This document discusses difficult patients from the perspective of a family medicine consultant. It begins by defining difficult patients as those with whom physicians have trouble forming effective relationships. It then describes common types of difficult patients such as somatizing patients, dependent clingers, entitled demanders, and manipulative help-rejectors. Risk factors for difficult patients are identified including psychiatric disorders and functional impairments. The document provides cues for identifying difficult patient behaviors and discusses strategies for handling situations like breaking bad news to patients and families.

1. Difficult Patients
Dr Faisal Al Hadad
Consultant of Family Medicine
Occupational Health&
PSMMC

2. Introduction

Difficult patient: the one with whom the physician has trouble
forming an effective working relationship.

This term has become politically incorrect.

In one study, American doctors rated 15% of primary care
patients as 'difficult'.

3. Types of Difficult Patients

Somatizing patient: patients who express personal distress in
the form of somatic symptoms and refuse to believe that no
organic disease is present.

Dependent clingers: are excessively dependent on the doctor,
desperate for reassurance but will return continually with a new
array of symptoms.
e.g. "Thank you, my back's much better but I've got chest pain
now."

4. Types of difficult patients

Entitled demanders: Patients who make excessive demands by
frequent visits, pressure for tests, medications or referrals. They are
frequently complaining when every request is not met.
e.g. "I must see a specialist for my ingrowing toenail right now!"

Manipulative help-rejectors: continually return to the surgery to
report that treatment failed. Where any symptom is relieved, it is
rapidly replaced by another.
e.g. "None of the painkillers have helped my back, I'm allergic to
those other pills, Pain Clinic did nothing. You've got to help me!"

5. Types of difficult patients

Self-destructive deniers: whilst suffering from a potentially
serious condition, will make no effort to alter their selfdestructive behaviours.

6. Angry Patients

7. Seductive Patients

8. Grieving Patient

9. Risk factors
Risk factors related to the doctor:

Perception of high workload

Poor job satisfaction

Poorer postgraduate qualifications

lack of training in counseling and communication skills

10. Risk factors
Risk factors related to the patient:

Psychiatric disorders (particularly somatoform disorder, panic
disorder, dysthymia, GAD, MDD and probable alcohol abuse or
dependence)

Functional impairments

High use of health care

Lower satisfaction with care

11. Cues indicating difficult patient

A new patient who comes after leaving another physician and
extravagant in his praise for you while expressing great hostility
toward the former doctor ?Demander

Frequent visits for problems that never respond to treatment;
persistent complaints of symptoms with repeatedly negative tests
and unhelpful consultation ?Somatising

Disagreement over prescription drugs. The relationship with the
doctor is good as long as they receive their prescription. The
medications may be taken for a spurious diagnosis ?Dependent

12. Cues indicating difficult patient

Cues from our own feelings. When a patient evokes a feeling of
anxiety, pressure, boredom, or frustration; or when we
particularly want to please and impress a patient.

13. (Breaking Bad News (BBN
Dr Faisal Al Hadad

14. Case Discussion
Abdullah is a patient of yours who comes to see you one
day with his wife Sharefa. Sharefa is also a patient of
yours who was admitted to hospital for investigations for
liver. The results of the liver biopsy showed a well
differentiated hepatocellular carcinoma. This result had
been disclosed to Abdullah only. He has come to you
today asking for your assistance in telling his wife the
results of her investigations.
How would you handle this situation?

15. Before Consultation

Ensure appropriate physical setting (quite and private
consultation room)

Avoid interruptions during the consultation

Ensure enough time for the consultation

Be aware of the details of the patient and all necessary
information

What information is to be conveyed and in what order?

Ensure family support during consultation

16. During consultation

Fire a warning shot then pause before going on

Find out how much the patient knows

Find out how much the patient wants to know

Clarify the information you are giving and check understanding.

Elicit the patient's concern

Honestly and accurately

17. During consultation
Effective communication skills:










Clear language
Eye contact
Empathy
Attentive listening
Unhurried manner
Body language
Appropriate touch
Appropriate use of silences
Encourage patient to ask questions
Summarizing

18. During consultation

Explanatory leaflets

Avoid unnecessary distress

Avoid overload patient with information

Leave the patient with an early follow-up plan and a
realistic hope.

19. After consultation
(Roger Neighbour (1987
Inner Consultation

Connecting

Summarizing

Handing Over

Safety Netting

House Keeping

20. Thank you