Managing Difficult Patients - Society of Clinical … Difficult Patients William Robiner, Ph.D. HEALTH PSYCHOLOGY DEPARTMENTS OF MEDICINE AND PEDIATRICS U NIVERSITY OF M ... » Anxiety

Managing Difficult Patients

William Robiner, Ph.D. HEALTH PSYCHOLOGY

DEPARTMENTS OF MEDICINE AND PEDIATRICS

UNIVERSITY OF MINNESOTA MEDICAL SCHOOL

Raise Your Hand If

You became a health professional

because you wanted to deal with difficult

people

Raise Your Hand If

You have ever encountered a

noncompliant patient

You have ever encountered a difficult

patient

You see anybody else in the room who

might be a difficult patient

Raise Your Hand If

You have ever

been a

noncompliant

patient

Raise Your Hand If

You have ever

been a

noncompliant

patient

You have ever

been a difficult

patient

Impossible People Exist! You will encounter them!

You can’t avoid them!

You can’t fix them!

You can’t make them like

you!

You can’t beat them!

They may not want your

help!

Friendly Advice: Develop

good boundaries with

them.

Deal With It!

You Can Please:

? of the People ? of the Time

What may be the favorite song

of difficult patients?

What is a difficult patient? Raise your hand if you think it is somebody who

Takes poor care of himself/herself

Doesn’t follow your direction(s)

Communicates poorly

Is mean/belligerent

Has chronic pain or doesn’t get better

Wants prescriptions you question

Narcotics

Is unintelligent/“clueless”

Wastes healthcare resources

Wants to sue you

Definition of the Difficult Patient

… “patients who are medically challenging, interpersonally difficult, psychiatrically ill, chronically medically ill, or lacking in social support.” 1

A patient “whom most physicians would dread to treat.” 2

1Adams J, Murray R: The general approach to the difficult patient. Emerg Med Clin North Am 1998;16:689-700. 2Groves JE: Taking care of the hateful patient. N Engl J Med 1978; 296:883-887.

What is a difficult case?

“When we call a client difficult, what we

really mean is that we, the therapists, are

having difficulty working with him/her.”

(Wessler)

Wessler, R., Hankin, S. & Stern, J. (2001). Succeeding with difficult patients. San Diego, CA: Academic Press.

What is a difficult case?

“Difficult patients are those who make us feel frustrated, uncomfortable, or ineffective” (Duxbury)

Difficult patients present some type of threat: They can reject us or harm us (Duxbury)

Difficult patients are those whose disorders don’t respond to treatment (Pollack et al.)

Duxbury, J. (2000). Difficult Patients. Oxford: Butterworth-Heinemann. Pollack, M.H., Otto, M.W., & Rosenblum, J.F. (Eds.). (1996). Challenges in clinical practice: Pharmacologic and psychosocial strategies. New York: Guilford.

Difficult cases are characterized by:

Multiple treatment failures

High risk of abuse

High risk of violence

High risk of legal action

High risk of suicide

Difficult people are those who lead us to

do things we don’t want to do:

React in ways we are not happy with

Do our jobs ineffectively

Feel guilty, anxious, upset, frustrated,

inferior, defeated, manipulated,

conned, used, exhausted, ‘etc.

Do their share of the work

Labels for Difficult Patients

“Gomers”

“Shpos”

“Frequent flyer”

“Heart sink” patients

“Thick chart” patient

“Slow load” patient

(in EMR)

“Train wreck”

“Hateful”

“Turkey”

“Nudnik”

“Crocks”

In Mental Health

Somatoform Disorders

Impulse Control Disorders

Personality Disorders- “Axis II”

» Borderline

» Antisocial

» Narcissistic

» Histrionic

» Dependent

» Obsessive Compulsive

Difficult Patients in Counseling

Demanding

Angry/Blaming

Unlikable

Treat others (e.g., partner) badly

Defensive

Unappreciative

Others? Bernhardt, B. A., Silver, R., Rushton, C. H., Micco, E., & Geller, G. (2010). What keeps you up at

night? Genetics professionals’ distressing experiences in patient care. Genetics in Medicine, 12, 289-297.

