Introduction and the History of “Difficult Patients”

What makes a patient difficult? Any number of explanations may suffice: challenging diagnoses, complex and imperfect treatments, or vexing system issues converging in a single case. Most challenging perhaps are the difficulties which arise not through the technical challenges of biology or operational obstacles of modern healthcare, but from the difficulties which arise between two people: the provider and the patient. This paper will summarize recent developments in managing the latter issue which—as the evidence will suggest—is more about the relationship than about the patient.

Illness, pain, anxiety, and uncertainty do little to soothe one’s temperament. These states are common, expected, and even requisite in the experience of many patients. These states can also contribute significantly to irritability and frustration. It is little wonder, then, that some patients may be seen by their providers as difficult. A bit more wondrous, perhaps, is the time it has taken for perceptions of difficult patients to evolve since early concepts of “hateful patients” in need of restraint and medication [1, 2].

Much of early literature on difficult patients categorized problems in terms of patient behaviors such as care avoidance, ambivalence, and demandingness [3]. After a generation, medicine is beginning to look past blaming patients for difficult relationships. Recognizing and responding to the role of physicians and other providers in perpetuating disruptive relationships—and their critical role correcting these issues—has become the central theme as well as a regulatory priority in modern medicine [4]. This should not be taken to justify or excuse intentionally disruptive behavior by patients or family members; this is a significant issue, with as many as 80% of practices dismissing disruptive patients in a 2-year time frame [5]. Rather, it is intended to stress that the patients do not bear responsibility alone for problems in the relationship between themselves and their providers and the providers—as professionals—may have a special duty to correct these conflicts.

Earlier approaches to difficult patients amounted to defusing the provider’s hostility and countertransference while creating protective shells around the provider and patient alike. More progressive approaches suggest that while such countertransference can be extremely disruptive to the doctor-patient relationship, it is best used as a telltale. When a clinician notices such strong feelings, it should be a signal to step back and reflect on what is not working in the relationship and how they, as a provider and a professional, can act to improve the relationship [6••].

Further, it has been compellingly argued that physicians have an ethical duty to rebuild and correct such pathological relationships when feasible and to consider a positive relationship as central to the purpose of healthcare [7]. A broader, integrated perspective on the centrality of the relationship to the mission of healthcare emphasizes that there are mutual and reciprocal responsibilities between the patient and provider [8]. Patient complaints may be rightly seen as the leading indicator of problematic relationships and processes making their recognition and management of the utmost importance [9, 10].

As perspectives on the nature of difficult relationships have evolved, new models and interventions have been developed. The medical field has developed better approaches to understanding complaints, the link between disruptive and difficult relationships and adverse outcomes, and the use of de-escalation and mediation to mitigate adverse outcomes. Verbal de-escalation, an intervention rooted in emergency psychiatry, has been embraced not just across medicine but has begun to penetrate other fields as well. This paper will summarize relevant and recent developments in the field of difficult clinical relationships.

Disruptive Relationships Impact Team Performance

Numerous factors can contribute to anger or hostility from patients. Some of these factors may be intrinsic to the patient or family member, some to the environment, some to the provider. Such emotional displays can be unsettling to providers and impair optimal decision-making. The role of emotion and stress in disrupting complex decisions related to future outcomes, risk, and complex tasks has been well studied for generations and are well recognized as factors in clinical scenarios as well [11•, 12, 13]. It is little surprise then to note that the rudeness or hostility of patients or their family members can significantly decrease the quality of medical decision-making by their providers as has been shown in at least two recent empirical studies [14, 15•]. Many clinicians can relate to the experience of feeling unsettled or distracted when an initial approach to a patient or family member is interrupted with unexpected, and hostile.

Reassuringly, one of these same studies also identified interventions that can be taught to providers to mitigate the impact of such behavior [14]. Inviting structured feedback early from parents of children with complex care needs can be helpful in improving outcomes and decreasing complaints [16]. By proactively identifying patient and family needs and preferences in cases anticipated to be highly complex or particularly conflictual, it is possible to avoid unneeded misunderstandings, assumptions, or conflicts later on. This approach seems similar to the use of recovery plans and advance directives which have been beneficial in mental health and medical settings alike.

Complaints Matter

Complaints can be a leading indicator of concerning provider behavior and systems issues and warrant careful monitoring and thoughtful response [9, 10]. Capturing complaints can be challenging; complaints may be handled at multiple levels or locations within an organization with varying degrees of capture of cases or specific information. When enough data is collected, identified trends and patterns can suggest problematic processes and behavior patterns which can be corrected. When there is inadequate information in the complaint feedback process, it is intrinsically difficult to identify appropriate targets for performance improvement. Critical steps include centralized reporting, simplified complaint reporting processes, and improved cultural engagement with the intention of improving response times and satisfactory resolutions [17].

Assuring that specific feedback is delivered to appropriate providers is a recurring theme and may provide an early opportunity to correct behaviors leading to increased risk of malpractice litigation [18]. In addition to the specific feedback, deliberate and structured interventions to improve provider performance are critical. Patient complaints may not be evenly distributed: most providers will incur some complaints but the high-complaint outliers can be a high yield target for supportive intervention [19]. Comparative data between providers can help identify high-risk outlier providers and serve as a useful metric for individual providers reflecting on their performance compared to their peers. Few physicians—or other providers for that matter—like to think of themselves as in the lagging quintile.

