Managing Difficult Encounters: Understanding Physician, Patient, and Situational Factors

ROSEMARIE CANNARELLA LORENZETTI; C. H. MITCH JACQUES; CAROLYN DONOVAN; SCOTT COTTRELL; JOY BUCK

ROSEMARIE CANNARELLA LORENZETTI, MD, MPH, C. H. MITCH JACQUES, MD, PhD, CAROLYN DONOVAN, DNP, PMHCNS-BC, FNP-C, SCOTT COTTRELL, EdD, AND JOY BUCK, RN, PhD

A more recent article on managing difficult patient encounters is available.

Am Fam Physician. 2013;87(6):419-425

Author disclosure: No relevant financial affiliations.

Family physicians commonly find themselves in difficult clinical encounters. These encounters often leave the physician feeling frustrated. The patient may also be dissatisfied with these encounters because of unmet needs, unfulfilled expectations, and unresolved medical issues. Difficult encounters may be attributable to factors associated with the physician, patient, situation, or a combination. Common physician factors include negative bias toward specific health conditions, poor communication skills, and situational stressors. Patient factors may include personality disorders, multiple and poorly defined symptoms, nonadherence to medical advice, and self-destructive behaviors. Situational factors include time pressures during visits, patient and staff conflicts, or complex social issues. To better manage difficult clinical encounters, the physician needs to identify all contributing factors, starting with his or her personal frame of reference for the situation. During the encounter, the physician should use empathetic listening skills and a nonjudgmental, caring attitude; evaluate the challenging patient for underlying psychological and medical disorders and previous or current physical or mental abuse; set boundaries; and use patient-centered communication to reach a mutually agreed upon plan. The timing and duration of visits, as well as expected conduct, may need to be specifically negotiated. Understanding and managing the factors contributing to a difficult encounter will lead to a more effective and satisfactory experience for the physician and the patient.

Difficult encounters are estimated to represent 15 to 30 percent of family physician visits.^1,2 Factors contributing to these difficult clinical encounters may be related to the physician, patient, situation, or a combination. Physicians can recognize these visits as challenging by acknowledging their feelings of angst or helplessness generated during the conversation.^1–4 These encounters are also characterized by a disparity between the expectations, perceptions, or actions of the patient and physician.^5–7 The resulting frustration can be influenced by a variety of factors, including the physician's background, skill level, and personality. The situation may be compounded by the patient's complex medical needs, personality, health literacy, or communication style.^5,8–10 Other influences include aspects of the practice environment and health care system.^2,6,11–13

Physicians who report the most difficulty with patient relationships also report lower job satisfaction and higher levels of professional burnout than their colleagues.¹ To handle difficult encounters more effectively, the physician must learn to recognize the many variables associated with these encounters, and adapt his or her approach to the patient, starting with enhanced communication skills.^7,12

Clinical recommendation	Evidence rating	References
For challenging patients, set boundaries or modify your schedule if needed. This can improve your ability to handle difficult encounters.	C	⁶, ¹⁴
Try to be aware of your own inner feelings. This results in fewer patients being labeled as “challenging” and leads to better management of difficult encounters.	C	², ³, ⁶, ¹¹, ¹⁴, ²⁰
Employ empathetic listening skills and a nonjudgmental, caring attitude during patient interactions. This will improve trust and adherence to treatment.	C	³, ⁶, ⁷, ¹¹, ¹⁴, ²¹, ²⁷
Use a patient-centered approach to interviewing, such as motivational interviewing. Motivational interviewing has been shown to improve the therapeutic alliance with the patient and effectively influence behavior change.	B	³⁴, ^37–39
Assess challenging patients for underlying psychological illnesses, and refer for appropriate diagnosis and treatment.	C	¹¹, ¹², ³⁹, ^40–42
Assess challenging patients with symptoms of functional somatic disorders for past or current sexual abuse or significant trauma.	C	^22–24, ⁴², ⁴⁴

