Difficult physician–patient encounters

Authors


  • Funding: None.

  • Conflict of interest: None.

Abstract

Consultant physicians encounter patients, and families and carers of patients, who leave us feeling helpless, frustrated, irritated and even angry. There are limited opportunities for trainees and physicians to discuss how to recognize, manage, learn from and prevent these difficult physician–patient encounters. This paper addresses factors, including physician factors, that may contribute to making encounters difficult, categorizes the types of difficult encounters and provides generic and specific suggestions (based in part on published literature and in part on our personal experience) about prevention and management of many of them.

Introduction

As consultant physicians, we sometimes meet patients, and families and carers of patients, who leave us feeling helpless, frustrated, irritated and even angry. There is little practical guidance for the more common day-to-day troubling encounters in consultative practice,1 especially in Australian contexts. Published literature tends to focus on specific issues, such as patients with personality disorders or with drug dependence.2 Although the focus has traditionally been on ‘difficult’ patients, the contribution of physicians to difficult encounters must also be considered.3,4 Encounters are more likely to be deemed difficult when physicians have less than optimal communication skills or are lacking in other aspects of professional behaviour.5,6

There are limited opportunities, during training and afterwards, to discuss how to recognize, manage, learn from and prevent difficult physician–patient encounters, and to understand our own responses to such situations.7 By combining gleanings from published literature with insights gained from experience and what we have learned from colleagues, we aim here to raise awareness and promote discussion about such encounters and to improve physician satisfaction and possibly patient outcomes.

Factors contributing to difficult encounters

It is more productive to regard an encounter as difficult, rather than to label patients as problematic.8,9 As difficulties are perceptions, similar encounters may be perceived as difficult by one physician, but not another. As well as factors inherent in physicians and patients, contributions may also arise from the setting, purpose and timing of encounters.

Physicians vary in personality, training and experience. Some seem to attract and manage difficult encounters well, while others seek to avoid them. Reflecting on our communication skills and professional attitudes, and seeking to understand why we chose to become physicians and what we wish to offer patients, may help us to prevent and manage difficult encounters (see ‘Physicians’ contributions to patient–doctor encounters’ below).

Particular patient behaviours make some of us feel uncomfortable. Examples include patients who are perceived as demanding, needy, abusive, inflexible, argumentative, vexatious or overtly familiar or flirtatious.

Physician–patient encounters occur in different settings and circumstances. For example, there is less potential for encounters to be difficult when consultations are unhurried and conducted in quiet offices rather than in busy hospital settings, where privacy and confidentiality might be also compromised. The potential for difficulty also seems less in elective than in more urgent consultations.

Perceptions and expectations concerning the purpose of a particular encounter are relevant. Our expectations may differ from those of the patient or the referring doctor. For example, the patient might expect only a focused assessment of the presenting problem and thus detailed questioning may be perceived as threatening. Some aspects of the history and physical examination, while satisfying the expectations of referrers and physicians, may also give rise to patient dissatisfaction, unless such issues are anticipated and explanations provided. Perceptions of relatively long waits for appointments may also predispose to difficulties and need to be addressed.

Some patients who seem to be difficult or demanding when unwell may not seem like this when recovered or when trust is gained. This issue is especially relevant in consultative practice, where it is less likely that physicians have known patients or families prior to the illness prompting referral.

When difficulty is perceived during consultations or courses of treatment, it may help to try to identify which of the above factors apply or could be relevant. Discussion with colleagues is often useful. Perceptions of potential difficulty should lead to diagnostic trails, similar to those arising from key elements of the history and physical examination. Thus, if the issue appears to be one of patient anger, spending time exploring past medical experiences or other potential contributing factors to anger would be warranted.

Categories of difficult doctor–patient encounters

Many encounters might be perceived as potentially difficult, even to experienced physicians (Table 1). These encounters are equally challenging for general practitioners who, when understandably frustrated, seek our input, assistance and support. Our skills as consultants should include the ability to handle comfortably these challenging problems even if we cannot offer a cure or improvement of patients’ situations. Encounters may seem difficult long before the reasons for difficulty emerge. We continue to learn from our own and shared experiences.

