Approach to Difficult Patient Interactions

Fremonta Meyer

Ilana M. Braun

Although the frequency of difficult patient encounters specifically in primary care practices is unknown, up to 30% of patients in the general hospital setting exhibit difficult behavior at one time or another. Difficult behaviors can take many forms: late arrivals to appointments or no-shows, intense questioning of the clinician, rejection of treatment recommendations, demand of unnecessary tests or medications, frequent e-mails or ill-timed pages, and abusive behavior toward staff. Patients may exhibit such behaviors in response to suffering caused by illness, perceived medical error, adverse life events, or simply as a result of the psychological threat posed by being a patient. Cultural differences, psychiatric disorders including personality disorders, life circumstances, and relational styles can also manifest themselves as difficult behavior. Exogenous factors, including physician attributes and the challenges of negotiating the health care system, may contribute to patients’ difficult behaviors in the health care setting.

PSYCHOLOGICAL MECHANISMS, INTERPERSONAL FACTORS, AND CLINICAL PRESENTATIONS (1, 2, 3, 4, 5, 6, 7, 8, 9 and 10)

Psychological Mechanisms

Difficult interactions often derive from feelings of threat, be they from illness, loss of independence, conflicts in other parts of life, or perceived physician error. Preexisting personality disorder is another potential source.

Threat from Illness

People often become angry when their wishes and aims are frustrated by disease. Illness can provoke difficult behavior when it brings with it the prospect of disfigurement, pain, and emasculation; lost effectiveness, opportunity, or autonomy; abandonment; or even death. Some patients are particularly sensitive to and react against the helplessness, lack of control, and enforced passivity that illness confers. Others resent that the vagaries of chance seem to have unfairly singled them out for misfortune.

Threat of Dependence and of the Doctor-Patient Relationship

Some people have difficulty tolerating the role of patient. For them, participation in the doctor-patient relationship represents the threat of dependence, infantilization, and emasculation—of allowing someone powerful to take control of and responsibility
for them. Their anger functions to keep the physician at a distance. It is a defense against any closeness or attachment to the doctor that might develop.

By contrast, other patients crave such intimacy. These persons may become difficult if they sense that their doctors are treating them dismissively, not taking them seriously, or not caring about their case as much as they would like.

Threats or Conflicts Elsewhere in Life

Sometimes, anger directed toward a physician is displaced. Patients commonly besiege or reproach their clinicians in response to stresses that they are encountering elsewhere in their lives. Often in such instances, the animosity and hostility seem inappropriate to the situation and disproportionate to any provocation the doctor can identify. Usually, this displaced anger develops when a patient is in conflict with important people in his or life, including employers and close family, to whom the patient cannot properly express his or her emotion. In a process referred to as transference, the patient can also displace onto the current doctor the dissatisfaction and disillusionment that have actually been aroused by previous physicians.

Threat of Physician Fallibility

Many patients respond to illness by investing enormous faith in their physicians. Medical error, whether as a result of action or omission, can shake a patient’s sense of emotional security as much as it can lead to physical suffering. Anger in this context grows not only from a belief of having been wronged but also out of a frightening realization that the medical system, which has been entrusted with the patient’s care, is fallible.

Character Pathology: Borderline Personality

This form of character pathology commonly contributes to difficult behavior. It constitutes the common underlying factor for a variety of personality disorders, including narcissistic, antisocial, and histrionic varieties. Patients with these personality disorders tend to reveal their underlying borderline personality organization when under stress, such as that induced by illness. They often have difficult childhood histories entailing emotionally distant or neglectful caregivers and sexual and physical abuse; they are at high risk for domestic violence in their intimate relationships. Adverse life events and genetic factors appear to interact as risk factors. A serious medical illness often leads to intensified feelings of vulnerability, which exacerbates underlying fears of neglect and abandonment, and may lead to behavioral regression and further illumination of maladaptive personality traits. Primitive defense mechanisms are resorted to, including splitting and denial, and suicidal ideation is not uncommon.

Splitting.

In medical settings, these patients are prone to utilize primitive defenses such as splitting and denial. In splitting, the patient rigidly separates medical caregivers into “good ones” and “bad ones” and often cooperates with those perceived as good while rejecting the advice of those perceived as bad. As a result, different medical staff members experience the patient differently, which may result in inconsistent patient care and discord among the team. There may be disagreements on the patient’s level of pain, veracity of reported physical symptoms, and need for psychotropic medication. Patients often shift their alliances for unclear reasons, resulting in behavioral instability.

Denial.

Such patients may also engage in pathologic denial, leading them to refute the details or even knowledge of their illness, decide suddenly that they are cured, or flee from medical treatment. The opportunities often afforded by the medical setting to switch providers, get second opinions at other institutions, and ultimately even divide care across several institutions can further fuel denial or splitting behaviors.

Suicidal Ideation.

In addition to posing management and interpersonal challenges, patients with personality disorders are at risk for suicidal ideation and attempts; in particular, 75% of patients with borderline personality disorder attempt suicide at least once, and approximately 10% eventually complete suicide, with prior attempts, hopelessness, impulsivity, and substance abuse increasing the risk of completed suicide. For this reason, clinicians must assess for the presence of suicidal ideation, intent, or plan and act decisively to assure the patient’s safety.

Personal, Physician, and Patient-Doctor Factors

All physician-patient relationships are influenced by dynamics within the patient, the physician, their interaction, the patient’s illness, and the hospital and larger psychosocial systems. When a difficult relationship develops, optimal care requires openminded examination of all these areas.

Patient Factors.

Although personality disorders are often implicated in difficult behavior, other psychiatric diagnoses such as depression, anxiety, somatization, substance abuse, delirium, dementia, and psychosis may also result in difficulty. For example, patients with anxiety disorders may be problematic when their high anxiety prevents them from retaining information about treatment options; they may then ask questions that suggest that they were not listening.

Only gold members can continue reading. Log In or Register to continue