Similarly, using consistent approaches to responding complaints and delivering bad news may be helpful. One simple model for responding to complaints uses the mnemonic BLAST: Believe, Listen, Apologize, Satisfy, Thank [20]. These elements are not necessarily unique to the domain of medical apologies but the mnemonic may be a useful tool for providers.

Adverse events and complaints both can have a significant deleterious effect on providers. The emotional impact can be staggering ranging from changes in clinical practice patterns, increased self-doubt, worry and anxiety, and even an increased risk of suicidal thoughts [21•, 22•].

Informed Consent as a Tool to Improve Engagement and Alignment

A simple—even fundamental—intervention to decrease complaints and conflicts can be improvements in the informed consent process. Often informed consent is seen as a cognitive exercise to explain and assess a patient’s preference between two interventions with an emphasis on the technical and quantitative aspects of the procedure and the outcomes. Done properly, however, informed consent can also be a powerful tool for exploring patient and family expectations, beliefs, feelings, and fears. In most settings, the technical aspects of obtaining informed consent are more than adequately met however the opportunity to explore the more affective elements of the process may be missed.

Complaints about the informed consent process can consume significant organizational resources in proportion to other types of complaints [23]. This would suggest that effort spent optimizing informed consent at the beginning of a sequence may be rewarded with savings in time spent fielding and managing complaints downstream.

A critical element of informed consent is assuring the patient or decision maker appreciates the nature of the decision at hand. While the concept of “appreciation” is often seen as a process dependent on the patient’s understanding, in many ways, it also directly reflects the efficacy of the process by which the clinical situation and options are explained to them by the provider. Some scholars have suggested that there is significant operational room and ethical need to improve the informing stage of informed consent to assure better understanding by the patient [24]. Significant recent research looking at improving the consistency of information provided and using multimedia tools, including prerecorded materials, can significant improve the quality of the informed consent process [25,26,27]. Prerecorded and printed materials can also assure that a uniform minimal standard of information is provided to all patients seeking similar treatment at a facility. In the context of medical ethics, this approach deftly supports both autonomy and justice.

Malpractice Risk and Complaints

A bad relationship between a provider and a patient as may be evidenced by negative affect or overt complaint may be a significant—and potentially correctable—risk factor for malpractice suits [28]. The correlation between hostility towards a provider and perceived hostility from a provider have long been recognized as risk factors for medical malpractice litigation [29•, 30•]. To wit: patients do not sue merely because of bad outcomes, but also—and significantly—because of bad feelings.

While providers may excel at discussing technical aspects of their care, communication with a patient about their emotions relating to high-risk procedures can be lagging [31]. A perception of a lack of empathy from the physician may drive malpractice litigation risk. Difficulty in communicating complex alternatives between different treatments can drive frustration [32]. Improving these “soft skills” may prove a useful strategy to improve the quality of care and decrease litigation risks. Interestingly, some of these same communications problems—especially processes which drive provider shame or anxiety after adverse events—can occur at a systems level. When such systems issues occur, malpractice risk may increase as incidents go unreported [33]. Open, supportive communication by doctors to patients and by hospitals to doctors can make a significant impact in decreasing adverse outcomes: further empirical evidence of the value of a just culture model of promoting safety [34].

There continues to be evidence that some providers fuel animosity of patients towards other providers through negative, critical, and undermining comments [35]. Put colloquially: we tend to throw each other under the bus. This finding is particularly alarming when one recalls past research where derogation by another provider can be a trigger for a patient to pursue a malpractice complain [29]. Any number of factors can contribute to this dynamic but hindsight bias—the cognitive error of judging a process by the outcome—is often a factor [36••]. A more psychodynamic interpretation would be the aphorism from work with patients with borderline personality that the patients do not split the providers but the providers allow themselves to be split.

Malpractice attorneys look at a number of factors beyond the purely academic criteria of negligence in choosing to pursue a case. Factors such as the relative likability of a provider versus a patient—the optics, if you will—can play a significant role in how attorneys respond to potential cases. So too can the perceived payout for a settlement or plaintiff verdict [37, 38]. A physician who is seen as cold and uncaring or unlikable, no matter how technically proficient, can become a more appealing target for litigation because attorneys are very aware of how jurors perceive and sympathize with different parties in a malpractice case.

Frequent complaints and low satisfaction scores about specific providers may be a useful predictor of future malpractice risk [39]. With the increasing prevalence of patient satisfactions surveys, this data can prove to be a useful tool in supervising front line providers about effective patient communication—and, perhaps, the opportunity to decrease the risk of litigation may prove a useful motivator for the supervisees. Patient feedback scores in isolation and without structured feedback and improvement plans may be of limited value [40]. Peer counseling amongst professionals may be one effective way to provide performance improvement coaching for providers with interpersonal issues leading to complaints and low patient ratings [41].

