Alone or in combination, various patient, physician, and healthcare environment issues can contribute to patients being perceived as difficult. And, since physician burnout can both increase the incidence of challenging patient encounters1 as well as result from these encounters,2 reducing physician burnout stressors and reducing the factors contributing to physician-perceived difficult encounters could help mitigate both.
What causes a patient to be perceived as difficult is generally not associated with a challenging medical issue. The “difficult” label tends to attach to a patient who provokes a negative emotional reaction from their physician. When a patient encounter becomes difficult, physicians often focus on that patient as the source of the problem, but a combination of factors usually contributes to a difficult patient encounter.3,4
Patients and physicians bring a unique frame of reference and set of expectations to medical encounters, which partially explains why a patient who is considered difficult by one physician may not be considered difficult by another physician. The treatment environment can also contribute to the difficulty of the circumstances. Recognizing and addressing the issues that make the patient encounter difficult can mitigate the stress of treating these patients and reduce the risk that the encounter will contribute to physician burnout.3,4
Studies indicate that various social and medical conditions commonly predispose a patient to being considered difficult, including:2,4,5
If the root of the difficulty is the patient’s underlying health issues (e.g., behavioral health, somatoform disorders, obesity), referring the patient for treatment with a specialist may alleviate some of the strain associated with treating the patient.
Studies also indicate that a physician’s personality, work style, and belief system can contribute to their perception that a patient is difficult. Physician factors that can increase this probability include:2,4
When a patient encounter becomes difficult and patient or environmental factors do not seem to be driving your discomfort, consider whether an adjustment to your point of view might resolve the tension.
Difficulty during a patient encounter may be exacerbated or caused by forces outside a physician’s or patient’s control, including2,3,6,7
Difficult patients have been categorized in various ways. Resources and strategies for managing different types of difficult patients overlap somewhat. For example, a common physician stressor when dealing with difficult patients is managing the time-intensive nature of these encounters but in many instances the resources and strategies are unique to the particular type of patient.
Patients seeking opioid prescriptions can contribute to physician burnout and physician burnout may be a contributing factor to the opioid epidemic. It can be a vicious cycle, but physicians can use these strategies for managing drug-seeking patients to break it.
Low patient activation, low health literacy, inability to pay for treatment, and behavioral health issues may all contribute to a patient’s failure to comply with treatment recommendations. This patient noncompliance is among the stressors that can result in physician burnout. Helping non-compliant patients overcome barriers to adherence may reduce the frustration associated with patient noncompliance that can contribute to burnout.
Angry Patients and Violent Patients
Dealing with angry, verbally abusive, or violent patients can contribute to physician burnout. Many of the triggers of patient anger are avoidable, or at least can be moderated. Often, understanding what is causing a patient’s anger can help de-escalate it and direct the follow-up after an outburst. In some cases, though, angry patients can escalate to violence. Physicians and other healthcare workers are frequent victims of violence by patients, patients’ family members, and visitors. Physicians can protect themselves and the people around them with preparation, training, and strategies for responding to angry or violent patients. De-escalation training, preparation, and knowing how to respond when a patient becomes angry or violent is the key to preventing and successfully managing these patient encounters.
Patients who self-diagnose based on internet research can contribute to physician burnout by combining three of its contributing factors: time pressures, lack of patient trust, and lack of control over managing a patient’s healthcare. Because these kinds of patients are unlikely to be satisfied with passively receiving medical information from their physicians, physicians instead can use patient-supplied internet information as a patient engagement and activation tool. Appointment time management strategies can help physicians control internet content discussions so that they don’t run over the appointment time. Managing patients who self-diagnose via the internet can help reduce physician burnout as well as provide an improved patient experience and better treatment results.
Particularly in a busy practice with tightly scheduled appointments, very needy patients can become overwhelming. The disproportionate need for reassurance in some patients can contribute to physician burnout. Various strategies can be used to reduce the stress associated with managing overly needy patients, including improving reassurance skills, establishing appropriate patient expectations, setting boundaries on your availability, and better management of appointment time. Establishing more control during these encounters can reduce the stress and frustration that feed physician burnout.
Preparation is the key to successfully addressing challenging patients in office practice. Setting expectations for patient behavior at the beginning of the physician-patient relationship can signal to patients that violent, disrespectful, aggressive, overly needy, and drug-seeking behavior will not be tolerated. Patient rights and responsibilities statements or patient brochures are two ways to communicate behavior expectations and help prevent disruptive patient behavior from causing physician burnout.
While appropriate termination of treatment is an option for repeated or extremely disruptive patients, not all challenging patients need to be dismissed from the practice. Some patients may need a reminder in the form of patient behavior agreements or written warnings following an incident. Once a patient is informed of behavioral expectations and the consequences of violating expectations, they may cease being problematic. If the patient’s behavior continues to be problematic, strong policies and documentation can facilitate termination of treatment in a manner that minimizes the risk of an abandonment claim. If a patient does file such a claim, evidence of policies and documentation can help successfully defend the allegation. Consider the following strategies:8
Patient Behavior Tools
Termination of the Patient Relationship
Service Recovery and Unanticipated Outcome Resources
Challenging patient encounters that damage or strain the physician-patient relationship present the physician with a decision to attempt rehabilitating the patient relationship or terminating treatment. Different kinds of challenging patients require different management and follow-up strategies. For example, de-escalation strategies may be too dangerous if the patient has a weapon. In those cases, call police or security. Immediate termination of treatment is also appropriate.
On the other hand, patients who are challenging because of a perceived service failure might be successfully calmed to a degree that the basis for their anger can be discovered and remedied. In that case, the appropriate follow-up might be a behavior warning or a patient behavior agreement. Sometimes, challenging patient behaviors destroy the therapeutic relationship. Termination of treatment with proper notice may also be appropriate in those cases.
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More Information on Managing Challenging Patients
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1. Elizabeth S. Goldsmith, Erin E. Krebs. “Roles of Physicians and Health Care Systems in ‘Difficult’ Clinical Encounters.” AMA Journal of Ethics, 2017;19(4):381-390.
2. Rosemarie Cannarella Lorenzetti, et al. “Managing Difficult Encounters: Understanding Physician, Patient, and Situational Factors.” American Family Physician, 3/15/2013; 87(6)419-425.
3. Leonard J. Haas, et al. “Management of the Difficult Patient.” American Family Physician, 11/15/2005; 72(10):2063-2068.
4. Dov Steinmetz, Hava Tabenkin. “The ‘Difficult Patient’ as Perceived by Family Physicians.” Family Practice (2001) 18 (5): 495-500.
5. Cora Collette Breuner, Megan A. Moreno. “Approaches to the Difficult Patient/Parent Encounter.” Pediatrics. 1/1/2011;127(1):163-169.
6. Medical Protection Society. “The Challenging Patient.” Casebook. May 2009;17(2):12-14. (resource not available online)
7. Eric D. Morgan, et al. “Continuity of Care and Patient Satisfaction in a Family Practice Clinic.” The Journal of the American Board of Family Practice. September 2004;17(5):341-6.
8. NORCAL Mutual Insurance Company. “Termination of the Physician-Patient Relationship: Breaking Up is Hard to Do.” Claims Rx. April 2020.