How to make the “difficult” patient encounter less difficult

This article reviews four types of “difficult” patient encounters that might well end badly. Each scenario is followed by communication techniques that PAs can use to improve the outcome.

Alison C. Essary, MHPE, PA-C; Susan L. Symington, MPAS, PA-C

Alison Essary is Assistant Professor and Coordinator, Clinical Master’s Track, and Susan Symington is Assistant Professor and Clinical Coordinator, both at the Midwestern University Physician Assistant Program, Glendale, Ariz. The authors have indicated no relationships to disclose relating to the content of this article.

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Clinicians label one sixth of all outpatient encounters with patients “difficult.”¹ Typically, these encounters challenge both the patient and the provider.² Common scenarios involve patients who are angry, silent, or confrontational; those who have chronic pain; those who demonstrate inappropriate seductive behavior; and those who are noncompliant. Table 1 outlines other common patient characteristics. Difficult patient encounters can lead clinicians to feel less enthusiastic about the delivery of health care, to feel manipulated during the encounter, and to hope that the patient will not return to the office.³ Unfortunately, patients whom clinicians label as difficult are more likely to have poor outcomes and utilize the health care system more frequently.¹ They also are more likely to sue.⁴

Labeling a patient difficult facilitates a potentially adversarial relationship between the clinician and the patient and interferes with the delivery of optimal care.⁵ One study showed that physicians with poor psychosocial attitudes are more likely to say that a patient is difficult.¹ However, it is usually not the patient who is being difficult. Rather, it is the encounter during the office visit that is difficult, or dysfunctional, and it is the provider’s responsibility to facilitate a positive encounter.²    

Unfortunately, this specific area of communication has not been widely studied by clinicians or educators.³ Most literature addresses the more global issues of effective communication and approaches to the medical interview. One technique that can be used to approach challenging patient scenarios is called BATHE.⁶ This is a pneumonic for the background situation, the patient’s affect, the problem that is most troubling for the patient, and the manner in which the patient is handling the problem. After eliciting this information, the clinician responds with empathy (see Table 2).

Most clinicians feel ill prepared to deal with dysfunctional patient encounters, and a technique such as BATHE can be adapted to a variety of scenarios. This approach can enhance the communication between the patient and the PA, provide a framework for discussion of a variety of complaints, and improve overall outcomes. This article describes four scenarios—patients who are demanding, angry, silent, and seductive—and identifies teaching points for each scenario and communication tools that facilitate a productive office visit.

Case 1: The demanding patient

The patient is a 35-year-old woman with low back pain. She states that she was lifting a heavy box and felt a “pop” and experienced immediate onset of pain in her low back and down her left leg. Her husband has chronic low back pain for which he has had multiple surgeries, so the patient is certain she will also need surgery. He takes a hydrocodone preparation for his pain, and she insists on having hydrocodone and MRI.

Instead, you order a plain radiograph of the lumbosacral spine and prescribe a short course of propoxyphene N-100 and an NSAID. You explain that you would like to wait 1 week before ordering an MRI scan. The patient responds, “I knew I should have asked to see the doctor. I want an MRI and the hydrocodone, and I am not leaving this office until I get both.”

The teaching points to keep in mind for this case include the following:

•   If the patient’s demands are not met, the patient may assume that you did not make the proper diagnosis.
•   Often the demands are related to a bad outcome of a close friend or relative.
•   The patient may feel that a diagnostic test or referral is being withheld to save money.
•   Demand for a specific narcotic can be a warning sign of an addiction problem.

