This document discusses strategies for handling difficult patients. It begins by acknowledging that difficult patients can strain time and resources through demanding excessive tests and attention. The document then categorizes four personality patterns that contribute to difficult behavior: dependent clingers who fear abandonment, entitled demanders who try to induce guilt, manipulative help rejectors with low self-esteem, and self-destructive deniers with clinically disordered personalities. Organic brain disorders from conditions like dementia are also noted to influence behavior. The document recommends strategies like taking deep breaths, remembering that behaviors are often states not traits, exiting respectfully if emotions escalate, and calling the nurse for assistance.

1. Handling “Difficult Patients”
David P. Russo, DO, MPH
Board Certified PM&R/Pain Medicine

3. Difficult Behavior
• What kind of
behaviors get
under your skin?
• What kind of
behaviors push
your buttons?

5. LET’S BE BLUNT. It’s hard to care for difficult
patients. It’s sometimes impossible to actually
like them. This species of sick individuals tends
to strain time, patience, and resources. They
often generate a cascade of phone calls. They
sometimes demand a heap of medically
unnecessary tests. They occasionally refuse
recommended treatment. Many have
unreasonable expectations. Some whine and
gripe incessantly. A few threaten to sue.

6. Mayer said she wrote the Health Affairs
essay out of frustration and as a plea to
physicians to listen to patients.
"I have found that those providers who saw
me as a partner rather than a passive
recipient of their knowledge and advice
were the most supportive and helpful.”

7. Recipe for Difficulty
• Fundamental attribution error
– Describing behavior as fixed attributes
– “States not Traits”
• Four Personality Patterns/Styles
– Dependent Clinger
– Entitled Demander
– Manipulative Help Rejector
– Destructive Denier
• Organic Brain Syndromes

9. Dependent Clinger
• They may begin by displaying
genuine gratitude, but quickly
evolve into panicked,
helpless, overwhelming
demands for attention and
aid
• Respond well to being
reminded about boundaries
• Really scared; fear of
abandonment

10. Entitled Demander
• Intimidate, devalue and
induce guilt to force the
doctor to meet their
needs.
• “Feed the ego.”
Channeling energy
appropriately and
constructively, voicing the
idea that the patient
deserves top medical care
• Really angry people

11. Manipulative Help Rejector
• Continue to report
treatment failures,
because do not seek
relief, but connection
• Respond well to
frequent follow-up and
validation
• Really suffer low self-
esteem. Do not believe
they deserve to be well.

12. Self-Destructive Deniers
• Profoundly dependent,
but use their self-
destruction to defeat
the physician
• Require a higher level of
care.
• Typically have
CLINICALLY disordered
personalities.

14. Organic Brain Disorder
• Term used to describe PHYSICAL changes in
the brain that effect behavior
– Traumatic brain injury
– Dementia
– Severe substance use disorders
• Changes in memory, mood, impulse control,
executive function
• These are VULNERABLE patients

15. What to do??
• Take a deep breath…
• Remember “states not
traits..”
• This goes with the
territory…

16. Call the NURSE!
• Name the emotion…
– I see you’re upset by this?
• Show Understanding
• Respect their feelings…
• Support and Summarize
• EXIT

17. THE END