The Medical Apology

The connection between well-delivered apologies and decreased risk for litigation has long been examined with new and more sophisticated research supporting this position [42•, 43•]. Apologies are not a panacea but can serve to defuse common sentiments in litigants including feeling unheard, excluded, or disrespected by the clinical team. Critical elements of effective apologies have been identified, including empathy, disclosure, and possibly early offers in the context of bona fide error that appear to be essential to providing effective apologies [44, 45].

Formal organizational processes and explicit culture supporting disclosure of errors can help counterbalance physician reticence to disclose errors [33, 46]. Preference for alternative dispute resolution pathways including apologies, mediation, and early offers seems to be ethically, legally, and even financially preferable for the organization [47, 48]. Practical manuals built on providing excellent customer care up front and appropriate service recovery through structured apologies after adverse events remain widely accepted and easily followed guidance [49, 50]. There is some continued debate as to whether state apology laws alone have any impact on malpractice risk, suggesting that it may require more than mere apology alone to mitigate malpractice risk after adverse events [51].

Providers Are Impacted by Adverse Events

The psychological impact of adverse outcomes on treatment providers can be significant, leading to the idea of “second victims” [22•]. The impact ranges from primary psychological distress (including suicidal thoughts), anxiety, stress, decreased work performance, and discord in social and romantic relationships. Failure of timely feedback or organizational support for second victims can prolong or worsen the impact [52••]. Knowing that disruptive and difficult patients can lead to increased medical errors, one can easily imagine a frequent sequence of initially difficult interactions, which in turn increase the likelihood of errors and enough hostility to pursue litigation, and the subsequent psychological impact on providers [14, 15•]. It is bad enough to face a lawsuit for a bad outcome; for a provider to be left wondering if initial shifts in treatment due to early patient complaints or resistance contributed to such an outcome is especially vexing.

Mental Health Consultation Can Help with the Management of Difficult Patients

Psychiatric consultation in the general medical setting has historically been a dual role: manage the psychiatric and behavioral health of the medical and surgical patients (consultation) and provide coaching and guidance in navigating difficult interpersonal relationships between patients and providers (liaison). The role of consult liaison psychiatry has taken a more central role in medical settings with the advancement of integrated medicine models in inpatient and outpatient settings [53, 54]. Optimally, integrated care models will allow improved coordination and collaboration between mental health and physical health providers in many settings. One of many potential benefits of integrated care is improved ability to quickly manage angry and difficult patients. Multiple studies continue to show that psychiatric or psychological consultation continues to be significantly helpful for medical teams dealing with difficult relationships with a patient [55, 56].

Training Can Improve Provider Readiness to Handle Conflict

Improving communication and empathy in providers is seen as a critical avenue to preventing and managing difficult interactions [57, 58]. Research has identified several factors in supporting staff responding to behavioral emergencies: negotiation skills and improved self-awareness play a prominent role [59]. Empathy and emphasizing treating people with dignity and respect are also identified in playing a key role in supporting family members and waiting patients [60]. Simulation training can be extremely helpful in helping professionals improve their communication skills for more challenging interactions [61]. One innovative program exposes professional students to customer service through mentored work as a reception desk to improve interpersonal and problem solving skills [62].

De-escalation: One Tool That Can Help in Many Situations

De-escalation is a systematic approach to defusing anger and agitation through verbal engagement, development or restoration of a collaborative relationship, and helping the person manage their own emotions through verbal techniques. This model has become a gold standard of first-line intervention for behavioral emergencies in psychiatric and emergency settings [63••]. The process and elements of verbal de-escalation used in managing behavioral emergencies overlap substantially with critical elements of apologies after adverse events and service recovery after complaints as outlined above. The elements are also similar to mediation and problem focused negotiation [64, 65]. The tools all address safe and effective approaches to correcting conflict while defusing intense emotion and play a critical role in many clinical settings [66]. While frontline practitioners can be taught effective techniques, improved and quantifiable approaches to measuring and modelling de-escalation will help develop this model further [67]. Recent national controversies about the use of force by law enforcement have become commonplace. In response, numerous law enforcement groups have endorsed a unified policy on the use of force which emphasized the role of de-escalation as a preferred intervention before any physical intervention when possible [68].

Conclusion

The last 5 years has seen continued movement from the concept of difficult patients to the recognition of difficult relationships where systems and provider factors can also play a significant role in creating and maintaining conflict. Simultaneously, methodologies for managing conflict have converged from across several service areas, most relevantly, in responding to complaints, apologizing for errors, and de-escalating agitation. Organizations may benefit from using conflict and complaint management models which not only meet the minimum regulatory requirements but which proactively explore, engage, and manage potential system and employee issues to decrease future risks.

As a parting consideration, note the following poem [see Box 1 below] that the author first saw in 2010. The original source remains unknown. It does an exceptional job of articulating the experience—and nidus of distress—for so many patients in modern healthcare facilities. The content is noteworthy, but so too is the context: it was found in a staff lounge at a general hospital’s security department. It was there, framed, as a reminder to the team to remember every day the experience of the people they care for.

Box 1 An anonymous poem expressing patient experience
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