Communication tools The first issue that needs to be addressed in this case scenario is that the patient doubts your ability to properly diagnose her back pain. Take care to respond in a nonjudgmental fashion. Use open-ended questions, and offer the patient an opportunity to explain what is worrying her. For instance, you might say, “You seem frustrated with the treatment that I am suggesting. Do you have concerns or questions about how I am treating your back pain?” The patient may then share significant background information—that her husband has a history of back pain and that his surgery was unsuccessful because of a delay in diagnosis. Awareness of the husband’s back pain and the unsatisfactory outcome of his treatment helps you better understand this patient’s anxiety as well as her demands. You can then not only discuss her back pain but also explain to her why her situation is different from her husband’s. If this approach is not effective, you may ask, “How do you feel a physician would have handled this?” Again, this question gives the patient time to examine her feelings. It also gives you the opportunity to determine whether asking the supervising physician to examine the patient would be appropriate. Working together to develop a management plan will usually facilitate patient compliance. If the plan is still unacceptable to the patient, you may then encourage the patient to seek a second opinion.⁷

In this situation, using the BATHE technique allows you to learn that the patient is most troubled by a fear that what happened to her husband will happen to her: multiple surgeries for chronic low back pain. Asking the patient what she worries about most would be an excellent way to address those fears. You can show empathy by letting her know you understand her problem. You might say, “I realize this back pain must be alarming and particularly difficult for you because you have already gone through a similar experience with your husband.”

This case also raises the possibility of addictive behavior. It is important, however, to distinguish between drug-seeking behavior and true addiction. An examination of this patient’s request for hydrocodone may reveal that she has used her husband’s hydrocodone, or it may suggest a history of narcotics use. Creating a narcotics contract and developing narcotics logs may help maintain accountability in such cases. In clinical practice, screening tools may well identify patients at risk for addictive behavior or those in need of intervention.

Clinicians’ attitudes toward substance-abusing patients are a major barrier to treatment of an underlying addiction.⁸ Simply denying addicted patients access to narcotics does little to treat the disease.⁸ By asking the patient, “How can I help?”—and utilizing community resources such as rehabilitation facilities, counseling programs, and pain management clinics—you may help stop the cycle of addiction.³

Case 2: The angry patient

It is Monday morning, and you have a full patient schedule. The third patient of the morning presents with right lower quadrant pain, fever, nausea, and vomiting. You suspect acute appendicitis and must arrange for hospital admission, schedule a surgical consultation, and coordinate care with your supervising physician. A scheduled 15-minute office visit lasts about 1 hour.

Although he has been advised of the delay, the next patient curses at you for not respecting his time. He threatens to file a complaint for “unprofessional conduct and poor medical care.”

The teaching points to keep in mind for this case include the following:

•   Emotional control is important in these scenarios. You may be tempted to respond defensively or emotionally to the patient’s outburst, but you should be respectful, empathetic, and professional instead.
•   The patient’s anger may be secondary to concerns that are separate from those that led to the outburst. Try to identify the true source of the anger.
•   Not all expressions of anger are verbal. Evaluate nonverbal signs of anger, such as a tense expression, tightened jaw, crossed arms, or any change from previous behavior.⁴
•   Identify potential threats to your safety.

Communication tools An angry patient may challenge even the most experienced clinician, but there are tools you can use to defuse the situation and improve patient-provider communication.⁹ Rather than responding defensively or finding an excuse to immediately leave the room, maintain a professional demeanor and try to learn the reason for the anger. A defensive or argumentative response may escalate the situation.

A three-step approach may be helpful. First, allow the patient to complete the angry outburst; then validate the frustration with empathetic comments such as, “I understand that you are upset at having to wait, and I apologize for the delay.” Second, involve the patient in the outcome by asking him to provide a solution: “What do you think I should have done?” or “Do you have any suggestions of how to solve this problem?” Third, provide the patient with an opportunity to discuss his concerns: “How can I help you today?” Acknowledging frustration and providing the patient with an opportunity to voice his concerns may calm him and allow you to begin the evaluation.

