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INTRODUCTION

Key Clinical Questions

  • image How do you identify a “difficult patient”?

  • image What strategies achieve long-term clinical results and reduce unnecessary admissions to the hospital?

The term difficult patient refers to a subgroup of patients that provoke unpleasant emotions—feelings of frustration, anger, helplessness, inadequacy, or irritation—in the doctors caring for them. Thomas Sydenham wrote in his famed treatise on hysteria “All is caprice. They love without measure those whom they will soon hate without reason. Now they will do this, now that; ever receding from their purpose.” These patients have a series of overlapping characteristics, shown in Table 228-1.

TABLE 228-1Descriptions of Difficult Patients from the Medical Literature

Although many authors see conflicts between clinicians and patients as specific to one dyadic relationship, most patients identified as difficult or disordered have a long history of failed medical relationships and are often dissatisfied when they arrive. They recreate the same dissatisfying relationships by repeating the behaviors that caused their previous experiences. Emotionally provoked staff members will likely behave in ways that only further confirm the patient’s expectation that he or she will receive poor treatment.

Many neurologic disorders and medical conditions, including tumors, endocrine and autoimmune disorders, and medications, cause psychiatric syndromes, such as personality changes, major depression, cognitive dysfunction, and executive dysfunction. All of these can result in behaviors that make patients “difficult.” The following discussion is organized around the conditions that most often provoke and sustain “difficult” behaviors, and reviews some behavioral approaches to managing these patients.

PATHOPHYSIOLOGY OF DIFFICULT PATIENTS

Studies of difficult patients are fraught with technical challenges but have generally found that about 15% of patients are perceived as difficult. Six psychiatric disorders had particularly strong associations with being labeled as difficult: somatoform disorder, panic disorder, dysthymia, generalized anxiety, major depressive disorder, and alcohol abuse or dependence. The presence of mental disorders accounted for a substantial proportion of the excess functional impairment and dissatisfaction of difficult patients, but not for all of it. It is not surprising that these “difficult patients” often fall into patterns of futile care, with similar cycles of short hospitalizations that do not result in any benefit. These patients often have not had an adequate diagnostic formulation, and receive poor care as a result of a disintergrated system of care, one in which there is little communication, no real long-term treatment plan that emphasizes rehabilitation, and rewards physicans and patients for short ineffective but time efficient “problem focused visits.”

Our diagnostic rubric for difficult patients is developed out of the ...

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