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Whenever and wherever health professionals congregate, the topic of difficult situations with patients and families often comes up. Literature suggests clinicians experience up to 20% of their patients as “difficult.” These difficult encounters often increase frustration and decrease satisfaction with our work. They may impede our ability to deliver the patient-centered care that is at the heart of high-quality, satisfying, and effective health care.

Fortunately, most difficult situations are both diagnosable and repairable. Most problematic situations are created by unsatisfactory communication between clinicians and patients, or by personal issues the clinician or patient unknowingly bring into the visit. Such issues may mirror similar problems within the clinician or patient’s own world and evoke negative reactions to an inherent or overt aspect of the patient’s illness, personality, or lifestyle.

Clinicians may view patients as “difficult” based on their similarity to those with whom they have had a close relationship and an interpersonal problem. For example, a clinician whose uncle used anger to control her may now have a strong reaction to an older male patient who responds angrily when she refuses to prescribe an antibiotic for an upper respiratory infection. Another common situation is the clinician who is unusually intolerant of patients who do not engage in behavior change. This clinician may well have had a close relative whom she could not convince to stop smoking and later died from lung cancer. These types of internal reactions are normal, however, allowing them to enter into the encounter often creates discord and unproductive conflict. Developing self-awareness in order to consciously examine one’s own internal reaction to a current clinical interaction and then actively choosing a response can ease difficult interactions. The key to success is to carefully examine how visits are progressing while monitoring one’s own internal thoughts and emotions in response to the patient and the interaction. Greater self-awareness about our own feelings, experiences, and beliefs can help clinicians approach clinical interactions with less judgment and frustration and hopefully build skill and confidence. The case illustrations that follow focus on some of the more common challenging situations that clinicians encounter, and offer specific approaches. Table 4-1 summarizes some general guidelines. Table 4-2 recommends practical strategies for approaching specific situations.

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

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