The BATHE technique can be applied to this scenario as follows. Once you have defused the situation, say to the patient, “Tell me what is going on with you today.” The response is likely to provide helpful background information. This patient is obviously distressed at having to wait, yet other circumstances have contributed to his emotional upset. Fatigue, weight loss, and loss of appetite led him to schedule the office visit and then conduct a brief Internet search on these symptoms. The search revealed some frightening diagnoses. Understandably, he is troubled by fear of a serious illness. The long wait in the examination room only heightened his fear and frustration. Posing the question, “How are you handling this?” allows him to acknowledge his fear and you to discuss appropriate coping methods. The patient’s fear is understandable and should elicit an empathetic response.

Threatening to file a complaint is intimidation, a tactic that is commonly used by patients who are behaving irrationally.⁴ Be sure to completely document an encounter of this sort, including any attempts made to address the situation, and all the care provided for this patient. You will need this documentation if there should be a complaint or lawsuit.⁴ You may also consider reviewing the case with your supervising physician.

Case 3: The silent patient

A 45-year-old woman who emigrated from Iran several years ago presents as a new patient. You have little experience with this ethnic population. When you ask the patient how she is doing, she does not make eye contact and answers very quietly that she is doing okay. You ask her several other questions about her overall health. The patient continues to look down at the floor and speaks so softly that you cannot hear any of what she is saying. You are frustrated and ask the patient to return in a week with a family member in hopes that this will improve communication.

The teaching points to keep in mind for this case include the following:

•   It is challenging to obtain an adequate history from a patient who either cannot, or will not, effectively communicate.
•   It is important to identify the cause for the silence.
•   The patient may view you as an authority figure and be afraid to speak.
•   Review the patient’s medications. Some medications may cause drowsiness or sedation.

Communication tools A patient may be silent for many reasons (see Table 3). If you can identify the problem, you can address its cause. If not, use an open-ended question to uncover the cause for the silence: “You seem quiet today. Is there a reason for this?” Allow ample time for a response. If there is no response, explain how important it is for you to have more information in order to help the patient. The clinician also needs to be self-aware; for example, a provider who is extroverted may be frustrated by a silent patient. Such a patient may be seen as uninterested or uninvolved in her health care.

Cultural barriers may also be playing a role. In this case, If the PA is male, it is important for him to understand that women from the Middle East may not make eye contact with someone of the opposite sex because in their culture, such eye contact may indicate a sexual invitation. Becoming knowledgeable about the cultures that are represented in your practice is essential for meeting the health care needs of all patients.¹⁰

The BATHE technique may also elicit background information. For instance, you might say, “You seem sad today. Are you depressed?” Hopefully, the answers to such open-ended questions would clarify whether this patient’s silence is attributable to a cultural issue or to depression. Perhaps adjusting to a different country and a different culture is the most troubling concern for her. She may also have a nonconfrontational personality, and speaking softly is an important part of her affect. Do not let yourself become frustrated by difficulties communicating; instead, recognize that for this patient, adjusting to a new culture may be challenging and speaking with a stranger about personal health issues may be difficult. To encourage a productive office visit and provide an empathetic response, you might ask, “What do you feel is the most important part of our visit today?” or “Is there someone who is close to you who can help to make decisions with regards to your health care?”

Identifying a specific cause for the silence may encourage a more collaborative relationship, one that is rewarding and beneficial.⁷ The patient who is silent may seem more difficult to care for, but the PA who develops self-awareness and recognizes any personal biases is unlikely to have a negative response to the patient.

Case 4: The seductive patient

You are scheduled to see a patient for an annual physical examination. At the end of the office visit, the patient asks you out to dinner. You are pleasant but firm in explaining the importance of maintaining a professional relationship. The patient feigns agreement and attempts to embrace you.

The teaching points for this case include the following:

•   The professional relationship between you and the patient should generally be terminated following seductive behavior. The exchange should be documented in the patient’s chart and the patient should be referred to another provider for care.
•   Aggressive or escalating seductive behavior may signal a psychosocial issue in the patient’s history that needs further evaluation.
•   You may feel threatened by the behavior, particularly if it is overt or involves physical contact.

