Maintain your cool. With any difficult interaction, a physician’s first obligation is to remain calm and professional, while modeling appropriate behavior. If the patient is angry or emotionally intense, talking over them or interrupting them only makes the situation worse. Try to see the interaction from the patient’s perspective. Both parties should work together to find a common ground.
Collaborate, respect boundaries, and empathize. One study of a group of 100 family physicians found that having the following 3 skills were essential to successfully managing situations with difficult patients11,12:
- the ability to collaborate (vs opposition)
- the appropriate use of power (vs misuse of power, or violation of boundaries by either party)
- the ability to empathize, which for most physicians involves understanding and validating the patient’s subjective experiences.
Although a description of the many facets of empathy (cognitive, affective, motivational) is beyond the scope of this article, it is worth pointing out that a patient’s positive perception of their physician’s empathy improves not only patient satisfaction but health outcomes.13 The Box describes a difficult patient whose actions changed through the collaboration and empathy of his treatment team.
Box 1
Collaboration and empathy: How a patient’s positive perception can improve outcomes
Mr. L, a 60-year-old veteran, is admitted to an inpatient unit following a suicide attempt that was prompted by eviction from his apartment. Mr. L is physically disabled and has difficulty walking without assistance. His main concern is his homelessness, and he insists that the inpatient team find a suitable “Americans with Disabilities (ADA)-compliant apartment” that he can afford on his $800 monthly income. He implies that he will kill himself if the team fails in that task. He makes it clear that his problems are the team’s problems. He is prescribed an antidepressant, and both his mood and reported suicidal ideations gradually resolve.
The team’s social worker finds an opening at a well-run veterans home, but Mr. L rejects it because he doesn’t want to “give up his independence.” The social worker finds a small apartment in a nearby community that is ADA-compliant, but Mr. L complains that it is small. He asks the resident psychiatrist, “Where will I put all my things?” The next day, after insulting the attending psychiatrist for failing to find an adequate apartment, Mr. L says from under the bedsheet: “How come none of you ever help me?”
Mr. L presents a challenge to the entire team. At times, he is rude, demanding, and entitled. The team recognizes that although he had served in the military with distinction, he is now alone after having divorced many years earlier, and nearly friendless because of his increasing disability. The team surmises that Mr. L lashes out due to frustration and feelings of powerlessness.
Resolving this conflict involves treating Mr. L with respect and listening without judgment. No one ever confronts him or argues with him. The team psychologist meets with him to help him work through his many losses. Closer to discharge, he is enrolled in several post-hospitalization programs to keep him connected with other veterans. At discharge, the hospital arranges for his belongings that had been in storage to be delivered to his new home. He is pleasant and social with his peers, and although he is still concerned about the size of the apartment, he thanks the team members for their care.
Verbalize the difficulty. It is important to openly discuss the problem. For example, “We both have very different views about how your symptoms should be investigated, and that’s causing some difficulty between us. Do you agree?” This approach names the “elephant in the room” and avoids casting blame. It also creates a sense of shared ownership by externalizing the problem from both the patient and physician. Verbalizing the difficulty can help build trust and pave the way to working together toward a common solution.
Consider other explanations for the patient’s behavior. For example, anger directed at a physician could be due to anxiety about an unrelated matter, such as the patient’s recent job loss or impending divorce. Psychiatrists might understand this behavior better as displacement, which is considered a maladaptive defense mechanism. It is important to listen to the patient and offer empathy, which will help the patient feel supported and build a rapport that can help to resolve the encounter.
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