How to deal with difficult patients

Issue: November 2010

ByJohn D. Kelly IV, MD

John D. Kelly

Dealing with difficult patients is perhaps one of the hardest parts of my job. Unlike the operating room where I feel much more control over circumstances, each patient brings with him or her a unique and unpredictable set of problems, expectations and attitudes.

Angry patients and those with a ‘negative bias’ toward physicians can be especially challenging. Doctors are under siege these days and orthopedists may be on the front line. It seems that every week another article in the press manifests about orthopedists and improper relationships with industry or how another surgeon ‘sold his or her soul to the devil’ in order to gain extra revenue. Sadly, patients read these indictments and may come to your office negatively biased against you. Furthermore, every week I seem to have my share of patients struggling with addictions. They can certainly be persistent and demanding in their quest for more narcotics.

Another difficult group is the workmen’s compensation cadre who seem to want to avoid returning to work at all costs. Finally, I tend to run late and my tardiness does tend to precipitate a fair number of angry comments from patients such as “my time is important too!”

What I have learned

How do I deal with these difficult patients? I have not reached ‘total enlightenment’ yet, but I would like to share what has worked for me.

Separate the pain from the patient: A priest once taught me, “every obnoxious behavior is a cry for help.” Try to recognize that beneath the demands and the irksome behavior is a human soul, just like you and me, who happens to be suffering. Pain, whether from addiction or a physical affliction, can turn the kindest of beings into Frankenstein. Try to see the pain and the feelings it engenders as separate from the patient. In the process, one must leave judgment at the door.

Practice humility and apologize: I am best able to navigate the sometimes turbulent times of office hours when I practice humility: I leave my ego in the hallway. We are healers and are here to serve the patients the best way we can. Our feelings of anger and annoyance usually result from ego defense. Ask yourself why certain patients bug you and you will learn much about your own ‘issues.’ Often, especially annoying patients may remind you of a quality about yourself you may be struggling with or an old hurt may have been activated. For example, authoritative and demanding patients remind me of former coaches and teachers who were unkind to me in my youth. When we own what we bring to each encounter, our patients will teach us much about ourselves.

From humility ushers the freedom to apologize. I frequently run behind schedule in the office. I greet the patient by apologizing for my tardiness and remind them that I do respect their time as much as mine. Phrases such as “forgive me for being late” go a long way in establishing a positive connection with patients. ‘Other centeredness’ gets us out of ourselves and our own stuff and frees us to truly serve.

Get back to the ‘Now’

When we are stressed, we show our patients our worst selves. We rush, interrupt often and tend not to honor the dignity of each patient. A great stress buster for me is something I learned from a colleague, Michael Baime, MD, who teaches mindfulness or the virtue of living in the moment. When I am feeling tense or inordinately stressed, I try to stop … breathe … and be. That is, I take a little break and focus on my breathing. Just a few mindful breaths will brings me closer to the present – where there is no anxiety or guilt. With practice, mindfulness gets easier to attain and will allow you to give what your patients need – you.

Stay the course

Narcotic requests and demands to sign forms for disability can truly be an energy siphon. When we stay true to our mission of willing only what is best for our patients, the negative energy dissipates. For narcotic usage, statements such as “I only want what is best for you and taking addictive medications is simply not good for you” help the patient understand you are in his or her corner ... you are not there to enable destructive behaviors.

For the work-evader, I have used statements such as “I am here to help you and I will do so only in an honest fashion. I am committed to telling the truth about what I believe about your condition.” Patients may not like what they hear, but they will come to respect you. You will have the satisfaction that you acted truthfully ... which is ultimately always in the best interests of the patient.

Suggestions

I would like to share some other pearls I have gleaned over the years:

Take the communications skills course offered by the American Academy of Orthopaedic Surgeons. You will learn new and exciting ways to connect to patients and soon find out that office hours do not have to be drudgery. Connection to others keeps us in positive energy.
Establish healthy limits to your volume. For me, when I see more than 40 or 45 patients a day, I tend to feel more rushed and in the process leave more frustrated patients than I care to admit. I also lose ‘connection’ and am less satisfied. Emotions are contagious and we reap what we sow. Spend enough time to fulfill patients’ expectations and they will be happy. Satisfied patients are more compliant, are kinder to staff and even will sue you less often (hugely important in Philadelphia).
Be gentle with yourself. We all make mistakes and have treated some patients less than kindly. Take a step back and ask yourself what you learned during that particular rough encounter.

We are in the most satisfying of professions. When we become more ‘other centered’ and less judgmental, office hours will become more fulfilling. We will bring more energy to the operating room, our staff and our loved ones.

Now if you will excuse me … I have some patients waiting.

John D. Kelly IV, MD, editor of Your Practice/Your Life, can be reached at University of Pennsylvania, Dept. of Sports Medicine, 235 S. 33rd St., Philadelphia, PA 19104-6322; 215-615-4400; e-mail: johndkellyiv@aol.com.

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