Physician Factors

Every physician brings his or her background, personality, and experience to each patient encounter. When the ability to improve a patient's condition is threatened or undermined, the physician's identity as a healer may be compromised.¹⁴ Difficult encounters may occur in several ways. Internet-savvy patients who present the physician with a printout of information and demand specific diagnostic tests or treatments can surprise or threaten the physician. The physician might perceive that his or her knowledge or ability is being challenged and respond defensively.^15,16 Similarly, when patients present with recurrent symptoms related to lifestyle issues, such as smoking, despite receiving adequate counseling, the physician might question his or her ability to relate to patients or influence behavior change.^2,14,17 Another common scenario is a patient repeatedly “losing” prescriptions for controlled substances, thereby undermining the physician's trust.

Whenever a physician's self-image as a competent health care professional is challenged, he or she is more vulnerable to professional burnout.¹⁸ To sustain quality patient care, physicians need to be proactive in promoting and achieving their own self-care.^18,19 Table 1 lists physician factors that can lead to difficult clinical encounters.^{2,3,5,6,11–13,18,20} Physician self-awareness is the first step to facilitating a more successful encounter.

Patient Factors

Several studies have identified and evaluated characteristics of challenging patients.^1,3,6,21 In surveys of physicians ranging from residents to highly-experienced physicians, the common factor was the patient's ability to frustrate or trigger an emotional response from the physician.^2,3,11 Recognizing this characteristic in a patient is important in approaching a potentially difficult encounter.

Table 2 lists patient factors that can lead to difficult clinical encounters.^{2,3,6,8–13,16,21–24} Contributing factors include common behavioral issues; significant medical issues or health conditions, including past or present trauma; underlying psychiatric diagnoses; and low literacy.^{6,8–10,22–24}

A patient classification system developed about 60 years ago is still used by physicians to understand and plan responses to challenging patients.^3,12,25,26 Table 3 provides methods to recognize and approach each of these types of patients.^{3,6,11,12,20,25–27} Other classification systems include multiple patient types that can evoke a strong, instinctive reaction in the physician, including patients described as dependent, angry, entitled, demanding, a chronic complainer, non-adherent, and self-destructive.^3,11

Patient type	Characteristics of the clinical encounters	Approach
Dependent clinger: insecure, desperate for assurance, worried about abandonment	Patient initially plays to physician's sympathies and praises him or her, making the physician feel special As the relationship develops, the patient becomes needy, wants/demands increasing personal time from the physician; the physician may feel resentful	Maintain a professional demeanor Establish boundaries early and consistently maintain them Involve the patient in decision making Assure the patient that you will not abandon him or her Schedule regular follow-up appointments
Entitled demander: often angry, does not want to go through necessary steps of assessment or treatment, may be reacting to fear and loss	Patient is aggressive and intimidating, forges a negative relationship with the physician Patient sees physician and health system as barriers to his or her needs Physician may feel anger, guilt, doubt, or frustration	Suspend judgment, and examine your own feelings Recognize that the patient's hostility may be his or her way of maintaining self-integrity during a devastating illness or other trauma If a specific emotion is evident, address it with the patient; do not react defensively when the patient expresses concerns Reinforce that the patient is entitled to good medical care, but that anger should not be misdirected at those trying to help
Manipulative help-rejecter: wants attention, has been rejected previously and has difficulty with trust, often has undiagnosed depression	Patient engages physician by subconscious manipulation Patient returns to the office often in cycles of help-seeking/rejecting treatment and does not improve despite appropriate advice Patient is confident that his or her health cannot improve Physician may be concerned about overlooking a serious illness	Recognize that the patient wants to stay connected to the physician, not necessarily to recover Engage the patient by sharing frustrations over poor outcomes Work with the patient to set limits on expectations Reformulate the health plan with the patient to focus on alleviating symptoms rather than curing the condition
Self-destructive denier: feels hopeless about changing the situation, unable to help himself or herself, fears failure, may have untreated anxiety or depression	Health problems persist despite adequate counseling and treatment Patient continues self-destructive habits Physician may feel ineffective and responsible for lack of progress	Recognize that complete resolution of issues is limited Set realistic expectations Redirect patient's behavior to identify causes of nonadherence (e.g., money, time, access to medical care or appropriate treatment) Celebrate each small success with the patient Offer/arrange for psychological support

