Difficult Patients

Difficult Patients

Anne Katz, PhD, RN, FAAN

Jun 11, 2015

We all have our fair share of so-called “difficult” patients. And, I would suggest that how we define “difficult” is as diverse as we are as health care providers and as individuals. Some patients come to us with that reputation—perhaps, a vague descriptor in a referral letter or a note in the patient’s chart. Maybe the receptionist or nurse makes a side comment that the next patient is “challenging” or “uptight,” and we accept their assessment.

Often the difficult patient is one who is anxious and/or overwhelmed, and this is manifested as anger or demanding behavior. I can deal with these kinds of difficult patients quite effectively for the most part. I strive to be on time, to see patients at the time of their appointment by building in 10 minutes between patients to allow for delays and for patients who take more time. I am fortunate that I have this luxury and don’t have to fit patients into a predetermined template that makes no allowances for patient delays, emergencies, and other unexpected usage of my time.

My “difficult” patients tend to be those who are in conflict with their partner and who have no apparent capacity for empathy. These are the patients who want what they want when they want it, and watch out if anyone gets in their way! One of these patients is a woman who has chronic health issues in addition to a diagnosis of cancer in the past two years. She wants to be loved and appreciated and has no insight into her behavior that pushes her partner away. She has done this so effectively that he is terrified of her and has stopped making any effort to comfort her because he just can’t seem to do anything right. She contradicts him during our sessions, interrupts him when he’s talking, and negates his opinions at every opportunity. She has started to interrupt me too—and I usually say very little and instead encourage couples to talk TO each other instead of listening to a lecture from me.

I have managed to bracket my increasing frustration with her. I have pointed out this behavior to her in our individual sessions, and when I do, she smiles, apologizes, and then proceeds to interrupt me whenever I decide to make a comment or ask a question. She has little insight into her demanding attitude towards her partner and constantly blames him for all that is wrong in her life. Their primary reason for seeing me in the first place, their lack of sex in the aftermath of her treatment, has retreated into the background of her battle to be right, all the time and with her partner, and increasingly with me.

I really hope that she will one day see, with clarity and acceptance, that she is making her partner’s life a misery and that she will never receive from him what she says she most wants. He cannot love and appreciate her because when she is bitter and mean she is not lovable and it is difficult for anyone, even someone who promised to be there, “for better or worse,” to move beyond the hurt of humiliation on a daily basis.

I know that he is not without his own contribution to this mess that they have created. He escapes to his office and spends long hours avoiding her under the guise of paperwork. He has stopped trying and so is not fully engaged in the work that they need to do in counseling. His spirit has left the marriage, and as much as she pushes him away, he has gone willingly.

So why do I continue to see them? I struggle with this question every time I see her name on my schedule. I truly believe that we can change our behavior and learn to be better than our instinctual selves. I see beyond her as a difficult patient and instead see her and them as a challenge, a broken partnership that could be mended, if only we could all, and I include myself in this, be kinder and gentler and more accepting.

So every time she walks into my office, alone or with him three steps behind, I take a deep breath and hope that this time it will be different and that she will allow herself to be vulnerable just this once, that she will hear someone else’s thoughts and not just her own, and that this time she will be able to change her behavior, even just for the 50 minutes in my office.

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Mary Joanne Deforest

Jun, 25 2015 12:49 AM

I wouldn't want your job for anything in the world. I fully understand the fear and anger that floods a person with the diagnosis. I call cancer a destroyer of families. If one person gets it, the whole family is coping with it.  

Unfortunately this can cause administration to not listen to a patient with problems. I politely requested a different oncologist, and they just humored me as a child wanting a big chocolate bar before a meal. This oncologist wouldn't order any lab work, called me "Missy", "Little Lady", and he wouldn't answer my question of how would my wound be cared for. The ACS recommends that bone and all soft tissue be removed, so I would have lost about a third of my face, and my meninges would  have been exposed. The smallest piece of lint or a fine eye lash that landed on my menages would have caused a topical infection on my menages. 

Nobody asked me what type of patient I would have been. I tore out IVs, transfusions, thrashed and got tangled in my tubes. I fight with the nurses when coming out of anesthesia. I was appalled that this doctor didn't know or care if I had clotting problems-my brother is a hemophilic. 

I went up and screamed and kicked the desk, cursed like a Bos'n Mate, sent Emails, which somebody always replied, "Ill talk to someone and get back to you in a few days."  Thank God that I was poached by a oncology radiology professor. I'm in remission for the incurable. I went to Japan by myself in April. But I went up to the desk, and showed them all of my receipts for certified letters to their administration, a thick file of Emails and their responses and no follow up. I told them that my last radiation was in 2 days, then I didn't have a doctor. I'm sure the TV news would like the story, along with the state licensing board, department of health, and it wouldn't be hard to find a lawyer. 

I met my oncologist in about 2 weeks. We stared at each other. So, I decided to ask him, if I could tell him what I knew. Then he could give me his opinions, and we could go from there.  We usually leave laughing. i had trouble with a PCP, and both of my oncologists took exception to that. They got me a new PCP that actually works with me to keep my thyroid under control, which keeps my BP down.  

Sometimes the problem isn't only the patient, as nurses and staff can make a simple matter into a complicated mess.  Soon, I'll be having my labs, my scan with contrast, and then my  visits. I have only one vein, so I like to have the draws done at the same time. I called the oncology office a month ago, and asked for  them to send the lab order in. I got hassle- lecture. I called the lab this AM, and his order hadn't been put in yet. I called his office and got another nurse. I told her that I called last month, gave her the image date, and that I have only one vein and I'm 73. I apologized, but I would start calling every day until the labs were submitted. I was having only one draw- and it wouldn't bother me to go in and tell him that his staff didn't get the lab order in. She said that I started early on this. I told her that God forbid, the doctor might do something called-take a vacation-and not be around, he might even go to a medical conference, so I was giving the office time to get this done. I'd also appreciate it if they let me know when the order was sent to the lab, as we both have a life to live-other things to do. I was called abou10 minutes later that my labs were submitted.

But throw sex, intimacy into the mix---My lip-a section of it and part of my nose was removed. I cannot imagine romantically kissing anyone. That's just my face, not any part of my torso. 

Anne Katz, PhD, RN, FAAN

Jun, 25 2015 7:19 AM

This is a frustrating and painful experience for you. One of the issues with so-called difficult patients is that everyone starts to treat them as difficult even when they are advocating for themselves. This is a right as a patient or consumer in the health care system - and unfortunately labels such as 'difficult' stick and are not helpful. When a staff member tells me that someone is 'difficult' I know that there is always a reason for their actions - and it is often fear and uncertainly and/or a history of not being taken seriously. When you talk to these 'difficult' patients, really talk and HEAR what they are saying between their words, it is often clear that the system or the health care providers have failed them in some way - not listened, not paid attention, not explained clearly enough, not tried to ensure that communication about what is to happen is understood.

Where I work we have two patient representatives (some times called ombudsmen) and we bring them in to help in situations such as yours where the patient has not been treated well. Thse professionals work with the patient and health care provider to find common ground - and we solve the problem of the difficult patient (or often difficult provider!) as best as we can.

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