How can we better manage difficult patient encounters?

Avoid the urge to act. When a patient suffers from unexplained symptoms, effective interventions require physicians to avoid certain “reflex” behaviors—repeatedly performing diagnostic tests, prescribing medications for symptoms of unknown etiology, insinuating that the problem is “in your head,” formulating ambiguous diagnoses, and repeating physical exams.¹² Such physician behaviors tend to reinforce the pathology in patients with unexplained symptoms. The time saved avoiding these pitfalls is better invested in exploring personal issues and stressors.

The point is that such patients should be reassured via discussion, rather than with dubious diagnostic labels and potentially dangerous drugs. This approach has been shown to improve patients’ physical functioning while reducing medical expenditures.¹²

Into action with our 3 cases

CASE 1 Given these principles, how would you handle Mr. E, the patient who is demanding an MRI for a simple tension headache? Although placating him by ordering the test, providing a referral to a specialist, or defending your recommendation through medical reasoning may seem to be more intuitive (or a “quick fix”), these strategies often lead to excessive medical spending, transfer of the burden to a specialist colleague, and ongoing frustration and dissatisfaction on the part of the patient. In this case, validation may be a more useful approach.

“I can totally understand why you’re frustrated that we disagree,” you might say to Mr. E. “But you’re right! you definitely deserve the best care. That’s why I’m recommending against the MRI, as I feel that would be a suboptimal approach.”

Often patients like Mr. E will require repeated validation of their suffering and frustration. The key is to be persistent in validating their feelings without compromising your own principles in providing optimal medical care.

CASE 2 Let’s turn now to Mr. A, who is requesting escalating doses of opioids. Some physicians might write the prescription for the dose he’s insisting on, while others draw a hard boundary by refusing to prescribe above a certain dose or beyond a specific time frame. Both strategies may compromise optimal care or endanger the doctor-patient alliance. Another quick solution would be to provide a referral to a psychiatrist, without further discussion.

Although the techniques we’ve outlined require practice, they need not be time-consuming. In cases like that of Mr. A, however, the patient’s demands are often a sign of more complicated emotions and dynamics below the surface. So you might respond by stating, “I’m sorry to hear that things haven’t been going well. How are you feeling about these things? How does the oxycodone help you? In what way doesn’t it help?”

It is important here to understand how the medication serves the patient—in addition to the ways it hurts him—in order for him to feel understood. Inviting Mr. A to have an open-ended discussion may allow him to reveal what is the real source of his distress—losing his job and his home.

CASE 3 Now let’s turn to Ms. S, who is convinced that she has a physical malady despite negative exams and tests. In truth, she may be depressed or anxious over her husband’s death. One way to address this is to confront the patient directly by suggesting that she has depression triggered by her husband’s death. But this strategy—if used too early—may feel like an accusation, make her angry, and jeopardize your relationship with her.

An alternative approach would be to say, “I think your problems are long-standing and could require a while to treat. Let’s see each other every 2 weeks for the next 2 months so we get adequate time to work on them.” This would be an example of structuring more frequent visits, while also validating the distressing nature of her symptoms.

These strategies are evidence-based
These techniques, while easily adaptable to primary care, are grounded in psychotherapy theory and are evidence-based. A seminal randomized controlled trial conducted more than 30 years ago showed that a patient-centered interview incorporating a number of these techniques bolstered physicians’ knowledge, interviewing skills, attitudes, and ability to manage patients with unexplained complaints.¹⁴

A multicenter study analyzed audio recordings of strategies used by primary care physicians to deny patient requests for a particular medication. It revealed that explanations based on patient perspectives were significantly more likely to result in excellent patient satisfaction than biomedical explanations or other explanatory approaches.¹⁵ Research has also shown that agenda-setting improves both patient and provider satisfaction.¹⁶

Some cases will still be frustrating, and some “difficult” patients will still need a psychiatric referral at some point—ideally, to a psychiatric or psychological consultant who collaborates closely with the primary care clinic.^17,18