A new approach to difficult patients

Every physician, nurse, emergency medical technician, respiratory therapist and clinician of every specialty has mused about how much better their work­place would be if they did not have to deal with difficult patients or demanding families. It is helpful to remember the four principles that form the basis of the physician-patient relationship:

1. Autonomy. Autonomy is the ethical principle widely considered most central to health care decision-making. In medical practice, autonomy is usually expressed as the right of competent adults to make informed decisions about their own medical care.
Adult and emancipated patients with decision-making capacity have the right to accept or decline offered health care, and physicians have a duty to respect the decisions of those patients, even if they disagree.

2. Beneficence. Beneficence means promoting the patient’s best interest by treating or preventing disease or injury and by informing patients about their conditions.
We also must protect our patients’ right to confidentiality.

3. Nonmaleficence. Do no harm. We are expected to avoid actions or treatments likely to cause the patient harm. Our patients trust us; they have faith in us that we will not harm them.

4. Justice. We are expected to allocate the benefits and burdens related to health care delivery fairly. We must act impartially regarding patients’ gender, race, age, or ability to pay.

In medical training, the hidden curriculum refers to the les­sons that medical trainees receive behind the scenes and in “the real world.” Some of these lessons stand in stark contrast to the ideals of humanism and professionalism proclaimed in medicine’s codes of ethics and echoed during the first day of medical school orientation.

And yet patients become problematic only when they evoke negative thoughts in the mind of the treating clinician — thoughts that create feel­ings of frustration, confusion, anxiety, sadness and disgust.

Those negative feelings can lead to undesirable actions such as arguing with, snubbing or prematurely discharging the patient. Those who entered the medical profession with the highest and noblest intentions do not want their actions to stem from feelings of anger, fear and hatred. We are far better than that.

In my book, “Changing How We Think About Think About Difficult Patients: A Guide for Physicians and Healthcare Professionals,” I detail the lessons I have learned about how changing the thought process can positively impact how the clinician feels and performs.

Human behavior has been described in the literature of psy­chology in terms of the motivational triad and the think-feel-act cycle. Human beings at their most basic level are motivated to seek pleasure, avoid pain and minimize effort. Our thoughts cause us to feel a certain way and act accord­ingly.

We can apply this think-feel-act triad to our clinician-patient relationships. Once we accept that our own thoughts and beliefs create our emotions and are what cause us to act — not the words, emo­tions and actions of others — we can obtain better results for our patients and for ourselves. If a “problem” exists only in our minds, we can solve the problem by changing how we think.

The arrival of a patient in an office, on the hospital floor, at the urgent care center or in the emergency department presents a situation or event over which we have no control. The situation is neutral until a physician has a thought about the patient. Often, the generous thoughts of the health care professionals cause emotions like compassion or concern that drive the actions and determine results.

Choosing better thoughts is not just wishful thinking or slap­ping an optimistic idea onto an unfortunate situation. The first step is finding an intermediate, slightly more positive thought that feels believable. We cannot just conjure up rainbows and dai­sies where the reality appears murky and dark. If we retrain our brains to think about people not as challenging patients, but as people who challenge us, what a difference that very subtle change in thinking would make.

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How to say goodbye

There comes a time when every practitioner will have to bid farewell to a staff member, patient, colleague, or community. Whether it’s because someone is terminally ill or moving away, these sensitive goodbyes can be challenging.


Here are some common send-off scenarios with suggestions for how to say so long.

Illness or death

When my friend was in the final phase of Stage IV breast cancer, she set the bar high for saying goodbye. A retired RN who was pragmatic at heart, she knew there was no hope for her survival. In her last days of cognition, she sent personalized thank you notes to the people who had touched her life. Her closing words still resonate with me. She wrote, “Farewell. I shall miss seeing you.” What a profoundly simple and thoughtful message.


Doctors need to know how to say goodbye with grace, too. Being the person who notifies someone about their imminent death and accompanies them on their final journey is a sacred position. That’s why it’s so important for medical practitioners to feel comfortable offering a heartfelt farewell when the time comes.


