Published in the September 2011 issue of Today’s Hospitalist
Are you finding that more and more of your patients seem to be "difficult"?
There’s no doubt that some patients just aren’t easy to get along with. But before labeling a patient "difficult," doctors should take a look at themselves and ask why a patient is able to push their buttons so effectively. After all, doctor-patient relationships “like all relationships “are a two-way street.
While there are toxic patients, there are also "situations where an interplay between the patient’s emotions and our emotions can escalate things and make caring for that patient difficult," explained Susan D. Block, MD, a psychiatrist and palliative care expert at Harvard Medical School, Brigham and Woman’s Hospital and Dana-Farber Cancer Institute in Boston. Physicians who understand that dynamic, she pointed out, may be able to care for difficult patients more effectively.
Dr. Block laid out strategies for dealing with difficult patients at this spring’s Society of Hospital Medicine annual meeting. In addition to going through a list of differential diagnoses of patients with difficult behaviors, she suggested that doctors apply that same diagnostic process to themselves.
"If we are burning out and are stressed in our own lives, a larger proportion of patients are going to feel difficult, and small problems are going to become amplified," said Dr. Block. "Try to be less angry and more curious."
According to Dr. Block, studies indicate that between 10% and 30% of patients exhibit difficult behaviors in health care settings.
That shouldn’t be a surprise, she added, because "any time people are in the hospital, they are scared." Fear, in turn, can "promote a kind of denial and a pushing away of the things they are most scared of. People deny when their backs are against the wall, and they can’t allow themselves to take things in."
This kind of denial, which is extremely common, "can cause us to feel frustration with a patient in the hospital," Dr. Block said. "It makes us get angry with the patient or distance ourselves."
Take this common type of difficult patient: know-it-alls who come in loaded with information from the Internet or their friends and who won’t accept anything different from their doctors. This is often the response of patients who are very anxious or people who may be used to being in charge of their personal life, a control that’s now upended by illness.
Many times, said Dr. Block, these sorts of conflicts are less about personality disorders and more about the communication skills of the health care team. Dr. Block recommended that physicians try to turn such a scenario around by recasting it. "This is the empowered patient," she said. "In some ways, he is doing what we want him to do “take care of himself, be a good advocate “but he may not have an appropriate amount of perspective to interpret the anecdote or the article."
In such a circumstance, physicians may find it effective to align with the patient, praising him or her for the efforts at self-care and asking for permission to offer some guidance and perspective on all the information.
And when dealing with such patients, Dr. Block said, it helps to respond with empathy and to refrain from feeling like you’re being attacked, which will just cause the tension to escalate further.
Good doc/bad doc
Another common behavior of difficult patients is a dynamic called "splitting," where patients identify one clinician as the "good doctor" and make that doctor feel great, while identifying others as bad doctors or bad nurses.
"It ends up creating team stress," said Dr. Block. "The nurses will be saying this patient is awful, and the doctor will be saying, ‘I don’t know what they are talking about.’"
When there appear to be big differences in how different clinicians view a patient, it is useful to get the different clinicians together as soon as you recognize the growing tension.
That way, people can share their points of view and help each other gain perspective on how the patient’s personality might be contributing to tension within the team. "Such a meeting can be helpful in developing a common treatment strategy for the patient, so that the patient is getting a coherent and consistent message from everyone on the team," Dr. Block pointed out.
Then there’s "projective identification," where a person “usually someone with a significant personality disorder or psychiatric illness “experiences an emotion, such as anger, and transfers that emotion to someone else, including the doctor.
"It sounds weird, but it’s true, and we see it all the time in the hospital," Dr. Block said. "You start feeling the patient’s anger, and you start acting in an irritable fashion, which then confirms the patient’s feeling of anger, and it escalates."
The first step toward deescalating the situation and gaining some control is to recognize one’s own responses, and then reflect on where the anger is coming from.
