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Apr/Jun 1995

The Difficult Patient
PCW Kee

ABSTRACT:

"Difficult patients" are a group of patients who rend to arouse feelings of helplessness, irritability and frustration in their doctors. Such feelings evoked in the doctors lead to anger, anxiety, withdrawal or passive aggression with adverse consequences for the patients. Instead of a healthy doctor-patient relationship which is healing, the doctor and patient are drawn into a conflict situation which is stressful and counter-productive.

"Difficult patients" can be categorised into four types: those who reject help, those who demand help, those who manipulate help and those who are beyond help. To manage such patients more effectively, doctors need to be in touch with their feelings, to develop an empathic understanding of their patients and to recognise the nature of the transaction between the patients and themselves.

INTRODUCTION

Ile human relationship between a patient and a doctor has been described as the centre of medicine and the unchanging core of medical work regardless of whatever technical advances that have been made'. As in all human relationships, problems often arise especially with individuals who have personality problems.

The encounter with the "difficult patient" is not uncommon in general practice. In U.K., it has been estimated that a family doctor with an average list of 2,500 patients will have between 5 and 10 such patients to care for2. These patients are called by a variety of names as shown below:

"obnoxious patients    whining "self-pitier"
"hateful" patients    "heart-sink" patients
frequent attenders    help-rejecting "crocks"
hypochondriacs    help-rejecting cornplainers
fat folder patients    doctor addiction syndrome

GOMER (Get Out of My Examination Room)

DEFINITION OF THE DIFFICULT PATIENT

"Difficult patients" have been described as those patients who arouse helplessness and exasperation leading to irritability, anger, frustration, fear and even hatred in most physicians','. Before diagnosing a patient as "difficult", it is important for the doctor to exclude other causes for the difficulties encountered in the relationship.

Firstly, the "irritability quotient" of the doctor may be high because of some other personal problems. Secondly, there may be language barrier between the patient and the doctor. Thirdly, the patient may be suffering from an illness which is difficult to treat such as a terminal cancer.

It is also important to bear in the mind that the objective of identifying the "difficult patient" is not to label that patient but to recognise the need for special skills to manage such patients.

ADVERSE EFFECTS OF POOR MANAGEMENT OF THE DIFFICULT PATIENT

Poor management of the "difficult patient" has a number of adverse consequences. For the patient, there is a higher risk of errors in diagnosis and a higher incidence of unnecessary referrals to specialists, unnecessary investigations and unnecessary procedures and operations.

When the doctor fails to manage the "difficult patient" effectively, he may experience feelings of helplessness and frustration leading to other negative emotions such as anger, fear, insecurity, guilt and depression. There is also an increase in stress arising from anxiety about missing an organic disease and a lowering of his self-esteem.

Unpleasant confrontations between the patient and doctor results in an unhealthy patient-doctor relationship. Very often, the patient and doctor are drawn into what is known in Transactional Analysis as "Games Transactions." Such transactions are characterised by a repeated set of behaviour by one person, an unconscious but expected response by the other person, and a predictable outcome consisting of negative feelings in both persons(5).

THE GAME TRANSACTION AND THE DRAMA TRIANGLE

Another way of denoting the game transaction is what is called the drama triangle. This is formed by three positions known as Rescuer, Victim and Persecutor.(5) For example, a woman presents with abdominal pain, headache and general weakness and is in the position of a Victim. After a careful history and medical examination, the doctor begins trying to find a way to help her and enters into the game transaction as a Rescuer.

Unfortunately, if the patient is a "difficult patient" who does not want to be rescued, she will reject all his suggestions such as seeing a gastroenterologist or neurologist and taking any medication.

The doctor comes to his wits' end and may end up as a victim feeling frustrated at his failure to help the patient. One doctor in such a situation became a persecutor by rejecting the patient and telling his nurse, "Do anything to her, pills, referral. Just don't let her see me. She expects doctors to do things that they are not able to do.(6)


Fig 1. The Drama Triangle

One important lesson from the above case is that with problems arising in the patient's life and relationships, rather than in his systems and organs, it is the patient, not the doctor who is "the one who knows more"(7).

TYPES OF DIFFICULT PATIENTS

The "difficult patient" may be divided into four types:

a. The patient who rejects help
b. The patient who demands help
c. The patient who manipulates help
d. The patient who is beyond help

a. The Patient Who Rejects Help

This group of patients has been described as Manipulative Help-Rejectors'. They will return again and again to the doctor to complain that treatment does not work and tend to play the "Why don't you.... Yes but..." game". Their objective of the consultation is to seek attention rather than relief of symptoms and this tends to provoke frustration in the doctor.

b. The Patient Who Demands Help

Another description of such a patient is "entitled demander"'. They try to control the doctor through the use of intimidation, devaluation and guilt induction. This is a reflection of fear and insecurity in the patient. In Transactional Analysis terms, such patients often draws the doctor into the game, "NIGYSOB" or "Now I've Got You, Son Of a Bitch"'. The end result is the evocation of guilt and anxiety in the doctor.

c. The Patient Who Manipulates Help

These are the "dependent clingers"3 who tend to make repeated requests for all forms of attention.

They have inexhaustible need for love and attention and provoke aversion and resentment in the doctor. The game which they may play is "Poor Me."'

d. The Patient Who Is Beyond Help

Such a patient has been called a "self destructive denier".' Their behaviour is often a chronic form of suicide as exemplified by the incurable alcoholic or non-compliant diabetic. These patients have given up hope of having their dependency needs met and resist treatment. It is therefore not surprising that they tend to provoke rejection in the doctor. The game transaction which they tend to be involved in is "Kick Me."'