Communication tools Boundaries describe the professional distance between the patient and clinician and can be violated by either party.¹¹ Yet, most clinicians are unable to identify seductive behavior in their patients.¹² These behaviors are typically subtle, and they may well occur because of lack of training, naïveté, and failure to recognize violations of boundaries. Cultural differences between the PA and the patient can give rise to interactions that could be interpreted as seductive by one or the other.¹³ Female clinicians tend to encounter more overt sexual behavior from patients, such as inappropriate affection or sexually explicit language.¹⁴ Patients who demonstrate such behaviors tend to have a history of abuse, emotional problems, and somatization disorders.¹²

The BATHE technique has a psychotherapeutic origin and is an ideal tool to use in this scenario. Investigation of this patient’s background reveals a recent rejection by a romantic partner, the discussion of which leads the patient to cry and express thoughts of suicide. Most troubling to the patient is that she was to be married in a few months, and the patient admits to not handling the situation well. This provides you or your supervising physician with the opportunity to explore coping mechanisms, identify counseling centers and support groups, and introduce therapeutic options for the patient’s depressive symptoms.

Engaging in a romantic relationship with a patient presents two significant issues: the clinician’s loss of objectivity and the imbalance of authority between the patient and clinician.¹² A loss of objectivity may lead the clinician to make inappropriate assessments or decisions on the patient’s behalf. By virtue of education, training, and level of responsibility, there is an inherent power differential between the patient and clinician. The patient relies on the clinician for knowledge and guidance; therefore, any actual or perceived misuse of this trust can potentially harm the patient and lead to a sense of exploitation.¹⁵ In fact, patients are at risk for significant emotional harm if they enter into an intimate relationship with a clinician.¹²

In this case scenario, the patient approaches you directly and then attempts physical contact after a firm refusal. Such behavior generally warrants a consultation with your supervising physician and transfer of care to another provider.

Conclusion

Encounters with patients often become dysfunctional because of a barrier to effective communication.⁹ Clinicians prefer to blame patients for such encounters by labeling the patient as difficult. Yet the literature suggests that there is a relationship between clinicians’ perceptions and the frequency of difficult patient encounters. Between 15% and 25% of patients in the primary care setting have unmet expectations,¹⁶ a problem which may also lead to difficult encounters. Establishing a compromise between the expectations of the clinician and those of the patient may improve the relationship and the overall health outcome for the patient.

Didactic and clinical training rarely provides clinicians with the interpersonal skills necessary to handle difficult encounters effectively,¹⁷ although recent emphasis on the patient-centered interview may encourage clinicians to enhance their interpersonal skills. Improved communication skills can help clinicians to better manage dysfunctional encounters and may help them to avoid conflict to begin with. Clinicians who emphasize the needs of the patient in addition to the treatment of the disease state improve patient satisfaction and develop more effective patient-clinician relationships.¹⁷ The BATHE format can accommodate a variety of patient complaints and conforms to the limitations of a 15-minute office visit. Other techniques include the use of active listening and reflection to build empathy¹⁸ and investigating the person of a patient.¹⁷    

Despite best efforts, some difficult interactions cannot be resolved satisfactorily. On these occasions, the PA should consult the supervising physician and perhaps refer the patient to another provider. Approaching the patient in an honest and straightforward manner can facilitate this process: “It seems that you are not happy with the care I am providing, and this is frustrating for both of us. I think you would be happier seeing another health care provider, and I would be willing to make recommendations based on your needs.” This approach provides the PA and the patient with an opportunity to acknowledge their difficulties with each other and gives the patient permission to obtain health care elsewhere.

Though challenging in daily practice, the development of a proactive and empathetic approach to dysfunctional encounters may salvage the clinician-difficult patient relationship and improve outcomes. The PA has the ability to turn a dysfunctional relationship between a patient and a clinician into a rewarding experience by developing and maintaining boundaries, establishing realistic expectations, and improving communication.  

Acknowledgement
The authors would like to acknowledge James D. Stoehr, PhD, for his editorial guidance and support.

(Photos: Punchstock)

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