The “Difficult Patient”

1. The “Difficult Patient” Aaron D. Storms, MD Carin van Zyl, MD Adult and Pediatric Palliative Care LAC+USC Medical Center Keck School of Medicine of USC

2. Objectives • Reimagine what makes a “difficult patient” difficult • Understand team and physician-based options for response • Understand the principle of interest-based negotiation

3. What makes a “difficult patient” difficult • Any patient who provokes discomfort in the healthcare team • Typically described as non-compliant, drug seeking, demanding, borderline, mentally ill, threatening • Includes frequent fliers, superutilizers • Often provoke frustration, anger and dread, especially in repeat encounters

4. Common patient features • They have higher burdens of mental illness, substance misuse, depression, anxiety, personality disorders, homelessness, sleep disorders and pain • Historical features often include adverse childhood events, involuntary admissions, unreliable social support, incarceration • Often have underappreciated cognitive issues preventing full understanding of treatment and consequences • Can present with or without a clear medical complaint

5. Types of challenging patients • Clingers: needy patients who evoke aversion and need boundaries • Demanders: entitled patients who intimidate, devalue, guilt • Help rejecters: pessimistic, needy, nothing-works patients who evoke self-doubt • Self-destructive deniers: display injurious behavior, ignore recommendations, and evoke strong negative feelings

6. Personality disorders Persistent patterns of internal and behavioral experiences that differ from social norms, causing distress and difficulty in daily functioning • High rates of not seeking treatment and few effective treatments • Cluster A: paranoid, schizoid, schizotypal • Cluster B: antisocial, borderline, histrionic, narcissistic • Cluster C: avoidant, dependent, obsessive-compulsive

7. Factors affecting the difficult relationship • System factors: health insurance, operations, wait times • Provider factors: communication style, burnout, empathy, ownership of problem • Patient factors: history and experience with healthcare personnel It’s not just the patient responsible for the difficult interaction

8. What does this do to the healthcare team? • Affects morale • Affects decision-making • Affects empathy • Affects trust • Increases risk of missed or delayed diagnosis

9. Countertransference • The emotion or attitude induced in the provider toward the patient • Can take place in minutes and affects medical decision-making • Can be objective: coming from the patient’s actions and attitudes • Can be subjective: induced by the provider’s own experiences

10. Team-based strategies for managing the relationship • No staff member is responsible for system level factors, but every kind encounter can change a person’s life • Use the knowledge of experienced staff to promote patient advocacy and find creative solutions to dilemmas • Group debriefings to manage stress constructively • Multidisciplinary meetings to address as many factor levels as possible

11. Personal changes in interactions to increase value • Constant reassurance • Limit setting • Being very thorough and patient • Respect privacy • Show concern for feelings yet focus on objective matters related to treatment • Make patients participants in their care

12. Positions vs interests • Position: Outward public stance one takes in a conflict. The stated claim about what one believes or wants to happen • Interests: The values, needs, motivations, concerns, and desires that undergird the positions one takes Fiester. J of Clin Ethics. 2015

13. Stay in the ring, mediate, develop a third story • Adopting a role of mediator in a conflict gives you the authority to stay in the ring, even if they want you to leave • Develop a “third story” that bridges the patient and staff perspective • Validation of patient views provides enough dignity to motivate engagement

14. Stay in the ring “Before I leave, I’d like to help. I need to understand what you think is wrong with what’s happened. I’m also worried that you might not be getting the help you deserve because the staff is afraid of you. Could you help me understand why? There must be a good reason. Maybe we could start by you telling me about your experience.” Develop a third story Mediate

15. Negotiating, concession and control-sharing • Negotiating is not giving in when there is benefit to both sides • Compromises are okay when limited, and part of a contingency plan • Difficult relationships require control-sharing to succeed, since loss of control is part of the problem

16. Concede, negotiate “Yes, you do have better chemistry with some of the staff. I can talk to nursing about preferential assignment. We don’t usually do that, but we can make an exception if you’re willing to be more accommodating.” Compromise Negotiate with limit setting

17. Honest limit setting and playing softball • Empathic confrontation, giving an honest but assertive explanation of why there are differing opinions, and outlining the limited options • These patients know they are disliked, and there’s no benefit to glossing over the staff’s real attitude.

18. Limit setting Honesty “We can’t work in unsafe environments. I’m sure you know some things you say frighten people. This will make them less likely to help you.” Playing soft ball

19. Communication tips for dealing with conflict • Deal with conflict when it’s starting (open communication) • Opportunity for shared decision-making, improved satisfaction, will save time • Recognize your own feelings (give yourself a few minutes). Goal is not to “win” the argument • Listen and then listen some more • Not judgmental (hard!), “I’m the doctor, the patient should be listening to me” • Instead consider “Why would this intelligent person sitting in front me have this point of view or request?” • Show patients and family that you care and address their emotions

20. Communication tips for Dealing with Conflict • Finding shared interests, partnering to find solutions • Physicians provide the scientific evidence, and clinical judgment and family provides the values • It’s not your job to change people’s minds. Goal is to find a solution that is clinically, ethically and legally acceptable • You will not reach consensus in every case: Use supporting services (ethics, risk management, hospital administration) • You can’t “fix” long-standing personality problems or issues related to family dynamics

21. References • Moukaddam N, Flores A, Matorin A, Hayden N, Tucci VT. Difficult Patients in the Emergency Department: Personality Disorders and Beyond.PsychiatrClin North Am. 2017 Sep;40(3):379-395. • Knesper DJ. My favorite tips for engaging the difficult patient on consultation-liaison psychiatry services. PsychiatrClin North Am. 2007 Jun;30(2):245-52. • Hawking M, Curlin FA, Yoon JD. Courage and Compassion: Virtues in Caring for So-Called "Difficult" Patients. AMA J Ethics. 2017 Apr 1;19(4):357-363. • Fiester A. The "difficult" patient reconceived: an expanded moral mandate for clinical ethics. Am J Bioeth. 2012;12(5):2-7. • Fiester A. Contentious Conversations: Using Mediation Techniques in Difficult Clinical Ethics Consultations. J Clin Ethics. 2015 Winter;26(4):324-30.