Managing the “Difficult” Patient

Dana Beall Brown, PhD Clinical Psychologist Weight Management Center, Wake Forest Baptist Health

Agenda

� Defining “difficult” � Contributing factors � Consequences of difficult encounters � Management strategies � Opportunities

Defining “Difficult” Patients �  10-20% of patients are considered “difficult”

(Hahn, et al. 1994; Hahn et al., 1996; Hinchey & Jackson, 2011; Jackson & Kroenke,

1999) � Common descriptors: argumentative,

non-“compliant”, hostile, unpredictable, time-consuming, manipulative, self-destructive

Defining “Difficult” Patients

� 4 “types” (Groves, 1978)

� Assessment (e.g. DDPRQ) (Hahn et al., 1994)

◦  How demanding was this patient today? ◦  Did you find yourself secretly hoping this patient won’t return? ◦  How hopeless do you feel about helping this patient? ◦  How difficult is it to communicate with this patient? ◦  How at ease did you feel when you were with this patient today?

Multiple Factors to Consider �  Also termed “difficult clinical encounters”

�  Multiple factors: ◦  Patient –stigma, multiple vague symptoms, mental

health disorders, psychosocial factors ◦  Provider – biases, poor communication skills,

stress, inexperience

◦  System – limited time, access to care, inadequate processes

(Hahn et al.,1996; Hinchey & Jackson, 2011; Lorenzetti et al., 2013; Robiner & Petrik, 2017; Sulzer, 2015)

Consequences of Difficult Clinical Encounters � Patients: ◦  decreased trust, interference with treatment/

care, uncontrolled symptoms, higher utilization (Hahn et al., 1996; Hinchey & Jackson, 2011; Jackson & Kroenke, 1999)

� Providers: ◦  stress, burnout/decreased job satisfaction,

reduced quality of care, guilt (An et al., 2013; Bernhardt et al., 2010)

�  System: ◦  increased burden and cost (NIHCM, 2012)

Management Strategies

1)  Provider awareness, accountability 2)  Clinical effectiveness 3)  Strategic communication 4)  Team support

Provider Awareness

�  Influenced by our own thoughts, emotions, behaviors (Halpern, 2007; Robiner & Petrik, 2017)

� Challenging old assumptions i.e. what if they’re not “difficult”? (Fiester, 2012)

� Benefits of challenging perceptions and labels: ◦ Reduces negative thinking ◦  Strengthens ability to see the bigger picture ◦ Creates options

Improve Effectiveness

�  Listening �  Empathy – A little goes a LONG way! �  Motivational Interviewing (Miller & Rollnick, 2002)

�  Treatment of mental health conditions �  Utilize team perspectives

Strategic Communication

� Right time, right place, right way � Consistency from interdisciplinary team �  Straightforward, considerate messages � Proactive approaches

Opportunities

� Team support � All’s well that ends well � Posttraumatic Growth (PTG) ◦  Positive change resulting from hardship or

struggle (L.G. Calhoun and R.G. Tedeschi, UNC Charlotte)

References An, P. G., Manwell, L. B., Williams, E. S., Laiteerapong, N., Brown, R. L., Rabatin, J. S., …Linzer, M. (2013). Does a higher frequency of difficult patient encounters lead to lower quality care? The Journal of Family Practice, 62 (1), 24-29.

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(5), 289-297.

Groves, J. E. (1978). Taking care of the hateful patient. New England Journal of Medicine, 296, 883-887.

Fiester, A. (2012). The “difficult” patient reconceived: An expanded moral mandate for clinical ethics. The American Journal of Bioethics, 12, 2-7.

Hahn, S. R., Thompson, K. S., Willis, T. A., Stern, V., & Budner, N. S. (1994). The difficult doctor-patient relationship: Somatization, personality, and psychopathology. Journal of Clinical Epidemiology, 47(6), 647-657.

Hahn, S. R., Kroenke, K., Spitzer, R. L., Brody, D., Williams, J. B. W., Linzer, M., & deGruy, F. V. III (1996). The difficult patient: Prevalence, psychopathology, and functional impairment. Journal of General Internal Medicine, 11, 1-8.

Halpen, J. (2007). Empathy and patient-physician conflicts. Journal of General Internal Medicine, 22(5), 696-700.

Hinchey, S. A., & Jackson, J. L. (2011). A cohort study assessing difficult patient encounters in a walk-in primary care clinic, predictors and outcomes. Journal of General Internal Medicine, 26(6), 588-594.

Jackson, J. L., Kroenke, K. (1999). Difficult patient encounters in the ambulatory clinic: Clinical predictors and outcomes. Archives of Internal Medicine, 159, 1069-1075.

Lorenzetti, R. C., Jacques, C. H. M., Donovan, C., Cottrell, S., & Buck, J. (2013). Managing difficult encounters: Understanding physician, patient, and situational factors. American Family Physician, 87(6), 419-425.

Miller, W. R., Rollnick, S. (2002) Motivational interviewing: Preparing people for change. New York: The Guilford Press.

National Institute for Health Care Management (2012). The concentration of health care spending. Washington, D. C.

Robiner, W. N, & Petrik, M. L. (2017). Managing Difficult Patients: Roles of Psychologist in the Age of Interdisciplinary Care. Journal of Clinical Psychology in Medical Settings, 24, 27-36.

Sulzer, S. H. (2015). Does the “difficult patient” status contribute to de facto demedicalization? The case of borderline personality disorder. Social Science and Medicine, 142, 82-89.