Situational Factors

Modern office visits are often intensive, with priority given to pathophysiological issues rather than the patient's psychological needs.^7,26 The wider availability of medical knowledge to patients, including misleading information, can result in many patient questions and the need for more in-depth discussion.^15,26 The growing prevalence of patient-centered approaches that emphasize medical care tailored to patient preferences also exacerbates time pressures during difficult encounters.⁷

General Principles

The patient and physician each bring a frame of reference and set of expectations to an office visit. Empathy helps the physician suspend judgment and foster a relationship in which he or she is perceived as a healer and ally, not just a service provider.^{6,17,19,20,28,29} Better health outcomes are achieved when the patient and physician have congruent beliefs about who is in control of necessary changes to improve health.³⁰ A focused assessment may reveal underlying, potentially treatable mental or psychiatric conditions; a history of abuse; or difficult family or social situations.^31–33 If controlled substances are necessary for treatment, screening the patient for potential substance abuse (and referral for treatment if necessary), implementing a pain contract, and checking with state substance registries are essential components of patient care.³¹

Following the principles of effective communication can help physicians prevent or manage difficult encounters.^7,11,13,28 Acknowledging that the patient's symptoms are valid is important to the potential effectiveness of treatment, as is demonstrating a willingness to work with the patient on a continuing basis. For an emotionally charged encounter, the physician must be able to redirect the situation (Table 4).^{11,12,14,20,27,34} The CALMER (catalyst for change, alter thoughts to change feelings, listen and then make a diagnosis, make an agreement, education and follow-up, reach out and discuss feelings) method is another approach to a difficult clinical encounter (Table 5).³⁵

Strategy	Physician actions	Examples
Active listening	Understand the patient's priorities, let the patient talk without interruption, recognize that anger is usually a secondary emotion (e.g., to abandonment, disrespect)	“Please explain to me the issues that are important to you right now.”
Active listening		“Help me to understand why this upsets you so much.”
Validate the emotion and empathize with the patient (understanding, not necessarily sharing, the emotion with the patient)	Name the emotion; if you are wrong, the patient will correct you; disarm the intense emotion by agreement, if appropriate	“I can see that you are angry.”
		“You are right—it's annoying to sit and wait in a cold room.”
		“It sounds like you are telling me that you are scared.”
Explore alternative solutions	Engage the patient to find specific ways to handle the situation differently in the future	“If we had told you that appointments were running late, would you have liked a choice to wait or reschedule?”
		“What else can I do to help meet your expectations for this visit?”
		“Is there something else you need to tell to me so that I can help you?”
Provide closure	Mutually agree on a plan for subsequent visits to avoid future difficulties	“I prefer to give significant news in person. Would you like early morning appointments so you can be the first patient of the day?”
Provide closure		“Would you prefer to be referred to a specialist, or to follow up with me to continue to work on this problem?”

Element	Approach
Catalyst for change	Identify the patient's status in the stages of change model*
Catalyst for change	Recommend how the patient can advance to the next stage
Alter thoughts to change feelings	Identify the negative feelings elicited by the patient
	Clarify how these feelings influence the encounter
	Strategize how to reduce your own negativity and distress
Listen and then make a diagnosis	Remove or minimize barriers to communication
	Improve working relationships
	Enhance probability of accurate diagnoses
Make an agreement	Negotiate, agree on, and confirm a plan for health improvement
Education and follow-up	Set achievable goals and realistic time frames, and ensure follow-up
Reach out and discuss feelings	Ensure a strategy for your own self-care

For some patients, the physician may need to schedule more frequent focused visits, set appropriate boundaries for each visit, and agree on achievable goals.^6,14 If it is determined that a longer visit is needed for a more complex patient encounter, physicians can bill for face-to-face counseling time as long as it is adequately documented.¹² Whether the physician-patient relationship continues or ends, the patient must understand and agree with the decision.⁶

Approach to the Difficult Clinical Encounter

On a day when you are significantly behind schedule, your next patient is a 58-year-old divorced woman who smokes and has poorly controlled diabetes mellitus and hypertension. She is a college graduate and business executive. At every visit, she describes at least one new symptom, often with specific demands for testing or medication. Despite your repeated counseling on the importance of smoking cessation and controlling blood pressure and glucose levels, the patient remains nonadherent to lifestyle changes. You feel a sense of dread as you enter the room.

