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Whenever and wherever health professionals congregate, it doesn't take long for the topic of difficult patients to emerge. Patients and families we experience as difficult increase the personal frustration of delivering care, decrease our satisfaction with work, and make it difficult to deliver the person-centered care that is at the heart of high-quality, satisfying, effective health care. Why, we ask, would someone come to the office, emergency department, or hospital and harass, abuse, demean, or lie to us?

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Fortunately, most difficult interactions are both diagnosable and repairable. Aside from the unusual person who is determined to be difficult, many problematic situations are created by unsatisfactory communication between practitioners and patients or by personal issues the practitioner or patient unknowingly bring into these important interactions. Such issues can mirror similar problems within the practitioner's own world and provoke negative reactions to the patient's physical condition, sexual orientation, or personality.

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Increasingly, medical educators are finding that practitioners consider patients difficult based on their similarity to others, often family members, with whom they have had interpersonal problems. For example, a physician whose uncle used anger to control her may now have problems with an older male patient who responds angrily when she refuses to prescribe an antibiotic for an upper respiratory infection. Another common situation is the practitioner who is unusually intolerant of patients who won't stop smoking. This practitioner may well have had a close relative whom he or she could not convince to stop smoking who later died from lung cancer. Developing the self-awarness to separate one's own past experience from a patient's current behavior can significantly moderate ones aversive response and reduce interactions that create difficult patients. The key to dealing with such situations is to carefully examine how visits are progressing while monitoring ones's own responses to the patient and the interaction. Greater self-awareness about one's own feelings, experiences, and beliefs can help practitioners offer more nonjudgmental care to their patients. The case illustrations that follow focus on some of the common challenging situations practitioners encounter, and offers specific approaches to dealing with them. Table 4–1 summarizes some general guidelines for working with difficult patients. Table 4–2 recommends practical strategies for approaching specific situations.

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Table 4–1. General guidelines for working with difficult patients.
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Table 4–2. Tips for approaching difficult situations or patient behaviors.

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