What Does It Take to Be Labeled a “Difficult” Patient?

Physicians rate 15% of patient visits as “difficult,” according to the results of a classic study.¹ Patients perceived as difficult were more likely to have depression or anxiety, poorer functional status, unmet expectations, or reduced satisfaction, and they used more health care services. But “difficult” may, at least in part, be in the eye of the beholder. The authors of the study also observed that physicians with poorer psychosocial attitudes were more likely to experience patient encounters as difficult.

TOP 6 IRKSOME PATIENT BEHAVIORS
In a recent article, Cox and Childs² reviewed this and other studies and also asked physicians to rank patients' behaviors that are “doctor-irking.” Here are the top 6 irksome behaviors:

• Meddling family members in the examination room.

• Patients' reticence about their use of herbal medicines.

• Patients' discontinuation of prescribed medicines without informing their physician.

• Asking for a “magic pill” to avoid lifestyle changes.

• Responding to direct-to-consumer (DTC) advertising with the request, “I need a prescription for . . .”

• Asking for additional tests such as an MRI scan.

POSSIBLE SOLUTIONS
These 6 frustrations were addressed, but as expected because of their many dynamics, solutions were not readily forthcoming. Some potential interventions were helpful. For meddling families in the room, it was suggested that the physician, “speak directly to the patient, avoid taking sides in any conflict, and evaluate all parties' understanding of the information or management plan.”²

For the other irksome behaviors, however, awareness of their ramifications may help the doctor-patient relationship, but there is no “cure-all.” For instance, if a patient discontinues a drug without letting his or her physician know, the risks of abrupt discontinuation should be reviewed. One example may help. The FDA has listed 40 adverse effects consequent to the abrupt withdrawal of a benzodiazepine.² All of us have dealt with the frustration of “I saw this drug on TV and I think it will help me.” Even though that frustration shows me why the United Kingdom and Canada have outlawed DTC marketing, I am not sure there is any ready fix other than patience and gentle counseling.

The patient who says, “I'll take an MRI,” presents a similar problem. Although the Dartmouth Atlas has demonstrated that more is definitely not better, or safer, than less, I am not sure my patients will readily grasp the important ramifications of that study.³

THE BOTTOM LINE
Although physicians subjectively described 15% of their encounters as “difficult,” the ones who had problems of their own more often than not applied that specific descriptor.¹ Identifying a person as a “difficult patient” should place the onus on the physician to determine why. Did that individual have a bad experience? Did he just lose a job? Did a family member die of a disease that the patient is worried he might have?

The response to the data by Dr Scott Fields, vice chairman of family medicine at the Oregon Health and Science University in Portland, is right on target: “Who cares? The patient is the center of care, not the physician. This is part of what is wrong with how we provide care. We need to be much more worried about why the patient does what he/she does and much less about how it affects us.”² I agree.

Disclosures:

Dr Rutecki reports that he has no relevant financial relationships to disclose.

References:

REFERENCES: 1. Jackson JL, Kroenke K. Difficult patient encounters in the ambulatory clinic: clinical predictors and outcomes. Arch Intern Med. 1999;159:1069-1075.

2. Cox L, Childs D. Six patient behaviors that drive doctors nuts. http://www.medpagetoday.com. Published June 23, 2009. Accessed July 28, 2009.

3. The Dartmouth Atlas of Health Care. The Dartmouth Institute for Health Policy and Clinical Practice. http://www.dartmouthatlas.org.