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  1. How do you identify a “difficult patient”?

  2. What strategies can clinicians use to 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. These patients are described in the records of the earliest physicians. 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 230-1.

Table 230-1 Descriptions 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 psychiatric conditions that provoke and sustain “difficult” behaviors, and introduces the concept of a behavioral approach to managing these patients.

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Case 230-1

A 28-year-old man with HIV and hepatitis C presented to the hospital for a complicated cellulitis and abscess of hand and forearm that developed after an altercation. The emergency room physician performed an incision and drainage and admitted him to the hospital for intravenous antibiotics. The patient acknowledged occasional nasal heroin and cocaine use but denied addiction. At the time of admission, the attending ordered oxycodone 10 mg every six hours as needed. The health care team suspected that the patient was homeless when he refused to provide a telephone number or family contact.

During multiple prior admissions the patient had displayed such hostility that nurses limited their interactions with him. The nurses reported the smell of tobacco smoke near the patient's bathroom, but he declined a nicotine patch. He left the floor to smoke and often returned appearing sleepy and intoxicated. He received escalating doses of intravenous (IV) narcotic medication from cross-covering clinicians. The day team did not appreciate ...

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