Although every difficult clinical encounter has unique aspects, recognizing several key components appears to be useful in managing these situations.

You feel a sense of dread as you enter the room. Physician awareness of inner feelings may result in fewer patients being labeled as “challenging” and may lead to better management of difficult encounters.^{2,3,6,11,14,20} Internal signals such as a sense of dread or negative feelings toward the patient, including anger or frustration, will influence the patient-physician relationship.^2,3,6 Strategies to help physicians identify personal factors that may contribute to a difficult encounter include self-reflection, recognizing biases, discussions with an experienced or trusted colleague, participating in Balint groups, or possibly seeking help from a psychotherapist.¹⁸ The primary responsibility to address and resolve problems with the physician-patient relationship rests with the physician rather than the patient.³

You are significantly behind schedule. Environmental factors often contribute to a difficult encounter. The most common are extended wait times and negative interactions with office staff. A positive tone may be established by acknowledging a delay, thanking the patient for waiting, and giving an honest explanation.³⁶ Recognizing that the challenging patient requires more time and energy, the physician can plan for longer visits or schedule visits at the beginning or end of a clinic session. If the patient is new to the practice, frequent visits may be helpful to get to know the patient and to ensure that unresolved issues are addressed as soon as possible.^6,27

Despite your repeated counseling on the importance of smoking cessation and controlling blood pressure and glucose levels, the patient remains nonadherent to lifestyle changes. Empathy requires understanding the patient's circumstances and perspective. Empathetic listening skills and a nonjudgmental, caring attitude are necessary to improve patient trust and adherence to treatment.^{3,6,7,11,14,21,27} This approach may decrease unnecessary diagnostic testing and reduce the risk of malpractice accusations.³⁶

A patient-centered approach to interviewing is important for the physician to appreciate the patient's perspective.²⁸ Motivational interviewing is an increasingly common and studied technique, in which the physician explores the patient's desire, ability, need, and reason to make a change. Motivational interviewing has been shown to improve the therapeutic alliance with the patient and effectively influence behavioral change.^34,37–39 Identifying and clarifying the patient's expectations may allow him or her to more easily express dissatisfaction, or provide insights into appropriate treatment strategies. Asking patients to offer causes and potential solutions for their problems fosters a more collaborative relationship for care. Mutually agreed upon strategies offer better opportunities for patient adherence to treatment.^30,35

At every visit she seems to describe at least one new symptom, often with specific demands for testing or medication. Appropriate treatment of psychological conditions is important in the successful care of challenging patients.^40,41 Some patients express vague symptoms and are frustrated that a cause cannot be diagnosed or treated. These patients may have underlying depression, anxiety, or personality disorder.^11,12,39,42 A previous article in American Family Physician addresses the care of patients with personality disorders in the primary care setting.⁴³

Patients with symptoms of functional somatic disorders should be screened for previous or current exposure to violence or to physical, mental, or psychological abuse.^22–24 Functional somatic syndromes may be a result of intense bodily responses of varying organ systems to overwhelming stress. Targeted therapies may be beneficial.⁴⁴ Family physicians should be familiar with behavioral and psychiatric health care professionals and community services in their area so that they can make appropriate referrals. Patients with addiction, personality disorders, or significant psychosocial conditions require a team approach to care.