"If your introspection leads to the understanding that the patient may be angry, it can be helpful to take the patient’s perspective, perhaps, and ask the patient what it is like to be worried that the doctors are angry at him or her," Dr. Block said. "This builds an alliance with the patient and can defuse the patient’s anger."
In terms of differential diagnoses, Dr. Block said, physicians should think strongly about everything from depression, anxiety and somatization to substance abuse, history of trauma and financial difficulties. A depressed patient, for instance, may be particularly unresponsive or overly negative, while an intensely anxious person may not be willing to trust anybody.
People suffering from substance abuse disorders can be manipulative. And patients struggling with poverty and financial problems may be seen as willfully non-compliant when they may want to adhere to clinical recommendations but don’t think they can afford to.
To address such issues, Dr. Block said, physicians need to share the burden and call in appropriate specialists. Psychiatrists and social workers are trained to deal with issues that internists are not.
Then there are the most difficult of the difficult: those with personality disorders, including the paranoid, antisocial, histrionic, dependent, narcissistic, borderline and obsessive-compulsive. For these patients, Dr. Block again recommended that hospitalists call on psychiatric and social work colleagues for help.
And if psychiatric consults are hard to come by, said Dr. Block, medications that can help during a hospitalization include SSRIs to treat anxiety and depression, mood stabilizers and antipsychotics to treat impulsivity, and antipsychotics to treat paranoia and distorted thinking. However, physicians should avoid prescribing benzodiazepines because the drugs often reduce patients’ ability to control impulses, a common problem in many patients with personality disorders.
Dr. Block also pointed out that doctors should consider their own personalities and likes and dislikes when struggling with patients they find to be a challenge.
"We like certain people and we don’t like others," she noted. "Certain things are hot buttons for us, and others are not. The emotions that a patient stirs up in us “whether it is boredom or worries about our competence “are emotional responses that affect our clinical behavior."
Personality traits that can get physicians into trouble include having a strong need for control, being uncomfortable with displays of emotion or with particularly needy patients, being unable to set limits, and having "unrealistic expectations" for how a patient should behave. Any one of these can lead to feelings of frustration and anger on the part of a physician.
One example of unrealistic expectations is the patient who keeps demanding pain medications when physicians feel he or she has had enough, a situation that hospitalists attending the session said they frequently encounter. "Our expectations are not aligned with those of the patient, and that creates frustration," she said.
But Dr. Block recommended that hospitalists remember that there is a much bigger problem with under-prescribing inpatient pain medications than overprescribing. "I think there is less risk to being bamboozled in the hospital than leaving someone in pain," she said.
Half the battle, she suggested, is understanding yourself and your own psychological makeup so you can control your side of the relationship and not escalate an already fraught situation.
At the same time, doctors have to work to set limits, Dr. Block said, be able to say "no" and stick to it, and stop worrying about whether or not a patient is going to like them. The key in setting limits, for example, is to do so before your own anger has a chance to escalate “and to do it in a gentle, firm and non-punitive manner.
"As physicians, we also have an obligation to protect our colleagues from unacceptable behavior from patients," Dr. Block pointed out. That means sometimes having to step in to tell patients that mistreating a nurse’s aide or a housekeeper will not be tolerated and will make it harder for them to get the best inpatient treatment because people will be afraid of them.
"Patients who are behaving badly in these circumstances," Dr. Block said, "are often, when gently confronted, able to gain some control over their behavior.
Take only your fair share
Dr. Block also offered this advice: Individual doctors shouldn’t become their group’s designated point person for difficult patients simply because they are better at dealing with such patients than their colleagues. Having to deal with more than your fair share, she said, is a recipe for burnout, so make sure you don’t keep loading up your daily panel with patients your colleagues don’t want to see.
"If you are a magnet for these patients, you need to negotiate some limits," said Dr. Block. "Self-care is important, and these patients make us feel generally lousy."
Deborah Gesensway is a freelance writer who covers U.S. health care from Toronto.