Table 1. Examples of potentially difficult encounters
Angry patients, families or carers
Overprotective families or carers
Over-controlling or dominating partners, carers or parents
Patients without a firm diagnosis
Patients who seem to resist getting better (including ‘somatizers’)
Patients who seem to have ‘unusual’ personalities or beliefs
Patients who offer expensive or otherwise inappropriate gifts
Patients who are themselves clinicians
Self-harming patients (including those with factitious disorders and Munchausen's syndrome)

There are many other clinical situations in which the possibility of a difficult encounter seems higher, but these are not individually addressed in this paper. These include encounters with patients who appear to be excessively demanding or dependent or who assume a sick role, often with secondary gain, patients who complain about us and/or other clinicians, are non-compliant, engender strong negative emotions in us or who have very different backgrounds or beliefs to our own. The following comments, however, may also be applicable to these encounters.

Generic strategies may prevent difficult encounters and when difficulties arise, generic and more specific approaches may assist management. Although proposed for general practitioners, some basic questions (Table 2) may also assist consultants, especially at initial consultations.8

Table 2. Questions to prevent and manage difficult encounters (modified from Pearce8)
How do you consider that I might be able to help you (or how did Dr . . . think that I might be able to help you)?
What are your expectations of this consultation (or of me)?
When did you last feel perfectly well?
Is it distressing for you to discuss this issue?
What do you think is the cause of your problem (or symptoms)?
Have you known other people with this condition (or these symptoms)? How did they fare?
What do you already understand about your illness (or symptoms)? What have you been told and what have you learned about it yourself?
Do you understand what is planned? How do you feel about this plan?

Difficult encounters often reflect poor communication. As in all encounters, the first approach is to seek to establish rapport, demonstrate respect and build confidence and trust. Patients appreciate our interest and concern, not only about addressing the relevant health issues, but also about them as people.5,10–14 Effective communication helps us understand patients as whole persons, so that we can imagine ourselves in their situations (i.e. empathy) and better understand how they feel and why they might behave in certain ways. Without diminishing the importance of establishing rapport, and of feeling and demonstrating genuine interest in the patient's issues, we also need to be cautious about over-involvement and inappropriately offering too much, for example a ‘cure’ when, as is so often the case, this is not possible. On the other hand, realistic offers of assistance which are within the limits of our own capacity are appreciated by patients and their families and carers.

Angry patients, families or carers

Anger with aggression is frequently a manifestation of anxiety or grief, a common response to a new and potentially serious health problem. Anger may also relate to past healthcare experiences perceived as unsatisfactory. It is generally helpful to acknowledge anger and distress as soon as possible and to listen attentively to concerns. Dealing adequately with anger and anxiety means dedicating time to listen. Consultations should occur in settings where interruption is unlikely and privacy assured. We must not only be seen to be listening but also hear what is said and respond appropriately. Angry people should be invited to take their time to raise all of their concerns, with interruption only for clarification. Even when we believe that situations have been misunderstood or that responses are clearly incorrect or inappropriate, defensive interruption with our own views is likely to aggravate the situation. Patients' perceptions of being given time for an adequate and genuine hearing may diminish anger in these situations and lead to reasonable dialogue. Often the next step is to ask the angered person how we might assist them to achieve their goals. Apologizing for contributions we might have made to their distress should be considered.

Anger, especially in family members and carers, may be an expression of perceived guilt. It is often sufficient simply for us to silently recognize this, if only to avoid making potentially aggravating comments. Even when those not directly involved deem that feelings of guilt are entirely unnecessary, such perceptions may persist.

Communication with family members can be problematic and a potential source of anger. For example, patients may not wish that any of their health information be shared while family members may all wish to speak directly with us. In the latter situation, it may help to ask families, with the permission of the patient, to nominate one member with whom we regularly communicate, on behalf of all. Where problems appear to relate to poor communication within a family, a formal family meeting may be warranted (see below).

Overprotective families or carers

It is not unusual to encounter families who insist that relatives should not be informed about diagnoses, especially of incurable conditions. This most commonly arises with elderly patients and in some cultures, particularly when we do not share common languages with patients.15,16 This obstacle needs to be handled with patience and tact. One approach is to ask patients, with family members present, if they have any questions and then separately ask the patient, when alone, the same question with the assistance of an interpreter. Sometimes, a formal family meeting17 is preferable, where the discussion, questions and responses are shared. The patient should understand the purpose of the meeting, approve the list of invitees and if possible attend. All present should be invited to ask questions, although identifying a key family spokesperson may help, for both current and future issues. If the patient's competence is in question, medico-legal advice may be needed.

