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Introduction

The physician-patient relationship is an incredibly special and close bond. It is often the most rewarding part of our jobs, the thing that sustains us and keeps us motivated. The relationships we build with our patients can span their lifetimes, bringing us much fulfillment and joy. But there will be times when we are faced with a less than rosy encounter, a troublesome request, an abusive patient. Though this may be discouraging and frustrating, there are tips and tools you can use to navigate even the toughest encounter. We must also realize that patients aren’t the only ones who can complicate a visit. Good doctors are aware of their own baggage, their own unconscious biases, and their own outside of work issues. By knowing yourself well, and recognizing when you are feeling stressed or trapped, you can take steps to diffuse the situation and engage the patient in a more productive way. This chapter will explore common categories of patient and physician factors contributing to challenging encounters, as well as the best way to end a clinical relationship if it becomes necessary.

Common Types of Challenging Patients

Angry/Defensive

Patients often come in with a preconceived notion of what will happen, for better or worse. They may be convinced they won’t be heard, sure they are in for a fight to get what they want, or feel like they have to prove their symptoms. Look at body language to see if a patient is angry. Let your office staff know you welcome their feedback about how interactions went with the patient as they were checking in or being roomed. A tip-off from the staff is a great help and keeps you from being blindsided. Try to talk to the patient about what they are seeking but don’t get drawn into drama. Ask direct questions such as “What most worries you today?” or “What are you most afraid of?”. Help the patient gain control of their own emotions and let them know you are on their side: “I’m here to help, and listen to you.” Stay calm and empathize with the patient as much as possible, using reflecting language such as “I can see why you are upset.” Follow that up with suggestions to improve their situation. Recognize your own triggers if they are present, and if you need to, step away to take a minute to regroup. If you feel physically threatened, or are worried your staff is in danger, separate yourself from the patient and ask for assistance from security or law enforcement.

Manipulative

This is the patient who uses guilt, threat of lawsuit, rage, and/or foul language to make their point and try to get what they want. They may tell you they will sue you if you don’t order a specific test they are demanding or accuse you of not doing your job or caring for them properly if you don’t prescribe a requested drug. Again, stay calm, be very aware of your own feelings and reactions, and do not escalate the situation. Be clear about boundaries. Try to understand the patient’s expectations but do not be afraid to say no to unreasonable, futile, or harmful requests.

Somatizing

This is the patient who comes in with a very long list of vague complaints to be addressed in one visit, the patient who perceives themselves “allergic” to a vast array of medications, who may present with exaggerated symptoms or complaints out of proportion to a diagnosis. They may also suffer from comorbidities such as anxiety or depression. They may be coming to you after “doctor-shopping” in the hopes that you, at last, will fix them. Be empathetic and practice active listening with this patient. Schedule longer visits with him, if possible. Be clear that you are partnering with him and offer frequent return visits so he knows you are going to stay on top of his care. Close follow-up often allows the patient to accept your management decisions more willingly and can help you to avoid unnecessary diagnosis tests and studies. And be sure to explore and treat any comorbidities.

Anxious

You may have heard this type of patient referred to as a “frequent flyer.” These folks may be too scared to ask the question they really want the answer to, and so come in often and with so many other questions to distract themselves. Or they may also be coming in frequently with very reasonable questions, just needing to be reassured time and time again. As with any challenging patient, be empathetic and try to identify the real issue they are facing. Do share with them that you have noticed their frequency of visits and use that as a jumping off point to see if they are having worries about undiagnosed symptoms, if they need extra reassurance, if they are having chronic pain or are simply lonely. Letting these patients know you understand their reasons will go a long way toward securing trust, thus encouraging them to open up with their real worries. As with the somatizing patient, don’t shy away from scheduling frequent follow-ups.

Common Physician Pitfalls

Doctors’ own attitudes and behaviors can also be part of the problem:

Fatigued Doctors

Many of us have been overworked at some point in our career. It feels like we are always being asked to do more with less, and this feeling of learned helplessness and the daily stress of being a healer can cause serious burnout. Prevention and remedies for burnout are beyond the scope of this chapter, but being aware of the possibility and seeking ways to diffuse stress in our lives is a cornerstone. Don’t be afraid to say no to commitments, delegate tasks to others when possible, and take time for self-care.

