My colleague Donna Agnew, MT, MSPAS, PA-C, and I have delivered many presentations to students regarding how to deal with patients who seem impossible to communicate with in clinical settings. After years of discussing this problem with a variety of practitioners working in different specialties, we realized that the art of dealing with individuals who are truly difficult is a daily occurrence in almost every medical practice.

Difficult patients seem to push all the wrong buttons for the clinician. These individuals may be demanding, have unrealistic expectations, be noncompliant, or wait until the end of the appointment to complain of a new problem. Difficult patients may complicate an appointment by exhibiting unusual degrees of anger, fear, mistrust, hostility, defensive behavior, boundary breaking, manipulation, or somatization. They may be prone to litigious behavior or “white-coat worship.” They may self-diagnose, demand unnecessary tests or medications, have an extreme sense of vulnerability, or just plain hate those awful paper gowns.

By the same token, the clinician may be grappling with his or her own feelings of depression, burnout, anger, fear, incompetence, frustration, anxiety, or prejudice. Struggles with time constraints or poor communication skills may also enter the picture. Finally, both parties have to battle such obstacles as language or literacy barriers, lack of privacy for patients in busy clinical settings, and insurance or managed-care issues.

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I do not have all the solutions, and during our presentations, Ms. Agnew and I acknowledge that we are only clinicians, educators, and students (much like our audiences). To that end, we ask session attendees to tell us what has worked for them in various situations and we attempt to support their strategies with the research.

So, what do they, you, and the research say to do?

  • Encourage teamwork with all members of the health-care organization, and don’t forget your patient is an integral part of this team.
  • Be honest with your patients and set clear limits when outlining their treatment plans. Many patients appreciate knowing where they stand and what is expected of them. 
  • Acknowledge that social issues invade all aspects of life—both yours and your patient’s.  A holistic view of the patient goes far in taking complete care of your charges. 
  • To explain medical issues, use language appropriate for the patient’s age and literacy level.
  • Learn what you can about a patient’s culture. Someone who is comfortable in your presence and sees your attempts at understanding is far more likely to share problems with you. 
  • Respect everyone, and keep in mind that our job is not to judge our patients; it is to prevent disease and treat problems. I often say that a person with an STD has a sexually transmitted infection, not a sexually transmitted moral digression. 
  • If you simply cannot provide your problematic patient with the same quality care you provide other patients, consider terminating the relationship in accordance with state laws.

Ultimately, a few key principles should apply when you care for any patient, difficult or not: Always try to improve your listening and understanding skills, avoid placing blame of any kind, increase your empathy, and be patient. Make the effort to maintain the attitude you probably had when you decided to enter this field—you wanted to help people. What an amazing joy to truly help and enrich the lives of others.

Dr. Paulk is an associate professor and academic coordinator for the PA program at Arcadia University in Glenside, Pa.