The content and flow of such meetings vary according to the situation, but the following questions are worth considering:

  • • Do we know the names, relationships to the patient and backgrounds of all present?
  • • What exactly are their concerns? For example, families and carers may be more concerned about how sensitively we convey bad news, rather than wanting to prevent this altogether.
  • • Do attendees appreciate that requests not to inform patients adequately may pose problems for patients and clinicians? Patients may learn of diagnoses from others and thus lose confidence in clinicians. In addition, most of us have difficulty deceiving patients. Consider providing family members with examples of what we might say if patients enquire directly about their diagnosis, prognosis or care plan.
  • • Do attendees understand that patients nearly always know or accurately surmise their situation and may be trying to protect their family from distress?

It can also be useful to ask family members what they consider the patient's wishes might be, as well as what their own wishes would be, if they were in the patient's situation. Sometimes, it is acceptable to support the family's wishes, at least for a period of time, so long as no harm is done to the patient. Indeed, forcing information on to a patient who does not want it at the time may be both unethical and harmful.

Over-controlling or dominating partners, carers or parents

This can lead to very difficult encounters. Intervening too soon to exclude the dominant person from the doctor–patient consultation may negatively influence an already fraught family relationship. We counsel patience in this situation, as after several consultations, dominating individuals have usually developed sufficient confidence (or run out of energy) to cease attending, after which the other issues can be addressed. The dominated person is often very reluctant to confront her or his situation. This may well be a long-standing pattern of behaviour about which little can be done within the consultation. With adolescent or young adult patients, it may also be difficult to see the patient alone, without unsettling the parents. One option is to delay the private consultation until the parent's confidence has been gained.

It is not easy to interview patients when others are present. A useful strategy, when the patient is accompanied, is to discuss this difficulty and explain that you will focus on the patient initially, and after this on others, including dominating persons. It may help to give others present pens and paper to record notes and questions, while you interview the patient.

Patients without a firm diagnosis

Establishing a precise diagnosis is often difficult and at times impossible. We, like patients, vary in our capacity to tolerate uncertainty. Although patients are often sufficiently reassured to learn that serious alternatives can essentially be excluded, the lack of a diagnosis is not only frustrating, but sometimes intolerable for some physicians and patients. When it becomes apparent that a firm diagnosis is impossible, especially when this is expected, it usually helps to state the fact that definite diagnoses are not always possible and that the consequence is to maintain an open mind about diagnosis, at least at this stage.

When diagnoses are not forthcoming, we find the following strategies useful:

  • • Repeating a detailed history and clinical examination. The history should include reconsideration of the social and psychological context, as distressing and undiagnosed physical symptoms are frequently caused or contributed to by anxiety, current stresses or masked depression.18,19
  • • Offering a second opinion, preferably before the patient requests this.
  • • Explaining that diagnoses may be classified into three broad categories, ‘physical’, ‘emotional’ and ‘unexplained’.
  • • When appropriate, considering self-harm, spouse-abuse and even factitious illness, including Munchausen's syndrome, which is discussed further below. In these situations, the assistance of a liaison psychiatrist can be invaluable. Should the patient be reluctant to be referred, advice can nevertheless be sought.
  • • Discussing how we all have limits to the stress that we can bear without becoming unwell and that some of us experience physical symptoms arising as a consequence of emotional distress at lower thresholds than others.

Physical symptoms secondary to anxiety and stress can be debilitating.19,20 Encounters with people in such distress are unavoidable, so we need to recognize such situations and be equipped to assist them, and thus remain empathetic and supportive.

Patients who seem to resist getting better (including ‘somatizers’)

Somatizing patients appear to express emotional distress through physical symptoms21 and they often seek medical care by exaggerating (possibly unconsciously) minor symptoms. A recent survey classified 18.5% of patients attending Australian general practices as somatizers.22 In consultant practice, a long history of symptoms arising in multiple organs or body parts, often associated with a history of surgical treatment where few or no abnormalities are found, is often the clue to diagnosis. If such patients are not recognized, inappropriate management is likely to be offered and sooner rather than later, we will regard encounters as difficult.

