The Difficult Patient

When I worked as an inpatient therapist, we had patients with a wide variety of personalities. Some were the lovable and sweet grandparent type. Some were young and angry. Some were old and angry. Some were confused but generally pleasant. Some socialized and joked, while others preferred to stay in their rooms. As a therapist, I needed to be able to adapt to each patient’s personality in order to recruit their participation and build a therapeutic alliance. But, no matter how agreeable and flexible I managed to be, there were always a few “difficult” patients.

One man threw his remote at me and put together the most impressive string of curse words every time I walked into his room and said “hello”. One woman hyperventilated to the point of passing out every time she thought about getting out of bed. One man refused all pain medications and then refused therapy because he was in too much pain…every day. One woman swore up and down that she was unable to walk 20 feet, and stood without assistance or losing her balance for 35 minutes to prove that she couldn’t take a step. Anyone who works in health care can conjure up a mental image of the quintessential “difficult” patient. These types of stories abound in both inpatient and outpatient environments.

A study from 1999 delved into the idea of the difficult patient[1]. According to this study, 1 out of every 6 patients is considered to be difficult, with providers using words like “black holes”, “frustrating”, “problem”, or “hateful” to describe this group. Patients were considered to be more difficult when they had a depressive or anxiety disorder, had multiple physical symptoms (specifically more than 5), symptom severity greater than 6/10, and were worried that their symptoms indicated a greater health problem. Additionally, patients were considered to be incrementally more difficult as their number of diagnoses increased. Physicians reported the most difficulty with patients who had low scores on the six domains of function – overall health, physical, pain, role, social, and emotional. Interestingly, patients who had symptoms with a clear biomedical cause, such as dermatologic symptoms, otolaryngologic symptoms, and genitourologic symptoms, were considered to be less difficult, possibly because they are clearly rooted in the biological model of health and respond well to medical intervention.

These findings make sense to me on a gut level. Providers like it when they can identify a specific cause for a patient’s symptoms and then can solve the problem with a specific action. If someone comes in with a urinary tract infection, a physician can prescribe antibiotics. Easy solution. If someone comes in with a funky skin spot, a physician can remove it. Easy solution. But when patients with multiple chronic conditions come in for a pain related complaint, and are feeling anxious that this pain might indicate a new chronic condition…there is no easy answer. These patients require reassurance, attention, education, and human connection in order to decrease catastrophizing and symptom magnification. Not to mention that, previous negative encounters with the medical system might predispose these patients to lead with a cynical or defensive posture. No easy solution.

An interesting twist from this study is that the researchers also looked at physician attitudes and how they contributed to the perception of any one patient as being difficult. Physician beliefs were assessed using the Physician’s Belief Scale. Researchers found that, when physicians scored higher than 70 on this scale, they rated 23% of patient encounters as difficult, compared to physicians who scored lower than 70, who rated only 8% of patient encounters as difficult. Those who scored higher than 70 on the Physician Belief Scale indicated via the 10-item Difficult Doctor Patient Relationship Questionnaire that they “were less eager to see patients from difficult encounters again, were more likely to be frustrated by such patients, found communication difficult, felt uneasy, and secretly hoped these patients would not return for follow-up.” Check out this chart comparing the responses between the >70 score group and the <70 score group. I can’t even overstate the differences.

	>70 on PBS	<70 on PBS
Less eager to see this patient again	82%	15%
Frustrated by the patient	66%	5%
Difficult to communicate with the patient	37%	0.5%
Felt uneasy during the interaction	51%	9%
Secretly hope this patient doesn't follow up	65%	3%

The researchers found no difference in the interventions that the difficult patients received vs the rest of the patients. They received the same diagnostic tests, prescriptions, and referrals, and they received the same proportion of patient-desired interventions. However, the difficult patients were more likely to report unmet expectations and to be less satisfied overall. The difficult patients reported being “dissatisfied with the physician’s technical competence, bedside manner, explanation of what was done for them, and time spent with clinician.” This finding is interesting, since the visit durations and quality of diagnostics and interventions were uniform. Patient outcomes were not different at 2 week or 3 month follow up times, although patients from the “difficult” group had double the number of physician visits and higher use of health services for a 6 month follow up period.

This study speaks to the importance of health care providers maintaining psychological openness to their patients in order to form genuine and helpful therapeutic alliance. If I go to a doctor’s appointment and sense that my provider is uneasy, feeling frustrated, and secretly hopes that I never come back, I am certainly going to feel dissatisfied with the appointment, even if I can’t identify exactly why. In school, we learn the term "biopsychosocial model" and we discuss its importance in abstract terms, but this study gives concrete importance to engaging the psychosocial aspects of our patients. By leaning into difficult interactions and engaging with a patient's emotional distress, instead of trying to distance and stick to a narrow biomedical view point, we may build trust, foster understanding, and in turn, that difficult patient might begin to seem more human. If we are serious about decreasing health care utilization and using patient satisfaction as an important measure of quality of care, then we need to teach communication skills and emotional skills to upcoming providers. Providers need to examine their beliefs and attitudes about the psychosocial implications of dealing with living humans, who have emotional and social needs that impact their physical health status.

Next week, I will review a study about exemplary physician communicators, to continue forward on this topic. In the mean time, I have attached the Physicians Belief Scale under the "Research" tab (the scale is on page 3 of the linked article) so that we can all examine our own beliefs and spend time thinking about how these beliefs might impact patient care.

[1] https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/485035