Emotional Effects of Difficult Patients &

Situations on Professionals

Anxiety

Guilt

Sadness

Anger

Shame

Powerlessness/responsible

Uncertainty

Bernhardt, B. A., Silver, R., Rushton, C. H., Micco, E., & Geller, G. (2010). What keeps you up at night? Genetics

professionals’ distressing experiences in patient care. Genetics in Medicine, 12, 289-297

Descriptions of Difficult Patients (Physical)

Multiple symptoms involving multiple body

systems

Poor response to usual treatments

Certain medical conditions

» Chronic pain/fibromyalgia/obesity

Terminal illness

Klein D, Najman J, Kohrman AF, et al: Patient characteristics that elicit negative responses from family physicians. Journal of Family Practice 1982;14:881-888.

Gillette RD. ‘Problem Patients’: A fresh look at an old vexation. Family Practice Management 2000; (July August)7:57-62.

Descriptions of Difficult Patients (Behavioral) Rambling, unfocused

» “Everything hurts”

Raises new problems as visit ends » “Oh, by the way…”

Self-destructive

Medication-seeking

Poor hygiene

Over demanding

Manipulative, hostile, exploitative, rude,

demanding, dissatisfied, controlling, lying,

litigious

Descriptions of Difficult Patients (Behavioral)

“Boundary-Busting” » Seductive (sexually or otherwise) » Dependent, clinging » Call a lot/demand extra time

Resistant to health professionals’

recommendations

» Under appreciative

Poor adherence with treatment » Inconsistent drug use » Miss appointments/come late

High utilization of healthcare

Descriptions of Difficult Patients (Psychological)

Unrealistic expectations of cure

Difficult to communicate with

Vague and shifting complaints

Undue concern

» e.g., about minor symptoms

Excessive preoccupation with physical

disease

Impossible People

Play the “blame game”

Confrontation may be fruitless

» ...and provoke denial and blame

Are not swayed by reason

May need to be treated like children

Provide valuable life lessons

Why Patients Miss Appointments

Emotion

» Fear bad news or uncomfortable procedure

» Scheduling delay implies unimportant

Perceived Disrespect by System/Provider

» Time in waiting room

» Symptom resolution by appointment- no sx

Misunderstanding of Scheduling

» Doing provider a favor

» Perception of schedules as fluid, negotiable

Lacy NL, Paulman A, Reuter MD, Lovejoy B. Why we don’t come: Patient perceptions on no shows. Ann Fam Med

2004; 2: 541-545.

Who are Difficult Patients?

“Patients we don’t like or

who don’t like us!”

Ed Shahady, M.D.

Who Might Patients Want You to Be?

Somebody caring, like

Marcus Welby, M.D.

Or…

Competent, like the

Surgeon General

Regina Benjamin, M.D., M.B.A.

Or…

Very smart

Or…

Who

should be

able to get

things

done

Or…

A good looking, well-trained, capable, helpful, patient, cheerful, professional, ethical, successful, wise, talented humanitarian

Or, if you are a nurse,

Florence Nightingale

Or, if you are an administrator

Or if you are a psychologist

Freud Skinner Rogers Linehan

Or maybe a famous

“psychologist”

But, Who Might Patients Think You Are?

Dr. Evil

Or…

Dr. Demento

Or…

Some Clown

Or somebody…

Who just doesn’t

help much

Perhaps…

Someone smart,

but unfeeling

Possibly…

An unconventional,

misanthropic

diagnostic genius

Potentially

Neurotic,

surreal, zany,

ridiculous,

pathetic

Maybe

A Kid

Or, if you are a nurse,

Nurse Ratched

Or, if you are an administrator,

A jerk saying “No!”

Or if you are a psychologist,

Somebody scary


Somebody who is

trying to force you

to talk


Somebody who

can read your

mind


Or is nutty


Somebody who

might judge you


Somebody nosy

Or even

An authority

figure telling

them what to do

Who is not listening…

Or with whom they might disagree

What Do They Want From a Helper?

Somebody who can see into the future?

What Do They Want?

A magician?

What Do They Want?

Somebody who will tell them:

"Don't worry about a thing" - I won't worry!”

'Cause every little thing gonna be all right.”

What Do They Want?

Somebody who

brings good news

But what kinds of news are there?

And What Do They Want?

If it is bad news?

What Do Providers Want From

Patients?

If it is bad news, DON’T

Scope of the Difficult Patients Problem

Older, more often divorced or widowed,

more acute problems, chronic problems,

chronic & medications1

Of Primary care patient encounters (n = 722):2

» ≈ 30% were troubling to physicians

» Psychosocial problems & lower social class

patients were associated with greater

frequency of difficulty 1Chandry J, Schwenk TL, Roi LD, et al: Medical care and demographic characteristics of difficult patients. Journal

of Family Practice 24:607-610, 1987. 2Havens LL. Taking a history from the difficult patient. Lancet 1978;1:138-40.

