The following is adapted from an article1 which originally appeared in the Journal of Clinical Outcomes Management and is used with permission from Turner White Communications, Inc. Copyright 1998. All rights reserved.
All clinicians encounter patients whom they regard as difficult.2-18 Clinicians diverge, however, on who merits this label.9,19 We have shown videotapes of "difficult" patients to more than 1,000 clinicians from a variety of geographic and practice settings. The clinicians are shown five sets of patients with three patients in each set and are asked to name the patient in each set who they would find the most challenging. Consistently, each of the 15 patients is judged both "most difficult" and "least difficult" by different clinicians. The exercise demonstrates that interpersonal perceptions and relationships are covariates rather than objective attributes of the patient.
Clinicians can often list demographic characteristics or personality traits that they associate with "difficult" patients. A perspective that identifies the locus of dysfunction in the patient, however, oversimplifies the clinician-patient relationship, overlooks the tremendous variety of experiences that occur in the medical care setting, and runs the risk of becoming a self-fulfilling prophecy. We have developed a model that recognizes four scores of difficulty: the patient, the clinician, the illness, and the system.
All of us, clinician and patients both, find ourselves in situations in which we catch ourselves reacting in ways we would prefer not to act. A statement, a request, or a tone of voice pushes our hot button, triggering an immediate intense reaction. Afterward, we may recognize our automatic responses and wish we had behaved differently. Later, we often think of better responses. Although we may try to justify our behavior, a nagging feeling of regret about how we responded is a reliable indicator that our hot button was activated. Our hot buttons may lead to difficulties in relationships.
Another source of difficulty may be the illness itself. It may be one that the clinician and the patient are unable to clearly communicate about due to anxiety, fear of failure, or even boredom. The health system, too, may be a source of difficulty, such as when an insurance benefit plan does not cover certain tests or treatments. A social system that lacks adequate resources to support healthy lifestyles also may pose difficulties.
Rather than label certain patients "difficult," we believe it is more useful to speak out about "difficult relationships" and to focus on ways of interacting in these relationships with the goal of achieving more satisfying outcomes.
Why Difficult Clinician-Patient Relationships Occur
We have identified three core problems associated with difficult clinician-patient relationships: frustrated success, inflexibility, and misaligned expectations.
Clinicians seek success, and success most often is defined as effective clinical problem solving or "cure."20 When success is unlikely or threatened, clinicians may use negative labels to describe patients. For example, a patient whose asthma is difficult to control due to socioeconomic or psychological stressors may frustrate the clinician.
Patients also want success. Patients may become depressed, angry, or demanding when treatment does not work or if they perceive that the clinician is blaming them for their illness. At the same time, clinicians may feel that the patient is blaming them for the lack of progress. These clinician and patient frustrations and blaming attitudes can contribute to mutual dissatisfaction.
Clinicians and patients may have a low tolerance for diversity, such as differences in language, ethnicity, socioeconomic status, values, gender, or health beliefs and practices. For example, in one study, the "least troubling" patients were described by male physicians to be middle-aged, "hard working" men with illnesses that quickly resolved or with which they came to terms quickly.19
Allopathic clinicians may be inflexible in their rejection of alternative treatments such as acupuncture or chiropractic care. Patients also may be inflexible. They may have strong preferences to be treated by a male or a female clinician, to see a specialist or a generalist, or to participate little or extensively in health care decisions. When clinicians or patients "dig in their heels" and insist on getting their way, they are likely to be regarded as difficult.
Clinicians and patients frequently differ on the expectations they hold for one another.16,21,22 Patients may enter treatment with a specific expectation, such as obtaining a prescription for a narcotic or getting an MRI for a headache. Physicians may have a different expectation, such as expecting the patient to learn to live with the chronic pain or to attend physical therapy and follow an exercise regimen. When expectations for treatment or the roles that each will take differ, either party may label the other as "difficult."