Still, it’s natural to agonize over what to say to the dying. A simple and sincere statement like the one my friend shared can suffice. Offering a similar sentiment to their loved ones goes a long way toward their healing, too.


When it’s a doctor who is facing his or her own mortality, it’s only fair to let patients know that there will be a change in the practice. Since it’s probably impractical to notify patients one by one, a concise general announcement will usually suffice. There’s also the chance that a physician will die unexpectedly, in which case their executive or administrative team will need to promptly decide on a plan of action for notifying patients and colleagues of the sudden death.

Retirement or relocation

A strong physician-patient relationship takes time to develop. Losing a trusted doctor for any reason, including retirement or relocation, can be difficult for patients. But it’s not only patients who will need to accommodate the change: Clinic staff will also be affected.


It’s respectful to offer an explanation to both groups well in advance of closing, selling, or moving a practice. Employees should be notified first so they can begin adjusting their career plans. Letting staff know about the change before patients means they can also help spread the word in a considerate and efficient manner.


One of the final acts of compassion a physician can offer patients is to provide ample time for them to absorb the news of departure. Adding recommendations for practices that are accepting new patients and helping with the transfer of medical files are other caring gestures.

Disagreement or disharmony

Not every relationship works out. It’s likely that at least once in a physician’s career, he or she will have to part ways with a colleague, a group, or a patient.


If all efforts to mediate differences between parties have failed, it’s time to let the relationship go. When it comes to staff, most medical practices have policies in place for terminating an employee. If they don’t, they need to create some. These policies must be followed to the letter to avoid any potential problems down the road.

Medical partnerships that decide to disband will benefit from having legally binding, documented, and signed dispute and dissolution clauses in their contracts from the get-go. No matter how well practitioners get along in the beginning, it is prudent to discuss the eventuality of the partnership dissolving long before it actually comes to an end.

Whether because of distrust, disrespect, or dispute, sometimes patients need to be released from a practice. There are ethical and professional standards to be followed in these cases. The process of severing patient connections can range from being difficult to being frightening. Having a well-thought-out statement, a witness, a firm tone, and fixed boundaries can ease the gravity of the situation, though it’s rarely an easy thing to do.

No matter what circumstances lead to the need to say goodbye, preparation and forethought are the keys to easing the transition. And in some cases, as demonstrated by my dearly departed friend, it never hurts to end with, “I shall miss seeing you.”

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Two Types of Demanding Patients

Hell hath no fury like a patient who wants all his tests done, reported today, and/or to see the specialist immediately.


I divide them up into two groups. The first are the patients that are quite ill and scared as they have waited too long to get medical help and are afraid things will not turn out well. They generally tend to come in later in the day, especially on Friday or Saturday morning at the office. Friday, I can send them to the hospital lab for blood then have the lab page me with the results so I can call the patient at home.


For radiology, I call the department and ask that the films be read and have a report called to me. I advise the patients the hospital will charge more for the services when done this way. I also tell them that they should not hesitate to go to the ER, as these labs and x-rays can be done there and a decision on treatment can be made immediately based on the results.


The second group are the patients with an aggressive personality who want everything done right this minute, even if it is not an emergency. I give them the x-ray and lab slips and tell them to go immediately to the hospital.


It's funny how they change when they're informed that the hospital will be charging more for the tests, as their insurance may not cover as it is not an emergency. Referral is made to the specialist and I give them the number for the physician's office so that they can call concerning the appointment.


Since almost all the specialists are hospital employees, referrals can take weeks to months for the patients to be seen. They can get on a cancellation list, but the appointment will be at the convenience of that office. Lastly, I recommend the ER but explain that the waiting time until seen can be several hours.


When they call back demanding things I also recommend they call their insurance company so that I can make an out of town referral to a regional center for evaluation of the problem. Again they are welcome to call the center and demand an immediate appointment.

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