The Difficult Patient
Some Practical Strategies and Insights
for Physicians
A Presentation for SOMC Medical Education
Kendall L. Stewart, MD, MBA, DFAPA
November 18, 2011
intend to offer practical insights you can use starting today.
let me know whether I succeed on your evaluation forms.
3You can email me, message me on Facebook or stop me in the hall.
Why is this important?
• These patients will find
• Give them the chance, and
they will make your
professional life miserable.
• You can’t change them
(much), but you can change
the way you react to them.
• Changing how you react to
these people will make a
world of difference in the
quality of your professional
• After this presentation, you
will be able to
– Identify three common
behaviors difficult patients
– Describe three feelings
these behaviors often elicit
in physicians,
– Specify three typical
physician behavioral
responses, and
– Suggest three practical
strategies for minimizing
the disruptive impact these
people have on your life.
can be difficult too; I asked a crusty old ICU nurse to have her nurses fill out a survey.
nurse asked whether I would take the survey results personally.
How do difficult patients behave, and
why do the behave that way?
• Because they feel insecure,
they seek excessive
• Because they feel entitled, they
are demanding.
• Because they are poorly
motivated, they are
• Because they fear rejection,
they test their physician’s
• Because they feel threatened,
they are suspicious.
• Because they feel needy, they
are attention-seeking.
• Because they are angry, they
blame others.
• Because they are scared, they
cannot be satisfied.
• Because they are addicted, they
are threatening.
• Because they feel helpless and
hopeless, they cling to
unrealistic expectations.
• And this list is just a start.
patient called me as I was coming in from church.
patients are the most challenging patients you will ever meet.
How do these patient “make”
physicians feel?
Burnt out
And so on
most common complaints I receive are from drug seekers.
next most common come from conflict and misunderstandings.
3Some threats are very serious; a number of patients and their families have threatened to kill me.
How do these patients “make”
physicians behave?
We suppress our feelings and stew.
We distract ourselves by working harder.
We vent our frustrations on others.
We avoid the patient.
We arrange for treatment by committee.
We confront the patient when we are angry.
We fire the patient without adequate explanation.
We blow the patient’s concerns off.
We shunt and punt.
We punish the patient with extended waits, failure to
return calls, etc.
• We keep trying to make the relationship work long
after it’s clear we need to refer the patient.1,2
just can’t please some patients.
mother demanded that I simply follow the instructions of her daughter’s psychiatrist in Boston.
What are some effective strategies
for dealing with difficult patients?
Label them.
Study them.
Understand them.
Accept their feelings.
Anticipate their needs.
Confront them in love.
Appreciate them.
Contain them.
Hold them accountable.
Fire them.1,2
Monitor your own emotional
• Remain emotionally detached.
• When aroused, keep your
mouth shut.
• Analyze your reactions.
• Give yourself some time.
• Ask for help.
• Accept your limitations.
• Negotiate a trade with a
• Give yourself a break.
• Just say “no” when they
these patients before your resentment starts to grow.
woman with anxiety returned to inform me that she had not done anything I suggested, nor was she going to.
Confront in love.
• Why should you?
– Failing to confront is
– Avoiding confrontation is
– Impulsively confronting in
anger is disastrous.
– Confronting lovingly and
respectfully is your only
chance for success.
– And confronting in love
means you never have to
say you’re sorry.
• Why should you?
– Failing to confront is
– Avoiding confrontation is
– Impulsively confronting in
anger is disastrous.
– Confronting lovingly and
respectfully is your only
chance for success.
– And confronting in love
means you never have to
say you’re sorry.1,2
of my most effective confrontations have occurred in church.
the evangelist demanded that all Christians face the rear, I stared right at him and declined to turn around.
What have you learned?
• You have difficult patients.
• How difficult they turn out to be is up to you.
• Their feelings trigger their difficult behaviors; your
feelings trigger your counterproductive responses.
• You will have little control over difficult patients; you can
have more control of yourself.
• Now you know what is wrong, and what needs to be done.
• Doing the right thing takes time, effort and practice.
• But managing difficult patients appropriately will make a
significant difference in the quality of your professional
your colleagues will be the most difficult people in your professional life.
student got into my car and said, “I hate psychiatry.”
3Later, he fidgeted during an interview.
The Psychiatric Interview
A Patient-Centered, Evidence-Based Diagnostic and Therapeutic Process
Introduce yourself using AIDET1.
Sit down.
Make me comfortable by asking some
routine demographic questions.
Ask me to list all of problems and concerns.
Using my problem list as a guide, ask me
clarifying questions about my current
Using evidence-based diagnostic criteria,
make accurate preliminary diagnoses.
Ask about my past psychiatric history.
Ask about my family and social histories.
Clarify my pertinent medical history.
Perform an appropriate mental status
Review my laboratory data and other
available records.
Tell me what diagnoses you have made.
Reassure me.
Outline your recommended treatment
plan while making sure that I understand.
Repeatedly invite my clarifying questions.
Be patient with me.
Provide me with the appropriate
educational resources.
Invite me to call you with any additional
questions I may have.
Make a follow up appointment.
Communicate with my other physicians.
Acknowledge the patient. Introduce yourself. Inform the patient about the Duration of tests or treatment.
Explain what is going to happen next. Thank your patients for the opportunity to serve them.
Where can you learn more?
American Psychiatric Association, Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition, Text Revision, 2000
Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical Psychiatry, Third
Edition, 2008
Stern, et. al., Massachusetts General Hospital Comprehensive Clinical
Psychiatry, 2008. You can read this text online here.
Flaherty, AH, and Rost, NS, The Massachusetts Handbook of Neurology, April
Stead, L, Stead, SM and Kaufman, M, First Aid© for the Psychiatry Clerkship,
Second Edition, March 2005
Klamen, D, and Pan, P, Psychiatry Pre Test Self-Assessment and Review,
Twelfth Edition, March 20093
Oransky, I, and Blitzstein, S, Lange Q&A: Psychiatry, March 2007
Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the Brain,
January 2008
Medina, John, Brain Rules: 12 Principles for Surviving and Thriving at Home,
Work and School, February 2008
Stewart KL, “Dealing With Anxiety: A Practical Approach to Nervous
Patients,” 2000
Where can you find evidence-based
information about mental disorders?
Explore the site maintained by the organization where evidence-based
medicine began at McMaster University here.
Sign up for the Medscape Best Evidence Newsletters in the specialties of your
choice here.
Subscribe to Evidence-Based Mental Health and search a database at the
National Registry of Evidence-Based Programs and Practices maintained by
the Substance Abuse and Mental Health Services Administration here.
Explore a limited but useful database of mental health practices that have
been "blessed" as evidence-based by various academic, administrative and
advocacy groups collected by the Iowa Consortium for Mental Health here.
Download this presentation and related presentations and white papers at
Learn more about Southern Ohio Medical Center and the job opportunities
there at
Review the exceptional medical education training opportunities at Southern
Ohio Medical Center here.
How can you contact me?1
Kendall L. Stewart, M.D.
VPMA and Chief Medical Officer
Southern Ohio Medical Center
Chairman & CEO
The SOMC Medical Care Foundation, Inc.
1805 27th Street
Waller Building
Suite B01
Portsmouth, Ohio 45662
[email protected]
[email protected]
and consultation fees benefit the SOMC Endowment Fund.
Are there other questions?
Jeffrey Hill, DO
OUCOM 1987
Sarah Porter, DO
SOMC FP 2007
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The Difficult Patient - Southern Ohio Medical Center