#101 The Myth of the Difficult Patient
Patients won’t always follow our advice or behave the way we prefer. Making peace with that is better for us and better for them.
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I took a deep breath and entered the room where Mary was waiting. Her weight was up more than 10 pounds in the past month, and she reported dyspnea (shortness of breath) on exertion. She had told the nurses she was only taking half her furosemide (diuretic) dose. I asked her why.
“I can’t take that dose, doc. It makes me pee too much,” she said.
“But you need it, Mary,” I said. “Your kidneys don’t work as well as they used to.”
“They work just fine!” she insisted. “I pee all the time. I don’t want to use the public toilet or get up in the middle of the night!”
What is a conscientious physician to do in a situation like this?
Many physicians have a mental template of a “good” patient. They follow our advice, take their prescriptions, call us only when appropriate, and know when they should go to the emergency department. Most of our doctor-patient relationships fall into this category, but the ones that don’t seem to keep us up at night.
Some studies show that primary care doctors describe patients as “difficult” in 15–20% of visits. (1) This description usually stems from patients not adhering to the plan laid out by the physician. Some patients neglect screening exams, reject vaccines, or do not take medications as prescribed.
Others are unwilling or unable to cease cigarette smoking, substance abuse, or unhealthy eating. Still others are chronic no-shows, have long lists of complaints, or are “frequent fliers.” (Note that I’m not talking about patients who are verbally or physically abusive here. That behavior is beyond “difficult” and should never be tolerated.)
But what if there are no “difficult” patients — only individuals with different priorities and different experiences with the health care system? What if we think of our job as to help educate competent patients and then allow them to make their own decisions, even if we know those decisions will harm them?
Of course, this is easier said than done. Many physicians are deeply committed to the idea that patients should follow our plan, take the medications and vaccinations we offer, and let our expert opinion be the final word. That way of thinking can lead to frustration.
To change the way we think, we must focus on the patient’s agenda rather than ours. That means adopting thoughts like the following:
• Mr. Smith can smoke if he chooses,
• Mary is doing the best she can right now with her medications,
• I have explained the risks and benefits. If the parents still choose not to vaccinate their child, that is their decision. The child is here now, so I will make sure she is OK.
We need not feel guilty or dispense judgement when people don’t behave the way we would prefer. We can accept people as they are, where they are. This mindset is better for us and our patients. It may also make patients less “difficult” in the long run, since patients who believe their doctors have compassion for them tend to adhere to the treatment plan more consistently. (2)
This mindset can also spur us to look for underlying reasons for nonadherence and seek creative solutions. (3) Maybe we can substitute out a medication that a patient stops taking because of side effects. Or explore treatment programs for a patient who can’t stop drinking . Or try telemedicine for a patient who no-shows because they lack reliable transportation. We cannot fix everything, but we become better physicians when we exercise our problem-solving skills.
Now, instead of being frustrated with my patient Mary, I can enjoy how her face lights up when I ask about her grandson. I can accept some challenging behaviors, get curious about her struggles, and feel better about our interactions.
I can remind myself that there are no difficult patients.
1.Jackson JL, Kroenke K. Difficult patient encounters in the ambulatory clinic: clinical predictors and outcomes. Arch Intern Med. 1999;159(10):1069–1075.
2. Doyle C, Lennox L, Bell D. A systematic review of evidence on the links between patient experience and clinical safety and effectiveness. BMJ Open. 2013;3:e001570.
3. Edgoose J. Rethinking the difficult patient encounter. Fam Pract Manag. 2012;19(4):17–20.
This article appeared in The Last Word column of the Family Practice Management magazine of the American Academy of Family Physicians.