Prevalence and Impairment

Of patients in 4 Primary Care settings (n = 627)

15 % were judged to be “difficult”

“Difficult” vs. non-difficult patients had:

More functional impairment

Higher health care utilization

Lower satisfaction with care

Difficult patients did NOT differ from non-difficult patients in:

» Demographic characteristics

» Physical illnesses

Hahn SR, Kroenke K, Spitzer RL, et al. The difficult patient: Prevalence, psychopathology, and functional Impairment.

Journal of General Internal Medicine 1996;11:1-8.

Underlying Reasons Patients can be “Difficult”

Feelings of fear, guilt, worthlessness, incompetence, shame

Loneliness, social isolation

Fear of abandonment

Life stress

Concern about personal safety: at home, on the street, in clinic/hospital, etc.

Past abuse (e.g., sexual)

Disorganized, chaotic life

Earlier adverse medical experiences

Gillette RD. ‘Problem Patients’: A fresh look at an old vexation. Family Practice Management 2000;7:57-62.

Underlying Reasons

Rational need for medical info/treatment

Involvement with tort law or Worker’s

Compensation system

Mentally Altered/Neurological Disorders

» Strokes

» Traumatic brain injury

» Developmental/organic disorders

Underlying Reasons

Mental Disorders

» Somatoform disorders

» Personality disorders

borderline, dependent, ASPD, OC, etc.

» Anxiety disorders

» Mood disorders

» Substance use disorders


28% of Americans have a mental

disorder1

Only ½ of those receive treatment

½ of those treated receive treatment only

through primary care providers

26% of patients in primary care have a

bona fide mental disorder2

25-80% of ambulatory medical patients

have some psychiatric morbidity3

Psychology’s Importance in Healthcare

1U.S. Department of Health and Human Services. (1999). Mental Health: A report of the Surgeon General. Rockville, MD: Author.

2Spitzer, R. L., Williams, J. B., Kroenke, K., Linzer, M., deGruy, F. V., Hahn, S. R. Hahn, Brody, D., & Johnson, J. G. (1994). Utility of a New Procedure for Diagnosing Mental Disorders in Primary Care: The PRIME-MD 1000 Study. JAMA, 272(22):1749-1756.

3 Barsky, A.J. Hidden reasons some patients visit doctors. Annals of Internal Medicine, 94 (1):492-498,

60% of psychiatric care is obtained

from general physicians1

Psychiatrists write < 1 in 4 of all

psychoactive prescriptions2

Non-psychiatric physicians treat >

6.4% of the whole population/year for

mental/substance abuse as part of the

de facto mental health system health1

Most Physicians Provide Mental Health Treatment

1Regier DA, Goldberg D., Tauru CA. The de facto US mental health services system. Archives of General Psychiatry. 1978:35:685-93.

2Moran M. Psychiatrists Write Fewer Than 1 in 4 Psychoactive Prescriptions. Psychiatric News October 16, 2009;44 (20) : 10. 3Regier D.A., Narrow W.E., Rae D.S., Manderscheid R.W., Locke B.Z., Goodwin F.K. The de Facto US Mental and Addictive Disorders Service

System: Epidemiologic Catchment Area Prospective 1-Year Prevalence Rates of Disorders and Services Arch Gen Psychiatry. 1993;50(2):85-

94.

7 of the top 10 health risk factors are

lifestyle or behavior factors1

60% of visits to primary care involve

behavioral health issues2

“100% of medical visits involve a

psychological or behavioral component”3

Psychology and Primary Care

1VandenBos, G. R., DeLeon, P. H., & Belar, C. D. (1991). How many psychological practitioners are needed? It’s too early to know!

Professional Psychology: Research and Practice, 6, 441-448. 2Cummings, N. A., Cummings, J. L., & Johnson, J. N. (Eds.).(1997). Behavioral health in primary care: A guide for clinical integration.

Madison, CT: Psychosocial Press. 3Belar, C. D. (1996). A proposal for an expanded view of health and psychology: The integration of behavior and health. In R. J.

Resnick, and R. H. Rozensky, Ronald H. (Eds.). Health psychology through the life span: Practice and research opportunities.

(pp. 77-81). Washington, DC, US: American Psychological Association.

