Difficult patients. Sigh! (Impact of patient requests on provider-perceived visit difficulty in primary care)

"No ma'am, your thumb isn't broken. I suspect the pain is as a result of pressing your call bell over 43 times in the last hour."

"No ma'am, your thumb isn't broken. I suspect the pain is as a result of pressing your call bell over 43 times in the last hour."

Sometimes physicians talk about the "difficult" patient with exasperation in their voice.  Nurses know these cases even better.

Most patients and families can tell your about a doctor or nurse who was terse, arrogant, disinterested, or even callous.

These encounters can be "soul-sucking," "difficult," and "draining." The individuals are labeled as "entitled," "unrealistic," "demanding," or ... worse.

That's not ideal terminology although the truth is that some patient encounters are harder than others, and we can't always figure out why. If we have a frustrating appointment, we equate the difficulty with the person, not the situation. As physicians, we often blame the patient!

"It's a personality disorder." "She's a rich, demanding snob." "He refuses to accept this."

On the surface are our attitudes, biases, and skill sets. Just like "difficult" doctors, "difficult" patients are, in our eyes, not open-minded, have not mastered skills of effective communication or listening, don't want to be told they are wrong, demand ridiculous things, or dig their heels in despite evidence that contradicts them.

Sometimes stubbornness is advocacy and it is necessary. Sometimes asking lots of questions is essential to developing an understanding from which a partnership can follow.

There is usually more to the story than just a clash of the personality of the clinician and the patient, and the health care provider should be sensitive to this; empathy means acknowledging that other people have "stuff" going on in their life. Fear, anger, embarrassment, uncertainty, and anxiety are among the many emotions that can make a clinical exchange sour.

With time and worldliness, and maybe some training, we grow and learn to help sort through that. Interestingly, the kind of encounters that health care providers find difficult are generally around people asking for tests.

According to Fenton et. al's paper, Impact of Patient Requests on Provider-Perceived Visit Difficulty in Primary Care, in the Journal of General Internal Medicine:

[Primary Care Provider] (PCP)-perceived visit difficulty is associated with patient requests for diagnostic tests, but not requests for pain medications or specialist referrals. In this era of “choosing wisely,” PCPs may be challenged to respond to diagnostic test requests in an evidence-based manner, while maintaining the provider–patient relationship and PCP career satisfaction.

They looked at 824 clinical encounters. Even adjusting for medical and psychiatric conditions, it was asking for tests that made clinicians rate the encounter as more difficult.

Fortunately, there are tools to help with this. A (not well curated) collection of Shared Decision Making tools is available on this site. Another time, I'll write about the evidence of efficacy (or lack thereof?) behind these aids.

The Choosing Wisely campaign is a prominent effort to facilitate these conversations about unnecesary tests. The Canadian and American sites both have many educational resources to help us with discussing diagnostics and therapeutics, and the AAFP has a great article on difficult patient encounters

It's not rocket science. We must remember that patients are human beings. Hopefully they will extend us, as providers, the same consideration.

At least he used the sensitive kind of tooth paste?

At least he used the sensitive kind of tooth paste?

Finally: yes, some people, whether doctors, patients, nurses, or family members, are just plain jerks.

Source: http://www.ncbi.nlm.nih.gov/pubmed/2537383...