RECOGNISING THE DIFFICULT PATIENT

It is important to realise that the emotions the patient elicits in the doctor are important clinical data as they are the clues to the kind of difficult patient that one has to deal with. Furthermore, any attempt to deny normal negative emotions only serves to place a heavy psychlolgical burden on the doctor.' Table I shows the different emotions evoked by the different groups of "difficult patients." Treatment strategies can then be formulated accordingly.

Table 1. Different emotions evoked in doctors by different types of difficult patients.


MANAGEMENT OF THE DIFFICULT PATIENT

To manage the difficult patient effectively, the doctor needs a repertoire of communications skills and strategies'. This involves the recognition of the important role of the doctor as a drug, listening to the patient's story and understanding the fundamental principles of supportive psychotherapy.


1. The Doctor As A Drug

Michael Balint has described the doctor's most powerful drug as the doctor himself. He further suggested that the doctor's use of himself or herself should be as conscious and considered as the act of proscribing a drug with due regard to the frequency, dosage and possible side effects.(9)

Just as doc tors can use their feelings as a diagnostic tool to recognise the kind of difficult patient, they also need to cultivate a greater awareness of their own behaviour, feelings, and relationships so that they can master them and use them therapeutically"(6) It is unfortunate that the healing effect of an empathic doctor-patient relationship tends to be labelled as the placebo effect.

At the same time, it is also important for doctors to recognise the significance and consequences of our interaction with patients. For example, an indiscreet statement by a doctor about the possibility of a heart attack may induce a cardiac neurosis in an anxious patient.

2. Listening To The Patient's Story

We need to see patients as human beings who are intelligent, free, social, artistic and symbolic beings rather than just being organs, cells, bones, tissues and immune systems. This means that medical treatment has to be more than objective and scientific. As patients have personal ifies, char-acter, virtues, vices, fears, thoughts, projects and loves, we need to learn to listen to the patient's story instead of just taking a medical history of their illness.(10)

It is only when doctors have an understanding of "the story" of the patient, that they will be able to reframe their observations and information and thereby interpret the patient! s behaviour in a new, more understandable way.

For example, a 36-year old female factory worker was thought to be a malingereras she was reporting sick very often. It was only when the doctor took time to listen to her that he was able to empathise with her. The patient had been struggling with the bereavement of her 8-year old son who had died from leukaemia nine months ago. Furthermore, her husband was a drug addict in detention at the Drug Rehabilitation Centre.

Rabinowitz et al have noted that family doctors need a mode of intervention that is different from normal, exploratory psychotherapy, which is often time-consuming and inapplicable in the context of family medicine. They found that sometimes, merely listening to a patient's story with its expression of emotions and meaning can produce desired changes(11).

Indeed, the most important message for doc tors is, to quote Norell, "Understand your patients if you can; love them if you must; but for Heaven's sake, notice them"(12).

3. Supportive Psychotherapy

The objectives of supportive psychotherapy are to support the patient's optimal ego functioning, to help the patient reframe his cognitive functions, and to take appropriate action in dealing with the problem in external reality(13).

Supportive psychotherapy is not giving personal advice, the dispensing of friendliness, or the automatic expression of encouragement and reassurance. It involves two simple techniques. Firstly, the doctor needs to help the patient to clarify the problems that are bothering him. Secondly, it involves confronting the patient with his or her defensive "not-thinking" behaviour with a non-threatening approach. "Not-thinking" behaviour limits the awareness of reality and reduces the capacity to think of ways to solve the problem".

The goal of supportive psychotherapy is more to effect healing rather than a cure. In this regard, Nouwen has defined healing as "the humble but also very demanding task of creating and offering a friendly empty space where strangers can reflect on their pain and suffering without fear, and find the condidence that makes them look for new ways right in the centre of their confusion"(14).

CONCLUSION

The difficult patient can be regarded as a nuisance -as someone we want to get out of our consultation room as quickly as possible. Or we can learn to see the difficult patient as a challenge to improve our communication and management skills. The problems we encounter with such patients serve to remind us of the fundamental truth that medicine remains essentially a question of interpersonal relationships.

Needleman has rightly observed that doctors have been trained to master technology and to use it to make diagnoses and to give answers. However, 90 per cent of the people who go to see a doctor do not come for such technological answers. The patient comes for some kind of a relationship, whether teacher- student, parent-child, or friendship. And this is especially true for those patient who doctors feel are difficult".

His description of the relationship between the question of caring for the patient and the development of medical technology is an apt summary of the problems and benefits of managing the difficult patient:

"What was clear was that with all the technology in the world, medicine remained almost entirely a matter of human relationships. With all the science in the world, the actual treatment of illness remained a matter of human relationships, without which the science was not only powerless but even destructive. To sacrifice the right quality of human relationship was actually to sacrifice the quality of science itself! The work of a doctor was right action and clear, impartial thinking. And all of this was impossible without the mastery of one's emotions - in other words, the growth of inner being that is and always has been the true context of what nowadays bears the tedious name of ethics."

PCW Kee
MBBS (Spore)
MMed(Int Med) Spore
FRACP, FAMS

Family Physician
11 Ghim Moh Road #01 -72
Singapore 1027