Mental Disorders & Difficult Patients

Difficult patients (67%) were much more

likely than non-difficult patients (35%) to

have a mental disorder (p < .0001)

Mental disorders account for a

substantial proportion of the excess

functional impairment and

dissatisfaction in difficult patients

Hahn SR, Kroenke K, Spitzer RL, et al. The difficult patient: Prevalence, psychopathology, and functional

Impairment. Journal of General Internal Medicine 1996;11:1-8.

Depression and Medical Illness

Illness Prevalence of Depression (%)

Cancer 5–50 (most studies: 20–25)

Diabetes 14–22

Fibromyalgia 20–71

Myocardial Infarction 18–25 (40–65 sx)

Alzheimer’s Dementia 15–57

Epilepsy 25–75

Stroke 10–40

Multiple Sclerosis 34–40

Parkinson’s Disease 40

Psychiatric Disorders in Difficult Patients

Hahn SR, Kroenke K, Spitzer RL, et al. The difficult patient: Prevalence, psychopathology, and functional

Impairment. Journal of General Internal Medicine 1996;11:1-8.

Doctors and Difficult Patients

Evidence suggests that the “problems do

not lie exclusively with the patient” 1

Patients are labeled “difficult” by physicians because of their frustration with the relationship or because of how

the patient sought healthcare2

1Gillette RD. ‘Problem Patients’: A fresh look at an old vexation. Family Practice Management 2000;7:57-62.

2Chandry J, Schwenk TL, Roi LD, et al: Medical care and demographic characteristics of difficult patients. Journal of Family Practice 24:607-610, 1987.

It Takes 2 to Tango

A difficult patient for one

doctor is not necessarily

difficult for another1

Doctors with poorer

attitudes about

psychosocial problems

perceive more of their

medical encounters as

difficult2

1Mathers NJ, Jones N, Hannay D. Heartsink patients: A study of their general practitioners. British Journal of General

Practice 1995;45: 293-296. 2Jackson JL, Kroenke K. Difficult patient encounters in the ambulatory clinic: Clinical predictors and outcomes.

Archives of Internal Medicine 1999;159:1069-1075, 1999.

Dealing with Difficult Patients

The patient “whose problems will not go

away...is an uncomfortable reminder of the

doctor’s inadequacy and impotence…”1

Providers’ internal reactions can include:

» Anger, depression, frustration,

resignation, repugnance, disgust

1Corney RH, Strathdee G, Higgs R, et al: Managing the difficult patient: Practical suggestions from a study day. Journal of the Royal College of General Practice, 1988;38:349-352.

2Simon JR, Dwyer J, Goldfrank LR. Ethical issues in emergency medicine: The difficult patient. Emergency Medicine Clinics of North America 1999; 17: 353-370.

Surveys of hospital staff members…blame

badly behaved doctors for low morale,

stress and high turnover.

http://www.nytimes.com/2008/12/02/health/02rage.html?pagewanted=2&_r=1&sq=abusive%20doctor&st=nyt&scp=2

Arrogant, Abusive and Disruptive — and a Doctor

Provider Contributions to Difficult Patient Interactions

Provider Personality and Beliefs

» Judgmental, perfectionism, stubborn

» Depression, self-esteem

» Anxiety, approval-seeking

» Need for control, defensiveness

Other Stressors

Work Style

Time

"If our fast-food society becomes also a

fast-care society, the process may

ultimately squeeze out the essential

ingredients of a workable patient-doctor

relationship, leaving both frustrated

doctors and frustrated patients."

Don Lipsitt, M.D., 1997

Editor, General Hosp Psych

Cultural Contributions to Difficult Patient Interactions The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures.

Anne Fadiman. New York, NY: Farrar, Straus, and Giroux, 1997. “The history of the Hmong yields…lessons ... Among the

most obvious … are that the Hmong do not like to take orders; that they do not like to lose;… they would rather flee, fight, or die than surrender;… they are not intimidated by being outnumbered; … they are rarely persuaded that the customs of other cultures, even those more powerful than their own, are superior, and… they are capable of getting very angry.” (p. 17)

What Do Difficult Patients Want?

“Difficult patients and difficult families

want to be heard and understood…If you

reach out and help them understand that

you want to make them happy,

comfortable, and help them get well, you

will diffuse most conflicts before they

even start.”

http://blog.mynursinguniforms.com/index.php/dealing-with-difficult-patients-and-difficult-families-while-nursing/

Relationship Building Techniques

PEARLS Partnership Let’s work together

Empathy That sounds hard...

