The patient from hell: 4 types of difficult patients and how to manage them

Challenging patient encounters occur an estimated 15% of the time. It may be tempting (and self-preserving) to attribute the difficulty to the patient. But not all difficult patient visits can or should be pinned on the patient; physicians play a big role, too.

“With most people who might be labeled ‘difficult,’ there’s something else going on,” said Ana María López, MD, MPH, president, American College of Physicians, Philadelphia, PA, in an exclusive interview with MDLinx.

“There may be the stress of the illness, and there may be some stress at home,” she continued. “So, it’s important for us as clinicians to try to identify and address what the underlying issue is. I don’t think that most people are difficult…Different things will push our buttons, but we must not blame the patient; it’s something we need to figure out. I encourage people not to interpret but just to ask.”

Difficult patient encounters

Here are four different types of challenging clinical scenarios and tips on how to manage them.

1. Resistant patients. Patients who are angry, frightened, or defensive can present with clenched fists, furrowed brows, hand-wringing, and altered breathing. You’ll also probably receive notice from staff about these patients before entering the room.

With this type of patient, avoid conflict, keep in mind your personal triggers, and modulate your interactions. Try to determine the source of the problem and how it relates to your patient’s medical condition. Discuss how to resolve the issue. Also, be empathetic, with expressions like “I can understand why you might feel that way,” which can be helpful in diffusing combative situations.

If at any point during the visit you feel threatened, get help. “If a [clinician] feels threatened, being safe is very important—whether you call security, call 911, or step out of the room,” stated Dr. Lopez. “If a person has some knowledge that the patient has a history of violence, having [another staff member] in the room is important.”

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2. Patients who somatize. Patients who somatize frequently present with histories of multiple vague complaints or exaggerated symptoms, and often display signs and symptoms of comorbid anxiety, depression, and personality disorders. These patients often engage in “doctor shopping.”

With patients who somatize, try to explain the diagnosis in an empathetic manner and treat any comorbid psychiatric conditions. Furthermore, maintain regularly scheduled appointments to air any concerns that crop up and thus avoid “doctor shopping.” Although it’s a good idea to meet with these patients every 2-4 weeks, refrain from ordering excessive diagnostic tests and procedures, which can be costly, invasive, and expose patients to unnecessary risks.

3. Manipulative patients. These patients use guilt, rage, and threats of legal action or suicide in impulsive attempts to get what they desire. In these patients, it can be difficult to differentiate between manipulative tendencies and borderline personality disorder. With manipulative patients, it is important to set limits, say “no” when you have to, remain cognizant of your own emotions, and understand the patient’s expectations, which can, in fact, be reasonable despite their actions.

4. “Frequent flyers.” Although some find the term “frequent flyer” derogatory, this patient presentation is well known to many. Empathy is vital with these patients, and it’s important to recognize that they may be lonely, worried, dependent or embarrassed. They also may be misinformed about the nature of their condition and seek additional clinical interaction due to lack of insight.

Try to understand what drives the frequent visits, whether it is concern about undiagnosed symptoms, need for reassurance, relief from chronic pain, or desire for human interaction. As with patients who somatize, the key to helping “frequent flyers” is regularly scheduled visits, as well as patient education and support personnel.   

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Physician characteristics

A doctor’s own attitudes and actions may play a major role in challenging patient encounters, including the following:

• Being angry;
• Being defensive;
• Feeling fatigued; and
• Feeling strained.

Physicians who possess clear anger triggers should explore their own personal issues and learn how to avoid being triggered. Furthermore, overworked or sleep-deprived physicians should make an attempt to cut back on high-stress responsibilities, get more sleep, and delegate responsibility as needed.

On a final note, if you encounter a clinic visit that—for whatever reason—is too difficult or challenging to manage, it’s okay to ask for help.

“There are times that we all meet someone we don’t sync with,” said Dr. Lopez. “In that situation, it might be valuable for both parties to find a different way of facilitating care.”

Such alternative options include discussing with the patient whether continuing care provided by another physician would be a better fit.