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Experiencing Difficulties

By Jock Hoffman, CRICO

Related to: Ambulatory, Communication, Emergency Medicine, Primary Care, Nursing, Obstetrics, Other Specialties, Surgery

While TV’s Seinfeld famously exposed the “difficult patient” phenomena, nobody laughs when a sour physician-patient relationship is referenced during a medical malpractice trial.

Even a cantankerous or serially non-compliant patient will earn a jury’s empathy if there is evidence that defendant clinicians allowed poor patient rapport to interfere with the appropriate pursuit of a diagnosis and treatment. Physicians at odds with their difficult patients risk their own reputations.

An adverse outcome combined with a difficult physician-patient relationship is rich soil for malpractice litigation. Across the CRICO-insured settings, cases featuring a difficult physician-patient relationship represent more than $31 million in incurred losses for 117 cases asserted from January 2004 through February 2008.

In terms of overall patient encounters, malpractice cases represent a small N, but this is not a small problem. By some estimates, one in six patients is deemed “difficult” by his or her physician. For the U.S. population, that label could apply to tens of millions of patients, many who are coping with an unresolved illness, scared, undereducated (or over informed)…and sometimes demanding of both your time and patience. If those traits compromise a physician’s ability to provide an adequate diagnosis or treatment—and the patient suffers real harm as a consequence—the aggrieved patient’s decision to file a lawsuit is unobstructed by compassion for the physician.

What constitutes a difficult patient? For some physicians, it is the aggressive, drug seeking, test requesting, diagnosis doubting, 30-year-olds who push their “difficult” button. For others, the most troublesome patients are 50-somethings who make no effort to participate in their health care, ignore dangerous symptoms, skip appointments, and fail to follow treatment or medication regimens. Whatever behaviors rile them, physicians and nurses (and office staff) cannot wish patients away because they are unlikeable or hard to deal with: they are duty bound to find ways to make the patient relationship tolerable, and the health care encounters appropriate and safe, or appropriately transfer their care.

Some organizations or practice settings offer training and coaching for managing difficult patient relationships, and independent help and advice are widely available to any physician who understands that the problem is serious and the consequences of ignoring it are potentially tragic.

Of course, sometimes it is the physician who makes the relationship difficult. Frustration over an elusive diagnosis, irritation at a patient's bad habits, time pressures, personal distractions, substance abuse, and myriad other factors can offset clinical competence. And while a “bad day” may pass for the physician, the patients he or she alienated may not forget those encounters. Chronic friction with patients may signal the need for peer or leadership intervention and help.


March 2, 2009
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