Issue #58 07.18.2022

The Difficult Patient Part II

In our newsletter a couple of weeks ago, we began talking about those difficult patients whose very names fill us with dread when they show up on our schedules or rounds lists. Those patients. The ones that can deflate our spirits and set a low tone for the whole day’s work in front of us.

Last time we discussed the angry patient, there’s another category of patients, when encountered, that instantly has many of us pulling away from them and creating some distance as swiftly as possible.

And who might those patients be?

The Entitled Demanders

We all know these patients – people who often:

• have an argumentative, hostile and confrontation presence with inexhaustible demands
• use medical jargon and infer they know more than their healthcare team
• use bullying language and actions
• mistrust the tests being ordered, the test results, their diagnosis, and their treatment
• use intimidation, devaluation, and guilt induction to scare and shame the healthcare team
• demand more testing, more consultations, withhold payment, or threaten litigation.  

They also display a sense of innate “deservedness” or entitlement, as though they are superior to everyone, including their physicians. They have a magical RIGHT to be treated better than they are, and better than everyone else!

Our “go-to” position as clinicians is usually one of two things:

First, we enter into a power struggle and “put them in their place.”

Second, we avoid them like the plague (and we have had recent experience with REAL plague!)

But in the end, that doesn’t shift the encounter in a positive direction and often results in the patient doing and saying the same things with more intensity at a higher volume. As for us? We end the encounter with a buzzing physiology and a bad taste in our mouths.

So what might we try instead that would actually move the needle in a way that is useful? Here are some suggestions that might make a difference:

1.     Slow down just enough to realize that this behavior is often a façade for underlying fear and powerlessness, increased by the awareness that their fate is in part in someone else’s hands. Loss of power when facing the unknown can be terrifying – and terror can lead to a loss of civility and critical thinking. This isn’t personal – so stay calm and clear!

2.     Collaborate with other members of the healthcare team to deliver consistent messaging. Mixed messages about tests and treatments will only make things worse!

3.     Don’t play the power game. Legitimate concerns can be acknowledged, but don’t be bullied into ordering tests or jumping on this rickety wagon with the patient.

4.     Clarify expectations. The patient IS entitled to clear communication and effective explanations, and a clear understanding of what they might expect from you and your team. They are NOT entitled to have unreasonable demands met and are not entitled to bully others.

5.     Acknowledge the patient’s entitled status. This one is perhaps the hardest to DO and to UNDERSTAND. The statement below is extracted from the original article on this topic in the NEJM, April 20, 1978 by Dr. James Groves who suggested saying something like this:

• “You have an illness that makes some people give up and you’re fighting it. But you are fighting your doctors too.

• You say you’re entitled to repeated tests, damages for suffering, and all that. And you are entitled – to the very best medical care we can give you.

• But we can’t give you the good treatment you deserve unless you help.

• You deserve a chance to control this disease; you deserve all the allies you can get.

• You’ll get the help you deserve if you stop misdirecting your anger to the very people who are trying to help you get what you deserve – good medical care.”

As always –

Take good care of yourselves and one another!