Principles of management include taking a detailed history of past episodes of ‘unwellness’ (including encounters with other health professionals), attentive listening to patients’ symptoms, considering treatable conditions, using investigations sparingly and mainly for patient reassurance, and encouraging and supporting such people to live with their symptoms. In these situations, regular appointments at an agreed minimal frequency may be justifiable. Over time, and especially when somatizers develop confidence, it may become possible for underlying psychological issues to be considered and addressed. Over-investigation may be harmful, as asymptomatic findings not relevant to the current problems, such as gallstones, uterine fibroids and ovarian and hepatic cysts, may result. Close collaboration and good communication with family physicians are essential. We should resist temptations to refer these patients to colleagues, including surgeons or subspecialist physicians, especially when this involves shifting rather than sharing responsibility. When we do seek other opinions, our colleagues should be alerted to anticipated difficulties.

Anxious physicians may be tempted to investigate and treat every new symptom, but this seems unwise. Simply listening, conducting a physical examination, arranging limited investigations if appropriate and providing ample reassurance is sound medical practice. As somatizers have the same risk of concurrent organic illness as others, this possibility must be kept in mind.

Similar advice applies to patients with symptoms across many body systems, especially when the focus of symptoms changes with each visit. In these patients, the background issue is often anxiety and stressful situations, or a perceived need for care and support, based on social and other problems. Advising such patients that their symptoms are ‘all in the mind’ may destroy any relationship physicians might have and is neither accurate nor fair. Physical symptoms experienced by such distressed people are just as real and unpleasant as symptoms of organic diseases. In due course, when trust is established, finding time and ways to explain the links between the mind and the body may assist some of these patients.

Patients who seem to have ‘unusual’ personalities or beliefs

We need to develop capacities to tolerate patients with different personalities, beliefs and backgrounds and those with alternative views of disease causation. This involves accepting individuals as they are and being neither judgemental nor confronting. As trust grows, it often becomes possible for us to at least assist such patients to understand their illnesses in our terms, so that they can make informed decisions about treatment options, especially about the diagnosis and treatment of serious disease.14

Some such patients may be diagnosed with a psychological or psychiatric illness and close liaison with treating psychiatrists may be essential. It can be difficult to decide whether new symptoms represent manifestations of physical or mental issues. Patients with personality disorder, especially those considered ‘borderline’, may create difficult issues. These patients can be particularly adept at ‘playing off’ members of the treating team against one and other. Setting agreed ground rules, and having only a single member of the team as coordinator and spokesperson, assists in their care.23

Patients who offer expensive or otherwise inappropriate gifts

The offering of inappropriate gifts is one way in which patients may try to become special. Distinguishing these from appropriate gifts may be difficult. Depending upon the nature of the gift, you may need to explain gently that professional ethical codes prevent you from accepting particular gifts.24 By applying such generic principles, the rejection of individual patients is avoided. Physicians who are perceived to become cold and distant, as a means of deterring the patient's enthusiasm for giving gifts, may find that rejected patients lodge complaints about other aspects of their care.

Patients who are themselves clinicians

Obtaining a full history, explaining matters to clinician-patients and anticipating and correcting misapprehensions can be difficult.25 We suggest treating clinicians like other patients, assuming in the first instance that they have no special knowledge arising from their professional background and experience. On the other hand, it often helps to explore later specific issues arising from and relevant to their own training and experience. Most clinician-patients harbour fears that they may have a serious or fatal disease and early reassurance, when justified, is good practice.

Self-harming patients (including those with factitious disorders and Munchausen's syndrome)

These diagnoses are often delayed, probably because we assume that persons seeking medical help never set out to deceive. As suspicions develop, doctor–patient relationships are at risk of becoming tenuous and patients may choose to seek care elsewhere, thereby delaying the correct diagnosis. As these conditions are uncommon, most physicians have limited experience in assisting these patients. We suggest that advice be sought from more experienced colleagues as early as possible. Consultation with others, and sometimes admission to hospital, may be useful to clarify the diagnosis and to determine if indeed treatment is possible.

Physicians’ contributions to patient–doctor encounters

Physicians’ contributions to difficult patient–doctor encounters have only recently been considered. As discussed below, appreciation of what we bring to encounters, especially when difficult, may reduce the proportion of patients who challenge us.

