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The ‘Difficult’ Patient

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As a Rugby Medic, I deal with my fair share of ‘macho’ patients- the kind who are young enough to believe that injury and illness do not affect them.
(Funny how all that seems to change at 40!)
The issue is multi-factored and incorporates the beliefs of the patient AND is heavily affected by their environment.
Whether its a player who refuses to allow me to debride a lac. Or insists that “I’m Fine” they don’t need their C-Spine assessed; refusal of care, unwillingness to accept circumstances and assistance or noncompliance, ‘difficult’ patients are everywhere to be found.
Luckily, working in a relatively acute care environment, noncompliance and resistance to care are not a huge issue though they ARE most certainly present.

After a bit of experience, but a hell of a lot more research, here are a few tips to dealing with the difficult patient.

Few articles in the literature deal with helping the physician with noncompliance. One useful article by Haynes et al makes a number of practical suggestions, including simplifying medication regimens, providing rewards and recognition for the patient’s efforts, and enlisting social support from family and friends
-Fred Kleinsinger, MD

From the article
by Fred Kleinsinger:

Though NCB is often not a direct manifestation of physician–patient conflict, communication tools that have proven effective in conflict situations can also be very useful in working with NCB.

Mirroring—Sometimes the simple act of mirroring what the patient says to you can defuse a difficult situation, even when you do not agree with the position the patient is taking. It also helps ensure that you correctly understand what your patient is telling you.
Patient: I think this is all a waste of time. I’ll never lose weight, I hate sticking my finger all the time, and I’m too busy and stressed to eat the way I know I should be.
Physician: I see that you’re very frustrated with how hard it’s been to live with your diabetes and that you feel that it’s been hard to do the finger sticks and to follow your diabetic diet. Did I get this right?

Try to be as nonjudgmental and empathic as possible in your mirroring statement. Successful mirroring shows patients that they have been heard and understood, which is a prerequisite to moving toward new solutions.

“I” Statements—Contrast in your mind the impact on the patient of the following two approaches to the same problem:
Physician: You’re doing a very poor job controlling your diabetes. Don’t you know this could lead to serious complications?
versus
Physician: I’m worried that if your diabetes isn’t better controlled, you could develop some serious complications.
Using statements that start with the word “I” and that express your genuine positions and concerns are much easier to hear and accept and foster a problem-solving versus a critical and blaming tone. Patients already often feel self-conscious and defensive when they are noncompliant. We want to break this cycle, and the physician’s working to sound more human and less authoritarian can enhance this possibility.

Enlisting Support—Most of our patients do not exist in a vacuum. They have their own formal and informal networks of support, including family, friends, associates, and other health care professionals. In many cases it can be helpful and appropriate for physicians to encourage patients to use other people in their lives to help improve compliance and self-care.
Patients can be asked to bring pertinent family members or friends to the medical appointment to discuss these issues. Sometimes these individuals will also have additional insights into the nature of the noncompliance problem that were not otherwise discoverable.

It’s interesting to think about how often we unconsciously employ these techniques already and how generally they tend to prophylactically resolve many issues that would have arisen.

As a last resort, I always find it is helpful to enlist the aid of friends or family of the patient to support you in convincing the patient of their need for care.
Peer pressure, when used moderately is a VERY effective tool!

Further Reading:
Great example of the above tips in practice by none other than Dr Minh Le Cong of the PHARM himself:
Click Here
Article by the Renal Network:
Article Here
Patient Perspective:
NYTimes Article Here

Cheers 😀