Discussions with so-called "difficult
"All patients are similar and
should be handled similarly." This ideal is not borne out in reality, as
in fact only a limited amount of affective neutrality is feasible. Various
studies (Gotthardt, Morgan, Peterson, Ritvo) showed that doctors and nurses
certainly differentiated between "nice" and "unpleasant", or "liked" and
The so-called "difficult"
patient is, as it were, at the extreme of the range of "unpleasant" and
"disliked". He is the opposite of the "ideal patient". An ideal patient
(according to Rohde, quoted by Gotthardt) is one who most suits the personal
work-related requirements of the staff. He recognizes their authority and
agrees without resistance to all therapy and procedures. He has no disturbing
individual peculiarities and requirements, shows trust and is grateful,
replies honestly, openly and comprehensively when he is asked questions,
but otherwise says nothing if he is not asked, and is quite satisfied with
the amount of communication which is allotted to him.
On the other hand, the "difficult
patient" asks for too much, he does not fit in, he refuses investigations
and suggestions for treatment, shows suspicious behaviour, does not react
in the way that is expected or usual, is critical of the doctors, nursing
staff, hospitals and practices, appears untrusting and inconsiderate, aggressive
and ungrateful. Further characteristics are that it is difficult to motivate
him, resulting in poor compliance, anxiety and hypochondria, apathy, indolence,
"clinging behaviour", and a tendency to demand too much attention from
the team. In a word: the difficult patient creates opposition, inhibits
the working atmosphere, costs a lot of time and frustrates doctors and
Are there predisposing
characteristics for difficult patients? Sex, age and disease have no
significant importance in the development of "difficult" patients according
to the studies of Gotthardt. It could be that prolonged hospitalization
or illness (over 3 months) is a predisposing factor. One interesting fact
is that there is an increased tendency to shun patients of the same sex
rather than the opposite sex, as shown in studies of medical teams by Morgan
One of the preconditions
for dealing successfully with difficult patients is an initial analysis
the possible reasons for the behaviour. The question should be raised
at the start of the review of the situation as to whether it is only I
who consider that the patient is unpleasant, difficult or problematic,
and is his behaviour, from his point of view, quite legitimate and
understandable? This is particularly difficult when a decision has already
been taken that the patient is difficult, and he is referred to with a
remark to this effect.
What reasons are there
for a patient appearing difficult and problematic?
The cozy interpretation is
that this is an expression of a primary psychopathological personality
structure. However this explanation probably really only applies to a few
of the so-called difficult patients. An objective criterion for decision
can be obtained by taking a social history, which will give clues as to
whether the personality is one which does not only create problems when
the patient is ill, or whether this also occurs in others areas of his
Further reasons can be a
but quite well-founded need for information or a inbuilt
approach to problems. The patient may have grown into the role of a
difficult patient as a result of experiences in which he received poor
or disappointing treatment. Influences which are specific to the illness
play a role, especially in chronic disease or prolonged difficult situations
(intensive wards). In addition, the status of a difficult patient can arise
as a mask for other disorders and illnesses, such as depressive
mood disorders or drug and alcohol-dependence. Of course egoistic elements
and an excessively demanding attitude can really be at the basis
of difficult behaviour.
In other words, the phenomenon
of a "difficult patient" should be regarded as a symptom and not
as a disturbance of daily clinical life, if one intends to deal satisfactorily
with these patients by discussion and other means.
Nevertheless it is important
to be clear that a patient who comes with inappropriate expectations is
often perceived as difficult by the treatment team.
Groves (1978) divided "difficult"
patients into four groups:
The dependent clingers
make themselves known by an apparently inexhaustible hunger to be noticed,
which can lead to the most extreme pleading for one's presence and care.
The "long-winded" also are included in this group. There is often a dread
of neglection or separation based on life-long experience. It does
not help these patients to be told what the limits are for medical care,
as this can lead to a sort of vicious circle with increasing anxiety. Meerwein
recommends that these patients are offered a framework to their treatment,
which is tailored to their requirements, which they understand and accept,
and keep to. Coping with the patient in this reassuring manner, always
involving him and letting him know what is expected in the future, can
often suffice to rescue him from the unhealthy circle of his dependent
clinging and the resulting defensive reaction of the treatment team. The
demanders are the sort of patients who insist that they are not receiving
the best treatment, neither what is best for them nor what they are worthy
to receive. They very often use pressurizing tactics such as defamation,
threats of lawyers or refusal to pay, any of which understandably can lead
to opposition on the part of the doctor. Anxieties are also usually present,
in the sense of dread of worthlessness. The objective of managing
these patients is to take as many steps as possible to raise their feeling
of self-worth, and to impress upon them the particular quality of the diagnostic
measures and therapy which will be arranged for them.
The manipulative help
rejecters are those patients who are always presenting with fresh symptoms,
and as soon as one is treated, another arises, leading to an unbreakable
chain of treatments, operations, and contact with doctors. This behaviour
should not be simply dismissed as "hypochondria", as it arises from dread
of losing the doctor, to whom the patient is very deeply attached and on
whom he depends. There is often a history of disturbance of the psychological
development due to frequent changes of personal attachments. This anxiety
"of the fragility and changing nature of personal relationships" must be
taken into account, and a frequent change of doctor avoided.
The self-destructive deniers
have usually given up all hope of fulfilling their desires, and believe
that self-destruction is the only way of self-actualization. These are
often people who suffered repeated mistreatment as children. They project
their destructive desires onto the doctor, releasing aggressive reactions
and make treatment exceedingly difficult. In many cases, only psychiatric
treatment has a chance of success.
What can doctors and treatment
teams do, so that difficult patients do not have to remain difficult?
The following ways are available:
basic principle of discussion and management is value-free acceptance
of the so-called difficult patient. This also means that a new patient
who is referred to as "difficult", should not be automatically categorized
as likely to raise problems. An unheard groan is a poor way to commence
discussions with these patients.
|There has to
be some attempt to analyze the reasons why the patient is (apparently)
behaving in a difficult or problematic way or drawing attention to himself.
This can lie in the patient himself, in his illness, in the situation or
in the medical team. One of the most common causes is anxiety.
|It is especially
important to be obliging and polite. If not, the tone of the discussion
is likely to become heated very quickly.
|It is important
to make the patient clearly aware of empathy, and to let him know
that he is accepted without prejudice. As these patients are usually
"experienced patients", they become aware of the attitude that they are
faced with immediately.
|It can be particularly
helpful to check with these patients whether in fact differing realities
are creating the difficulties.
with the "difficult patient"
|1) Basic premise:
of a patient is not fate but a symptom.
|2) Analysis of causes:
(separation, loss, desertion, worthlessness)?
|Due to illness
(chronic disease, extreme situations)?
expectation on the part of the team?
|A generally critical
|High need for
at requirements and criticisms
different realities are contributing
with difficult patients are usually characterized by a tense atmosphere.
Therefore the introduction of relaxation techniques can lead to
a loosening of the discussion and make the patient more approachable, a
precondition of which is that the person leading the discussion is himself
aware of the tension and attempts to reduce it. Occasionally it is possible
to remove tension by mentioning the problem openly with metacommunication.
If the "difficulties" of
a patient is perceived as a symptom that has various and possibly removable
causes, it is possible to prevent what otherwise is taken for granted:
that the difficult patient will always be difficult.
Geisler: Doctor and patient - a partnership through dialogue
Pharma Verlag Frankfurt/Germany, 1991
of this page: http://www.linus-geisler.de/dp/dp18_difficult.html