In the early 1950s Michael Balint, a Hungarian-born biochemist and later psycho-analyst, established weekly discussion groups for general practitioners at the Tavistock Clinic in London, where case histories of patients were reviewed. While the focus of these groups was primarily on why some patients were difficult to handle, the sessions also allowed the general practitioners to understand more deeply what aspects of their own personality and emotions contributed to situations. Balint's account of these sessions remains a classic20 and his work has led to physician support groups (Balint groups) in many countries.26 More recently, there has been increased interest in finding ways of helping doctors to appreciate the contributions their own personality and style bring to clinical encounters. Psychiatrists, but not physicians, have long included this topic in their training programmes. The introduction of the theme ‘personal and professional development’ into the Australian undergraduate curriculum over 20 years ago and the recent inclusion of a generic ‘professional qualities curriculum’ into the Royal Australasian College of Physicians (RACP) training programme, with communication as a key domain,27 have the potential to assist future consultant physicians to become more self-aware.

In one US training programme, ‘personal awareness’ is defined as ‘insight into how one's life experiences and emotional make-up affect one's interactions with patients, families and other professionals’.28 The creators of the programme emphasize that ‘physicians’ personalities, personal histories, family and cultural backgrounds, values, biases, attitudes and emotional ‘hot buttons’ influence their reactions to patients’. The core curriculum in this programme covers physician beliefs and attitudes, feelings and emotional responses in patient care, challenging clinical situations (including difficult patients, care of dying patients and medical errors), physician self-care, and group discussion to support and promote physician awareness.

A comparable term for ‘personal awareness’ is ‘self-reflection’, an aspect often overlooked as part of being a medical professional.29 A broader term than personal awareness, self-reflection also includes seeking to ensure that one's knowledge and competencies are current and that personal health issues are not interfering with clinical performance.

Both these terms should encourage physicians to think about not only difficult interactions but also who they are, their temperament and personality and what it is that makes them the sort of doctor they are or aspire to be. This should include analysis of our own biases, for example, our comfort in managing patients with different sexual preferences, or with particular conditions, such as morbid obesity. Do we prefer performing procedures over talking with patients? Are we interested in and alert to the psychosocial factors that contribute to illness and patients’ experiences of illness? Are we uncomfortable treating medical colleagues and if so why? Would more training in this or other problematic areas help? Understanding ourselves helps us to understand why difficult encounters arise with patients, and in knowing and accepting our individual limitations, strengths and weaknesses. In the absence of specific training in this area, some preventive strategies are suggested (Table 3).

Table 3. Preventing difficult patient–doctor encounters
Time and effort is required for listening and communicating well. This includes paying attention to how people are greeted and seated, establishing and maintaining eye contact and appropriate body language, establishing rapport, using ‘open’ before ‘closed’ questions and considering if and when to interrupt.
Never blame patients for less than ideal communication. We are professionals who should be trained and competent in communication.
Never get angry – again we are professionals. If anger is felt, it should be first recognized as such and then used as a ‘flag’ to consider why it has arisen.
Strive to never appear rushed (no matter how agitated you may feel). For example, to minimize the appearance of being rushed, it may help to sit when visiting patients in hospital.
Remember that multiple diagnoses do exist, despite the reductionist principle of ‘Occam's Razor’.30
Remember that psychosocial issues are often relevant in consultative practice.
Accept that some symptoms often remain unexplained.
Discuss ‘difficult’ patients with a colleague or with peers in a group.
Offer second opinions before patients request this. Patients may be surprised, but this surprise may mean that they already trust you.

The primary goals of medicine are caring for people who are unwell and seeking to keep people well.24 In choosing to become physicians, we are committed to these goals. Some of us seek and find careers that allow us to avoid difficult patient encounters, but there are other choices. Learning to deal more effectively with difficult encounters can be professionally rewarding. Those who have sought relevant training are likely to find this aspect of practice less stressful.31 Our own health and that of our colleagues should also be kept in mind. Sharing the care of patients with general practitioners and other colleagues is helpful. Other coping techniques include finding interests outside medicine and looking after our own emotional and health needs.32–34 Difficult encounters become less stressful when we are adequately rested and happy in our personal lives.

Acknowledgements

This paper is based in part on a talk given by KJB to a group of RACP advanced trainees. We acknowledge the invaluable insights contributed by liaison psychiatrist colleagues, Dr Yvonne Greenberg and Dr Robert Yewers and physician colleague, Dr Katrina Watson. In addition, Drs Richard Baker, Alex Boussioutas, Elif Ekinci and Greg Whelan kindly commented on a final draft manuscript.

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