Apology I'm sorry for...

Respect I appreciate your...

Legitimization Anyone would be.. ...

Support I'll stick with you …

http://nyumacy.med.nyu.edu/

When Using Confrontation

Choose power struggles carefully

» Enter only those that are worth having

» Enter mainly those that you can win

» Avoid Win-Lose situations

» Avoid Lose-Lose situations

» Take a long view

Seek to “win” wars, not battles

Be diplomatic

Have only a few priority goals

Coping with Difficult Patients- Communication

Avoid being judgmental

Be patient, tolerant

Get good history to understand patient

Use direct communication

Humor

Selective personal disclosure

Coping with Difficult Patients- Additional Strategies

Set limits for time and content

Referral for tests, labs, specialists,

alternative health, mental health

Develop treatment plan/contract

» Set limited objectives

» Schedule for addressing needs

Involve others- family/friends (with consent)

Steer focus away from emotional issues

when necessary

“A doctor’s job is to give you what

you need, not what you want.”

Carl Forester, M.D.

Benefits of Regularly Scheduled Appointments

Make patients feel cared for and understood

Address small concerns before they overwhelm patient

May gradually lead patient to more mature thought patterns

Reduce or eliminate unnecessary telephone calls, tests, admissions, ER visits


Coping with Difficult Patients- Stress-Management

Prepare for the encounter

» Breathe deeply/catch breath

» Check labs/chart in advance

» Spread out difficult encounters

Accept the situation

» “It’s life; this is part of my job”

Approach situation gingerly

» Choose words carefully

» Find things to appreciate

Neutralizing Impossible People

Maintain/protect your self-esteem

Avoid letting your anger take hold

Sidestep accusations/complaints

Don’t appear defensive

Don’t absorb their “impossibleness”

Use silence, humor

Use appropriate touch (e.g., handshake,

pat on back)

Responding to the Difficult Patient

Roberts L.W., Dyer A.R. Caring for "difficult" patients, in Concise Guide to Ethics In Mental Health Care. Arlington, VA, American

Psychiatric Publishing, 2004, chap 10

Steps in Managing Difficult Patients

Step 1: Understand yourself

Step 2: Understand your patient

Step 3: Think, don’t react

Step 4: Form an alliance

Step 5: Treat whatever is treatable

Step 6: Avoid the traps

Step 7: Get help

Step 8: Handle your emotions

Roberts L.W., Dyer A.R. Caring for "difficult" patients, in Concise Guide to Ethics In Mental Health Care. Arlington, VA,

American Psychiatric Publishing, 2004, chap 10

Step 1 in Managing Difficult Patients

Understand yourself

Be aware of your own biases and responses

Understand why certain types of patients

upset you

Realize you’re not a “bad” doctor if you have

negative feelings about some patients

Recognize that everyone has trouble

managing some patients




Understand your patient

Every difficult behavior is a form of

communication

Every difficult patient is trying to express

real fears and needs




Think, don’t react

Remember your duty to help and not harm

Focus on medical and psychiatric issues you

can treat

Strive to be empathic, consistent, and stable




Form an alliance

Find something you can agree upon

Educate the patient about your limits and

responsibilities

Reinforce positive behavior; don’t reward

negative behavior




Treat what is treatable

Screen for medical conditions

Screen for Axis I and Axis II psychiatric

disorders

Use therapy and medication to treat

problems




Avoid the traps of

Wanting to save the patient and be idealized

Wanting to reject the patient and not be hurt

Wanting to punish the patient

Doing anything to help the patient so he/she

won’t hurt himself/herself




Get help

Seek consultation

Foster team consensus

Encourage patient to participate in support

groups




Handle your emotions

Find constructive ways of venting frustration

Prepare yourself for seeing difficult patients

See managing difficult patients as a clinical

and administrative skill to master



Coping with Difficult Patients-

Learn and Be Proactive

Analyze cases

» What worked?

» What didn’t? Why?

Seek input from colleagues

» M & M Conferences

» Balint groups1

» QAI/Performance improvement

Videotape

http://americanbalintsociety.org/

The Transtheoretical Model of Behavior Change

Stages of Change

Prochaska J.O., DiClemente C.C. Stages and process of self-change of smoking: Toward and integrative model of

change. Journal of Consulting and Clinical Psychology 1983: 51(3): 390-395.