Data Sources: We searched the Cochrane Database of Systematic Reviews, CINAHL, PubMed, EBSCO Host, and Essential Evidence Plus. Search terms were difficult patient encounters, challenging patients, anger, noncompliance, physician-patient relations, physician-patient communications, heartsink patients, demanding patients, patient satisfaction, motivational interviewing, literacy, abuse, somatoform disorders, and chronic pain. We also searched the bibliographies of previously identified studies and reviews, the ClinicalTrials.gov registry, the U.S. Preventive Services Task Force, and UpToDate. We included only English-language publications. Search dates: November 30, 2011, and October 5, 2012.

An PG, Rabatin JS, Manwell LB, Linzer M, Brown RL, Schwartz MD MEMO Investigators. Burden of difficult encounters in primary care: data from the minimizing error, maximizing outcomes study. Arch Intern Med. 2009;169(4):410-414.

Haas LJ, Leiser JP, Magill MK, Sanyer ON. Management of the difficult patient. Am Fam Physician. 2005;15(10):2063-2068.

Steinmetz D, Tabenkin H. The ‘difficult patient’ as perceived by family physicians. Fam Pract. 2001;18(5):495-500.

DeMarco MA, Nogueira-Martins LA, Yazigi L. Difficult patients or difficult encounters?. QJM. 2005;98(7):542-543.

Jackson JL, Kroenke K. The effect of unmet expectations among adults presenting with physical symptoms. Ann Intern Med. 2001;134(9 pt 2):889-897.

Elder N, Ricer R, Tobias B. How respected family physicians manage difficult patient encounters. J Am Board Fam Med. 2006;19(6):533-541.

Ong LM, de Haes JC, Hoos AM, Lammes FB. Doctor-patient communications: a review of the literature. Soc Sci Med. 1995;40(7):903-918.

Lindquist LA, Go L, Fleisher J, Jain N, Friesema E, Baker DW. Relationship of health literacy to intentional and unintentional non-adherence of hospital discharge medications. J Gen Intern Med. 2012;27(2):173-178.

Berkman ND, Sheridan SL, Donahue KE, Halpern DJ, Crotty K. Low health literacy and health outcomes: an updated systematic review. Ann Intern Med. 2011;155(2):97-107.

Keller DL, Wright J, Pace HA. Impact of health literacy on health outcomes in ambulatory care patients: a systematic review. Ann Pharmacother. 2008;42(9):1272-1281.

Breen KJ, Greenberg PB. Difficult physician-patient encounters. Intern Med J. 2010;40(10):682-688.

Arciniegas DB, Beresford TP. Managing difficult interactions with patients in neurology practices: a practical approach. Neurology. 2010;75(18 suppl 1):S39-S44.

Pérez-López FR. Difficult (“heartsink”) patients and clinical communication difficulties. Patient Intelligence. 2010;2011(3):1-9.

White MK, Keller VF. Difficult clinician-patient relationships. J Clin Outcomes Manag. 1998;5(5):32-36.

Suarez-Almazor ME, Kendall CJ, Dorgan M. Surfing the net—information on the World Wide Web for persons with arthritis: patient empowerment or patient deceit?. J Rheumatol. 2001;28(1):185-191.

Boutin-Foster C, Charlson ME. Problematic resident-patient relationships: the patient's perspective. J Gen Intern Med. 2001;16(11):750-754.

Davis MA. A perspective on cultivating clinical empathy. Complement Ther Clin Pract. 2009;15(2):76-79.

Kjeldmand D, Holmström I. Balint groups as a means to increase job satisfaction and prevent burnout among general practitioners. Ann Fam Med. 2008;6(2):138-145.

Epstein RM. Mindful practice. JAMA. 1999;282(9):833-839.

Knesper DJ. My favorite tips for engaging the difficult patient on consultation-liaison psychiatry services. Psychiatr Clin North Am. 2007;30(2):245-252.

Jackson JL, Kroenke K. Difficult patient encounters in the ambulatory clinic: clinical predictors and outcomes. Arch Intern Med. 1999;159(10):1069-1075.

Eberhard-Gran M, Schei B, Eskild A. Somatic symptoms and diseases are more common in women exposed to violence. J Gen Intern Med. 2007;22(12):1668-1673.

