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Prepared byPrepared by
Dr. Mohammad AL-ShahraniDr. Mohammad AL-Shahrani
Under Supervision ofUnder Supervision of
Dr. Ahmad ShakerDr. Ahmad Shaker
Dealing with difficult patients and
managing a difficult consultation
To know the causes of difficult
consultations in general.
To be aware about different types of
How to deal by an appropriate way with
such difficult patients.
Groves (1978) developed four stereotypes
of difficult patients, whom he labeled
dependent clingers, manipulative help-
rejecters, entitled demanders and self-
These patients consistently trigger
negative feelings in physicians, who
cannot satisfy their endless demands
Around ( 10 – 20 % ) of daily consultations areAround ( 10 – 20 % ) of daily consultations are
considered to be difficult. These difficulties are eitherconsidered to be difficult. These difficulties are either
due to :due to :
1. Difficult patient .
2. Difficult doctor .
3. Difficult communication between the doctor and
4. Difficult environment.
Psychotic patient, suicidal patient etc.Psychotic patient, suicidal patient etc.
Depressive patient.Depressive patient.
Talkative patient.Talkative patient.
Withdrawn and isolated patient.Withdrawn and isolated patient.
Bereaved patient.Bereaved patient.
Angry patient.Angry patient.
VIP patient.VIP patient.
Demanding patient.Demanding patient.
Manipulative patient.Manipulative patient.
Hypochondrial “the worried well” patient.Hypochondrial “the worried well” patient.
Reluctant patient.Reluctant patient.
Somatizing patient.Somatizing patient.
Doctor in a hurry.
Passive (submissive) doctor.
Alien doctor (from different culture).
Doctor who have social or psychological
Social class differences.
The first step in addressing unnecessary
demands is to ascertain the patient's needs.
Allow the patient to fully tell the story, with
Ask the patient for details: “I understand you are
here because you want an MRI of your knee; I'd
like to understand how you reached that
Consider agreeing with the patient.
Dealing with Demanding Patients
Negotiate agenda and goals :
Reinforcement and help.
Compromise and be flexible.
Explain your rationale.
Pay attention to the way you say no.
Under pressure, breathe deeply and start over.
For some patients
“firm boundaries are the rule”
Dealing with Demanding Patients
summarize the points aloud for the patient.
This allows the patient to correct or amplify. It
also gives the patient the experience of being
heard and understood.
An attempt to reflect the emotion behind the
request is important. e.g “It sounds incredibly
frustrating to be laid up with knee pain for so long,
Dealing with Angry Patients
7 steps to deal with angry patients:
1. Handle problems privately
2. Listen to patients' complaints
3. Disarm anger with kindness
4. Delegate up when necessary
5. Follow through on promises
6. Involve the patient in prevention
7. Be grateful
Social class barrier
Presence of 3rd party
Patient Factors :
Dr. Factors :
Dealing with Patients
reluctant to talk freely
Give reasons for your
Comments on the patient
attitude. “if you talk more, I’ll
be able to help you.”
Generalization of the problem.
Asking at the right time.
Non - verbal
Showing real interest.
Patient reluctant to talk
many patients have a script of
what they want to say to the
Letting them speak uninterrupted
initially allows you to gather key
details form the history and lets the
patient disclose their agenda.
it is important that the doctor takes
control and directs the consultation.
Dealing with Talkative patients
Talkative patients need to be
politely but firmly steered back to
the key points.
One tactic is to acknowledge any
digressions and then focus the patient
back to the question asked.
Another tactic is to regularly
summaries problems and concerns
to allow you to impose focus to the
If you need to interrupt then use
non verbal as well as verbal signs
such as raising your hand to indicate that
you want to speak.
Close ended question
Non - verbal Comm.
Sympathy & empathy.
Recognize your true feelings.
Difficult patients evoke a
feeling of anxiety, pressure,
boredom, or frustration.
Be alert for counter-transferance
Involve colleagues in your
management plan. “you are not
Improve yourself .
Coping Strategies for the Doctor
Whatever the difficulty, the physicianWhatever the difficulty, the physician
maintains rapport, respect, and relationshipmaintains rapport, respect, and relationship
with these difficult patients by listening forwith these difficult patients by listening for
their concerns.their concerns.
By giving the impression of being unhurriedBy giving the impression of being unhurried
and having time to listen, the physicianand having time to listen, the physician
maintains relationship and conveys to themaintains relationship and conveys to the
patient that the physician-patientpatient that the physician-patient
relationship will continue undamaged by therelationship will continue undamaged by the
difficulty of the present moment. In thisdifficulty of the present moment. In this
way, the relationship becomes a part of theway, the relationship becomes a part of the
healing process.healing process.