the outset that problem patients cannot be managed well in these settings. The best approach may be to address their immediate needs, tell them that their ongoing problems need continuity-based care, and make appropriate recommendations and referrals. Other useful steps include the following:

  • Make sure administrative procedures are as “patient-friendly” as is practical to minimize patient anxiety, hostility and mistrust before the patient and the doctor meet.

  • Read all information about previous visits by the patient to the emergency department or to other units in the hospital. Your organization should make this information readily available to you.

  • Don't feel obligated to provide absolute symptom relief for conditions (e.g., recurrent headaches) that can be more properly addressed in an office setting.

  • If you prescribe habituating drugs, do so only in amounts that will last until the patient can be seen elsewhere.

  • Get involved in addressing institutional limitations that interfere with providing any of the aforementioned services.

Preventing problem behavior

Considering the enormous social and economic costs associated with the care of established, late-stage problem behavior, it is striking to note how little attention has been paid to preventing the disorder. A literature search will turn up some important contributions, but it's likely they haven't been widely read. [If you're interested in reading more on the subject, see the reading list.] Although the following recommendations have not been scientifically tested, they are consistent with published information and clinical experience:

  • Listen for evidence of excessive preoccupation with illness in parents and young adults, and try to steer them toward a healthier, more mature perspective on their health.

  • Try not to “medicalize” problems of living. Avoid repeated CT scans for chronic headache patients, hysterectomies for those with pelvic pain, back surgery for inadequate indications, etc.

  • Provide competent, continuity-based care for chronic diseases like asthma or diabetes so that patients and their families do not become overwhelmed with fear.

  • Work in the public arena to blunt the excesses of the workers' compensation and tort law systems.

The realities of managed care

In the tumultuous, rapidly changing American health care system, we often encounter substantial barriers to managing problem patients effectively. The situation brings to mind a poster I saw in a plumbing shop years ago:

If you can't find time to do it right, how will you find time to do it over?

It is as much in the interest of managed care organizations' as it is in ours and our patients' to manage these cases properly, and we should say so, loudly and clearly. However, I must leave to others any discussion of tactics that may help physicians receive fair compensation for doing the job right.

Ten useful coping skills for physicians

Caring for “problem patients” requires strong interpersonal skills, character and emotional maturity. The following list of skills represents an ideal that few physicians can fully achieve, but with self-understanding and practice most of us can come close enough to serve these patients well.

  1. Allow patients to vent their feelings. Listen long enough to show your empathy, but set practical time limits.

  2. Strengthen your communication skills. Remember that as a physician, you're also a teacher and a coach. Tailor your explanations and guidance to each patient's needs and ability to absorb information.

  3. Become a more effective history taker. Ask the patient what's been happening in his or her life. Ask about the course of the patient's symptoms over time. Answers to questions like these may give you insight into the significance the patient attaches to the symptoms. They may also provide you with clues about what the patient is skipping over or not saying.

  4. Try not to judge. Understand the difference between having high personal standards and trying to impose those standards on patients. View patients' disruptive actions as opportunities to learn more about their concerns, beliefs and needs.

  5. Remain calm and confident. Stay in control while working with patients who are angry, depressed, manipulative, seductive or overly dependent. Strong, self-confident professionals can tolerate such behavior; others cannot.

  6. Understand your own strengths and vulnerabilities. Know when to set limits on patients' demands in order to protect yourself from burnout.

  7. Be patient. The problem behaviors you see in patients have taken many years to develop, and human behavior seldom changes quickly.

  8. Be proactive. Cultivate the ability to move ahead with patient care in the face of incomplete diagnoses and complex psychosocial problems.

  9. Avoid becoming an enabler. It's unhealthy for a patient to be overly dependent on you. There is a proper dosage for empathy, just as there is for digoxin.

  10. Respect your patients. Protect patients' confidentiality, keep promises and show that you respect their feelings.

A final thought

You can seldom turn problem patients around completely, but a humane and thoughtful approach to their care can make their lives (and yours!) more comfortable. I can attest from personal experience that problem patients can become grateful patients and that you may come, in time, to enjoy caring for that same patient whose name on your appointment list once turned your stomach into knots.

Additional reading

Difficult Patient Encounters in the Ambulatory Clinic: Clinical Predictors and Outcomes. Jackson JL, Kroenke K. Archives of Internal Medicine. 1999;159:1069–1075.

Field Guide to the Difficult Patient Interview. Platt FW, Gordon GH. Philadelphia: Lippincott Williams & Wilkins; 1999.

Improving Patient Communication in No Time. Belzer EJ. FPM. May 1999:23–28.

Managing Somatic Preoccupation. Righter EL, Sansone RA. American Family Physician. 1999;59:3113–3120.

Somatization Reconsidered: Incorporating the Patient's Experience of Illness. Epstein RM, Quill TE, McWhinney IR. Archives of Internal Medicine. 1999;159:215–222.

Personality Disorders Among Difficult Patients. Schafer S, Nowlis DP. Archives of Family Medicine. 1998;7(2):126–129.

Using Common Sense With Difficult People. Flanagan L. FPM. January 1997:67.

The Difficult Patient: Prevalence, Psychopathology, and Functional Impairment. Hahn SR, Kroenke K, Spitzer RL, et al. Journal of General Internal Medicine. 1996;11(1):1–8.

Comprehensive Cost-effective Care of the Multiple Problem Patient. Gillette RD, Black DJ, Romaniuk M, et al. Journal of Family Practice. 1986;23(5):431–438.

The Cultural Meanings and Social Uses of Illness. Kleinman A. Journal of Family Practice. 1983;16(3):539–545.

Dr. Gillette is a semiretired family physician and family practice educator and a member of the Family Practice Management Board of Editors.

This article exemplifies the AAFP 2000 Annual Clinical Focus on mental health.

 

1. Barsky AJ, Borus JF. Functional somatic syndromes. Ann Intern Med.1999;130:910–921.

2. Crutcher JE, Bass MJ. The difficult patient and the troubled physician. J Fam Pract.1980;11(6):933–938.

 

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