Sack M, Lahmann C, Jaeger B, Henningsen P. Trauma prevalence and somatoform symptoms: are there specific somatoform symptoms related to traumatic experiences?. J Nerv Ment Dis. 2007;195(11):928-933.

Paras ML, Murad MH, Chen LP, et al. Sexual abuse and lifetime diagnosis of somatic disorders: a systemic review and meta-analysis. JAMA. 2009;302(5):550-561.

Groves JE. Taking care of the hateful patient. N Engl J Med. 1978;298(16):883-887.

Strous RD, Ulman AM, Kotler M. The hateful patient revisited: relevance for 21st century medicine. Eur J Intern Med. 2006;17(6):387-393.

Breuner CC, Moreno MA. Approaches to the difficult patient/parent encounter. Pediatrics. 2011;127(1):163-169.

Boyle D, Dwinnell B, Platt F. Invite, listen, and summarize: a patient-centered communication technique. Acad Med. 2005;80(1):29-32.

Halpern J. Empathy and patient-physician conflicts. J Gen Intern Med. 2007;22(5):696-700.

Christensen AJ, Howren MB, Hillis SL, et al. Patient and physician beliefs about control over health: association of symmetrical beliefs with medication regimen adherence. J Gen Intern Med. 2010;25(5):397-402.

Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society [published correction appears in Ann Intern Med. 2008;148(3):247–248]. Ann Intern Med. 2007;147(7):478-491.

Fishbain DA. Approaches to treatment decisions for psychiatric comorbidity in the management of the chronic pain patient. Med Clin North Am. 1999;83(3):737-760.

Giddens B, Ka'poua L. Promoting Adherence through Collaborative Teams (PACT): a practice model. In: O'Donohue WT, Levensky ER, eds. Promoting Treatment Adherence: A Practical Handbook for Health Care Providers. Thousand Oaks, Calif.: Sage Publications; 2006:174.

Searight R. Realistic approaches to counseling in the office setting. Am Fam Physician. 2009;79(4):277-284.

Pomm HA, Shahady E, Pomm RM. The CALMER approach: teaching learners six steps to serenity when dealing with difficult patients. Fam Med. 2004;36(7):467-469.

Zurad EG. Don't be a target for a malpractice suit. Fam Pract Manag. 2006;13(6):57-64.

Heckman CJ, Egleston BL, Hofmann MT. Efficacy of motivational interviewing for smoking cessation: a systematic review and meta-analysis. Tob Control. 2010;19(5):410-416.

McCambridge J, Strang J. The efficacy of single-session motivational interviewing in reducing drug consumption and perceptions of drug-related risk and harm among young people: results from a multi-site cluster randomized trial. Addiction. 2004;99(1):39-52.

Heisler M, Hofer TP, Klamerus ML, et al. Study protocol: the Adherence and Intensification of Medications (AIM) study—a cluster randomized controlled effectiveness study. Trials. 2010;11:95.

Fishbain DA, Cutler R, Rosomoff HL, Rosomoff RS. Chronic pain-associated depression: antecedent or consequence of chronic pain? A review. Clin J Pain. 1997;13(2):116-137.

Kroenke K. Efficacy of treatment for somatoform disorders: a review of randomized controlled trials. Psychosom Med. 2007;69(9):881-888.

Kroenke K, Rosmalen JG. Symptoms, syndromes, and the value of psychiatric diagnostics in patients who have functional somatic disorders. Med Clin North Am. 2006;90(4):603-626.

Angstman K, Rasmussen NH. Personality disorders: review and clinical application in daily practice. Am Fam Physician. 2011;84(11):1253-1260.

Schröder A, Fink P. Functional somatic syndromes and somatoform disorders in special psychosomatic units: organizational aspects and evidence-based treatment. Psychiatr Clin North Am. 2011;34(3):673-687.

Physician Factors

Patient Factors

Situational Factors

General Principles

Approach to the Difficult Clinical Encounter

Continue Reading

More in AFP