Dogmatic Doctors

None of us would be where we are if we didn’t have a certain amount of confidence in ourselves, and a deep devotion to our own beliefs and education. But when that confidence undermines our ability to see situations from another’s point of view, when it keeps us from exploring all the options, it can be a real barrier to good patient care. Identifying our own triggers yet again is so useful, ensuring we can avoid instances where our bias would impair our judgment.

Angry Doctors

If you are angry about your job, your personal life, your financial situation, you will be a less effective doctor and more likely to contribute to a less than ideal patient experience, regardless of whether the patient is challenging or easygoing. As with any job, it becomes incredibly important to check yourself and leave your emotions at the door. Stay calm, be proactive instead of reactive, and take a deep breath!

Common Difficult Situations

In addition to physician and patient factors, be aware that there are some situations which can lend themselves to difficult encounters. Patients accompanied by many people, language barriers, the giving of bad news, and a chaotic office environment all can be challenges. In each of these situations, do your best to optimize the visit: if language is a barrier, use a vetted interpreter rather than a family member. If giving bad news, ensure you make good eye contact, use clear language, and establish how much the patient wants to know before proceeding. As with so many situations, good communication, with an open heart and mind, is the key.

Dismissing a Patient from Your Practice

Despite your best efforts at nurturing the doctor−patient relationship, there may come a time when you feel the need to dismiss a patient from the practice. It is vital that your office has a set procedure already established and that this procedure is followed to the letter and documented fully, in each instance of dismissal. Reasons to dismiss may include failure to pay for services; failure to comply with care including frequent no-shows; verbal or physically abusive behavior toward the provider or office staff, both actual and threatened; a disconnect in fundamental philosophies of health, wellness, and illness, for example, unwillingness to vaccinate; or clear doctor-shopping or medication-seeking behaviors.

Dismissal Policy Considerations

  • Consider having a discharge warning in place in the protocols: this allows you to inform the patient of their unacceptable behavior/action and allows them a chance to change them while also letting them know that discharge will be the next step otherwise.

  • Under no circumstances can you dismiss a patient for any basis protected by law, such as ethnicity, race, religion, gender, HIV status, etc.

  • You must absolutely avoid patient abandonment, which is the unilateral dissolution of the therapeutic relationship without notice to the patient sufficient enough to allow them to procure the services of another physician when still in need of medical attention/care; this can be considered medical malpractice.

  • “Reasonable notice” is the key: if it is not otherwise stated in the payor contract, most sources consider 30 days reasonable, with the consideration of 45–60 days if you are in a specialty or location where it is difficult to find equivalent care

  • Check with payors, managed care contracts, and your institution (if you have one) regarding their specifications around termination of the therapeutic relationship.

  • It’s a good idea to have your legal team or risk management team review your policy once established.

Dismissal Process

  • Dismissal letter: A standard termination letter in writing, on practice letterhead, containing four elements: the notification of the dismissal, the effective date (usually 30 days from notification, see above), the reason for the dismissal, and the process whereby the patient can have their medical records sent to a new provider once the office receives this request in writing.

  • List of alternative providers: There are pros and cons to this − some sources suggest including a list while others caution against referring dismissed patients to colleagues; legally it is not required.

  • Communication with the entire office staff: Make sure the staff is aware of the patient’s dismissal date, to avoid accidentally reestablishing care.

  • Provision of care until the dismissal date: Make sure to be clear that your office will still care for the patient in the timeframe from the notification of dismissal until the actual dismissal takes effect; without this, you could be held liable for patient abandonment.

  • Document, Document, Document: A copy of the letter should be enclosed in the patient’s chart, and their response, if in writing, should be included as well; also include a copy of the written consent from the patient to transfer records to the next treating physician, when it is received; some sources suggest certified mail, while others support the use of regular mail; if you choose certified, keep a copy of the certification in the chart as well.