Stages of Change

1 Precontemplation

The problem exists, but person

minimizes or denies it.

Contemplation

Person thinks about problem

and initiating change

costs & benefits

Stages of Change

Preparation/Determination

Person commits to a time and

plan for resolving the problem

Action

The person makes daily efforts to

overcome the problem

Stages of Change

Maintenance

Person has overcome the

problem but needs to stay

vigilant to avoid relapse

Benefits of Stages of Change

Bad Good

Precontemplation Contemplation Preparation Action Maintenance

CALMER

“Six Steps to Serenity” for

Teachers to Help Residents Work

with Difficult Patients

Pomm, H.A., Shahady E., Pomm R.M. The CALMER approach: Teaching learners six steps to serenity when dealing

with difficult patients. Family Medicine 2004;36(7):467-9.

CALMER Questions for Providers

What stage of change is the patient

exhibiting?

What feelings do you have as you think about

the patient?

How might your feelings influence your

relationship with, and treatment of, the

patient?

What might be underlying the patient’s

behavior?

Pomm, H.A., Shahady E., Pomm R.M. The CALMER approach: Teaching learners six steps to

serenity when dealing with difficult patients. Family Medicine 2004;36(7):467-9.

CALMER (6 Step Action Phase)

Catalyst for change (vs. responsible for it)

Alter your thoughts ( change your feelings)

Listen and then make a diagnosis

Make an agreement with the patient

Education & follow-up

Reach out & discuss your feelings with

trusted colleagues after seeing the patient

• Attendings; peers; team Pomm, H.A., Shahady E., Pomm R.M. The CALMER approach: Teaching learners six steps to


Catalyst For Change

Focus on how you can help the patient

move to the next stage of change?

The only thing health professionals can

control is their own reaction to people,

situations, events

Health professionals can only be a

catalyst

You are not responsible for

changing patients’ behavior

or outcomes Pomm, H.A., Shahady E., Pomm R.M. The CALMER approach: Teaching learners six steps to


Alter Thoughts to Change Feelings

What can you tell yourself to feel less angry, frustrated, resigned, disgusted with patient?

“We feel what we think”

The way to control reactions (feelings) is to change thoughts “I can’t stand this” “This is difficult, but I can get through it”



Listen & Then Make a Diagnosis

Difficult patients are

draining, leading health

professionals to not “listen”

clearly to what they are

saying (biases, beliefs)

Listen carefully to really

hear or see what the patient

is describing or exhibiting



Make an Agreement

Let go of your agenda, even though you

may be right

» Recognize what stage of change they are in

» Agree on “doable” or achievable

recommendations

Confirm patient’s understanding of plan

» Patient’s behaviors

» Your actions/system actions

Pomm, H.A., Shahady E., Pomm R.M. The CALMER approach:

Teaching learners six steps to serenity when dealing with difficult

patients. Family Medicine 2004;36(7):467-9.

Education & Follow-Up

Based on your CALM analysis, how

can you best educate the patient? » Help patient understand rationale for tx

Prescribe “homework” based on

patient’s stage of change

» Include plan for follow-up

Pomm, H.A., Shahady E., Pomm R.M. The CALMER approach:

Teaching learners six steps to serenity when dealing with difficult

patients. Family Medicine 2004;36(7):467-9.

Reach Out/Discuss Your Feelings

How do you feel about the patient and their behaviors?

How can you take care of yourself when patients elicit feelings?

Reach out and talk about your feelings with someone you trust

» We all experience frustration at times with some patients

» You don’t have to do this alone!



If all else fails…

Terminate or Transfer? “How should doctors handle the difficult patient? Well

fire them of course. Difficult patients are dangerous

patients (i.e., more likely to sue). They …harm office

morale and consume time and energy. Cut them

loose…There really is no down side to firing

disgruntled patients.” Christophil M.D. October 4, 2009

“When I had an office-based practice, I fired a patient

every two months. It was always a relief for me and my

staff. Once a patient has been fired by 5-6 doctors, he

just might start to think he should examine and change

his behavior.” Steve Parker, M.D., October 4, 2009

http://www.kevinmd.com/blog/2009/10/doctors-handle-difficult-patient.html

Documents

Managing Difficult Patients - Society of Clinical … Difficult Patients William Robiner, Ph.D. HEALTH PSYCHOLOGY DEPARTMENTS OF MEDICINE AND PEDIATRICS U NIVERSITY OF M ... » Anxiety