All three core relationship problems are illustrated in the following monologue. The patient is a 27-year-old highway construction worker presenting to his primary care physician stooped over with his hand on his lower back:
Don't mind me with these positions. It's my back. It's like before. I will be talking and then all of a sudden I'll move and it will just lock up on me. It's like someone is twisting a knife in my back. I know it's the disk. I don't want to see a surgeon and I don't want to have any type of extensive work done on it. At work they're making noises about me and about this particular injury, so I think its time that we claim this as a disability. I brought these papers for you to sign.
In this scenario, the clinician's chance to succeed is limited by the patient diagnosing his own problem and prescribing his own treatment plan: which is no treatment. For the patient, success may be frustrated if his goal is to obtain disability papers. This also is an example of expectations being misaligned. The clinician may have the expectation that the patient will seek information, participate in a discussion of the available treatment options, and follow through with the appropriate medical treatment. At the same time, the patient may have the expectation that nothing will help him medically and he is entitled to go on disability, especially in light of his chronic pain.
Finally, inflexibility may be a factor. The clinician may not feel comfortable signing disability papers when it is clear to him or her that there are more appropriate options. The patient also appears to be inflexible in his willingness to explore other options. If these differences are not handled appropriately, both parties may leave the encounter feeling angry or dissatisfied.
A Three Zone Model: Comfort, Get Help, Challenge
Although stress is normal in the medical setting, interpersonal stress usually is minimal and the relationship between clinician and patient is not in jeopardy. Such interactions take place in what we call the "comfort zone." In the comfort zone, conventional interviewing techniques, such as Cohen-Cole's three-function approach (gathering information, building a relationship, and motivating ad-herence)14 and the Bayer Institute's 4E approach (engage, empathize, educate, enlist),23-26 are useful for obtaining information and furthering the relationship. However, when a core relationship problem exists, interactions move out of the comfort zone into more challenging zones of interaction. The boundaries of these zones are idiosyncratic to the clinician and the nature of the practice.
Sometimes the clinician-patient dyad does not have the resources to accomplish the medical or relationship tasks at hand, and the relationship moves into the "get help" zone. For example, with a diabetic patient who needs to make lifestyle changes, the clinician might extend the system to include a dietitian, behavioral therapists, and other family members.
When a patient or clinician is in the challenge zone, the person may have a global sense of distress accompanied by an interior monologue such as, "I wish I was somewhere else." But recognizing that a relationship is in trouble is not always easy. Feelings of distress may not be clear at the outset. Fortunately, there are three other clues that signal a difficult relationship. We refer to these clues as the IRS: either the patient or the doctor frequently Interrupts the other, frequently Repeats their statements (getting louder with each repetition), or uses Stereotypical responses that promote disengagement (responses that are too pat or general to be meaningful). These clues indicate that the relationship needs attention.
Although a large body of literature describing difficult clinician-patient interactions is available, empirical studies of techniques for dealing with these relationships are limited.26 We do know, however, that the problems of difficult relationships do not respond to conventional interviewing techniques and are not likely to disappear.
Clinical Approach for Difficult Relationships
In the following scenario, a 28-year-old woman who had been taking Clomaphine has had ovarian hemorrhage and intractable uterine bleeding leading to unexpected oophorectomy. Although this rare complication of fertility medication was noted and documented during the informed consent discussion, the patient decided to accept the risks in hopes of having a child. Neither party expected this outcome.
I can't believe this is happening. This replacement therapy is driving me crazy. I've tried very hard to go along with you. I never thought that this could happen. Three months ago I was thinking I would have a child! You told me you didn't think you'd take my ovaries. You quoted me statistics. You said you were sure that I'd be fine. Now I'll never have a child. I'm a wreck. It's impossible to have sex. You act as though you could care less that you've left me totally worthless without anything to live for. You have ruined my life and you promised me that I would be fine. I can't believe the way you are acting. You just don't care!
