It’s a scenario all office-based physicians are familiar with: Your day has been going well, and all your appointments have been (relatively) on time. But when you scan your afternoon schedule your mood shifts from buoyant to crestfallen. The reason: Three patients whom you find particularly frustrating are slotted for the last appointments of the day.
CASE 1 Mr. E, age 44, a high-powered attorney, has chronic headache that he has complained off and on about for several years. He has no other past medical history. Physical examination strongly suggests that Mr. E suffers from tension-type headaches, but he continues to demand magnetic resonance imaging (MRI) of the brain. “I think there’s something wrong in there,” he has stated repeatedly. “If my last doctor, who is one of the best in the country, ordered an MRI for me, why can’t you?”
CASE 2 Mr. A is a 37-year-old man who lost his home in a hurricane 3 years ago. Although he sustained only minor physical injuries, Mr. A appears to have lost his sense of well-being. He has developed chronic—and debilitating— musculoskeletal pain in his neck and low back in the aftermath of the storm and has been unable to work since then.
At his last 2 visits, Mr. A requested increasing doses of oxycodone, insisting that nothing else alleviates the pain. When you suggested a nonopioid analgesic, he broke down in tears. “Nobody takes my injuries seriously! My insurance doesn’t want to compensate me for my losses. Now you don’t even believe I’m in pain.”
CASE 3 Ms. S is a 65-year-old socially isolated widow who lost her husband several years ago. She has a history of multiple somatic complaints, including fatigue, abdominal pain, back pain, joint pain, and dizziness. As a result, she has undergone numerous diagnostic procedures, including esophagastroduodenoscopy, colonoscopy, and various blood tests, all of which have been negative. Ms. S consistently requires longer than the usual 20-minute visit. When you try to end an appointment, she typically brings up new issues. “Two days ago, i had this pain by my belly button and left shoulder blade. i think that there must be something wrong with me. Can you examine me?” she asked toward the end of her last visit 6 weeks ago.
The burden of difficult patient encounters
Cases such as these are frustrating, not so much for their clinical complexity, but rather because of the elusiveness of satisfying doctor-patient interactions. Besides a litany of physical complaints, such patients typically present with anxiety, depression, and other psychiatric symptoms; express dissatisfaction with the care they are receiving; and repeatedly request tests and interventions that are not medically indicated.1
From a primary care perspective, such cases can be frustrating and time- consuming, significantly contribute to exhaustion and burnout, and result in unnecessary health care expenditures.1 (See “Unexplained complaints in primary care: Evidence of action bias” also in this issue to learn more.) Studies suggest that family physicians see such patients on a daily basis, and rate about one patient in 6 as a “difficult” case.2,3
Physician attitudes, training play a role
Research has established other critical spheres of influence that conspire to create difficult or frustrating patient encounters, including “system” factors (ie, reduced duration of visits and interrupted visits)4 and physician factors. In fact, physicians’ negative attitude toward psychosocial aspects of patient care may be a more potent factor in shaping difficult encounters than any patient characteristic.3,5
Consider the following statements:
- “Talking about psychosocial issues causes more trouble than it is worth.”
- “I do not focus on psychosocial problems until I have ruled out organic disease.”
- “I am too pressed for time to routinely investigate psychosocial issues.”
Such sentiments, which have been associated with difficult encounters, are part of the 32-item Physician Belief Scale, developed 30 years ago and still used to assess beliefs about psychosocial aspects of patient care held by primary care physicians.6
Lack of training is a potential problem, as well. In one survey, more than half of directors of family medicine programs agreed that training in mental health is inadequate.7Thus, family physicians often respond to patients like Mr. E, Mr. A, and Ms. S by becoming irritated or avoiding further interaction. A more appropriate response is for the physician to self-acknowledge his or her emotions, then to engage in an empathic interaction in keeping with patient expectations.4
As mental health treatment becomes more integrated within family medicine,8 pointers for handling difficult patient encounters can be gleaned from the traditional psychiatric approach to difficult or frustrating cases. Indeed, we believe that what is now known as a “patient-centered approach” is rooted in traditions and techniques that psychiatrists and psychologists have used for decades.9