Some techniques for facilitating this relationship are outlined below.
The first step in resolving a difficult situation is an internal cognitive and affective review in which the clinician recognizes the tension, controls his or her own affective response, assesses the source and the nature of the difficulty, and commits to working on the relationship.
By Yourself Recognize tensions
(Oh no, I'm in for it here! I'm feeling defensive and afraid this woman is going to sue me. I want to pull out the chart and show her what we went over before.)
Don't just do something, stand there11
(I need a second to think. What if I acknowledge that she is upset and let her vent a while and pull my thoughts together.)
Assess the source of the difficulty
(Is the root of her anger me? herself? her illness? the health care system?)
Identify the nature of the difficulty
(This patient had an expectation that the surgery would go fine and she'd have at least one healthy ovary. Meanwhile, my expectation was that, while I also hoped for that outcome, I did what was necessary to save her life. This woman also is frustrated because she has defined success as being able to get pregnant. My guess is she needs to grieve the terrible losses she feels. Also the medication may be playing a role in the degree of her agitation.)
Make a decision to work on the relationship in addition to addressing the medical problem.
(I need to empathize with her and find out what this outcome and loss mean for her. OK, I'm ready to go.)
With the Patient Acknowledge the difficulty and offer a problem-solving approach
Doctor: Mrs. Jones, I hear that you are very troubled by this outcome, I see that you have suffered a terrible loss. I'd like to find out more about what this means to you and to find a way to deal with this together: if you are willing to talk to me about it.
Patient: What do you mean?
Discover the meaning of the illness
Doctor: You said that you feel totally worthless and have nothing to live for. That sounds awful.
Patient: Well it is. I've always dreamed of having children of my own. We put it off for a while so that we could establish ourselves and be able to provide the kind of life we wanted for our children. My husband is very upset and doesn't understand how this has happened to him. He wants a child very badly and now I can't give him that. I'm afraid he may leave me.
Doctor: That sounds like a tragedy for you both.
Patient: Yeah. I just feel so angry.
Doctor: It's totally natural given what you've just been through. It's going to take some time for you to absorb all that's happened. I can imagine that you also can't see any solutions at this point.
Patient: No, I just feel so terrible and frightened and alone.
Doctor: Mrs. Jones, is there something I could do for you at this point, anything you need from me?
Patient: No. I want to be angry at you, but I know you didn't really have a choice.
Doctor: Well, I imagine you have many questions about what happened and why. I'll be glad to cover those when you feel up to it. We also may need to adjust your replacement therapy.
Patient: Thanks, but you're right. I couldn't concentrate just now. I think I just need to be sad.
Doctor: I don't want to rush you. I know this is a difficult time and you need to grieve. Would it be OK if I step out and attend to other patients? You can stay here as long as you need and I'll check back in a few minutes.
Patient: No, that's OK. I think I'll wash my face and go home.
Doctor: Will you be OK to drive yourself or can I call someone?
Patient: No, really, I'll be fine.
Extend the system
Doctor: Just one other thing. Would it be helpful if we talked with your husband? Or, is there anyone else who can be a support for you?
Patient: That may be helpful later, but he's pretty angry at you also.
Doctor: Well, I'm available to talk to him at anytime it would be helpful.
Patient: Thanks. So, I'll be back in two weeks.
Doctor: Please call me if anything changes or if you have any questions.
Because the art of dealing with difficult interpersonal relationships is still quite primitive, these suggestions for working with difficult clinician-patient relationships are far from definitive. Although drawn from research findings in several disciplines, a great deal remains unknown. Thus, we must approach the use of these techniques from the perspective of the clinical trial, or what Donald Schon28 calls "reflective practice." Reflective practice calls upon the clinician to consider how effective a particular action was in achieving the goal that prompted the action: "I said X to him because I thought that he would respond Y. Did he? If he didn't, what else could I have said?"
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