Alone or in combination, various patient, physician, and healthcare environment issues can contribute to patients being perceived as difficult. And, since physician burnout can both increase the incidence of challenging patient encounters1 as well as result from these encounters,2 reducing physician burnout stressors and reducing the factors contributing to physician-perceived difficult encounters could help mitigate both.
More Information on Managing Challenging Patients
- Manage Challenging Patients to Reduce Physician Burnout
- Best Practices: Strategies for Managing Drug-Seeking Patients
- Best Practices: Helping Non-compliant Patients Overcome Barriers to Adherence
- Best Practices: Managing Angry and Violent Patient Encounters
- Best Practices: Strategies for Engaging Patients Who Self-Diagnose via the Internet
- Best Practices: Managing Encounters with Overly Needy Patients
Factors Contributing to Challenging Patient Encounters
What causes a patient to be perceived as difficult is generally not associated with a challenging medical issue. The “difficult” label tends to attach to a patient who provokes a negative emotional reaction from their physician. When a patient encounter becomes difficult, physicians often focus on that patient as the source of the problem, but a combination of factors usually contributes to a difficult patient encounter.3,4
Patients and physicians bring a unique frame of reference and set of expectations to medical encounters, which partially explains why a patient who is considered difficult by one physician may not be considered difficult by another physician. The treatment environment can also contribute to the difficulty of the circumstances. Recognizing and addressing the issues that make the patient encounter difficult can mitigate the stress of treating these patients and reduce the risk that the encounter will contribute to physician burnout.3,4
Studies indicate that various social and medical conditions commonly predispose a patient to being considered difficult, including:2,4,5
- Behavioral health issues
- Health issues that do not appear to have an organic basis
- Alcoholism or drug addiction
- Poor hygiene
- Excessive neediness
- Egotistic, demanding, or manipulative behavior
- Threatening, aggressive, violent, or angry behavior
If the root of the difficulty is the patient’s underlying health issues (e.g., behavioral health, somatoform disorders, obesity), referring the patient for treatment with a specialist may alleviate some of the strain associated with treating the patient.
Studies also indicate that a physician’s personality, work style, and belief system can contribute to their perception that a patient is difficult. Physician factors that can increase this probability include:2,4
- Strong assumptions about how patients should behave and how medicine should be practiced
- Bias toward particular medical conditions
- Cultural differences
- General unease with diagnostic uncertainty
- Stress or burnout
- Inadequate communication skills
When a patient encounter becomes difficult and patient or environmental factors do not seem to be driving your discomfort, consider whether an adjustment to your point of view might resolve the tension.
Practice and Healthcare Environment Factors
Difficulty during a patient encounter may be exacerbated or caused by forces outside a physician’s or patient’s control, including2,3,6,7
- Patient access to inaccurate online medical information, which can create unrealistic expectations and dissatisfaction resulting in patients becoming more demanding
- Management expectations of increased physician productivity without appropriate resources and support, which can create a healthcare environment where a physician is unable to satisfy patient demands
- Changes in insurance and access to care, which can disrupt continuity of care and can result in the patient’s decreased satisfaction and diminished healthcare results
Types of Difficult Patients3,4,5
Difficult patients have been categorized in various ways. Resources and strategies for managing different types of difficult patients overlap somewhat. For example, a common physician stressor when dealing with difficult patients is managing the time-intensive nature of these encounters but in many instances the resources and strategies are unique to the particular type of patient.
Patients seeking opioid prescriptions can contribute to physician burnout and physician burnout may be a contributing factor to the opioid epidemic. It can be a vicious cycle, but physicians can use these strategies for managing drug-seeking patients to break it.
Low patient activation, low health literacy, inability to pay for treatment, and behavioral health issues may all contribute to a patient’s failure to comply with treatment recommendations. This patient noncompliance is among the stressors that can result in physician burnout. Helping non-compliant patients overcome barriers to adherence may reduce the frustration associated with patient noncompliance that can contribute to burnout.
Angry Patients and Violent Patients
Dealing with angry, verbally abusive, or violent patients can contribute to physician burnout. Many of the triggers of patient anger are avoidable, or at least can be moderated. Often, understanding what is causing a patient’s anger can help de-escalate it and direct the follow-up after an outburst. In some cases, though, angry patients can escalate to violence. Physicians and other healthcare workers are frequent victims of violence by patients, patients’ family members, and visitors. Physicians can protect themselves and the people around them with preparation, training, and strategies for responding to angry or violent patients. De-escalation training, preparation, and knowing how to respond when a patient becomes angry or violent is the key to preventing and successfully managing these patient encounters.
Patients who self-diagnose based on internet research can contribute to physician burnout by combining three of its contributing factors: time pressures, lack of patient trust, and lack of control over managing a patient’s healthcare. Because these kinds of patients are unlikely to be satisfied with passively receiving medical information from their physicians, physicians instead can use patient-supplied internet information as a patient engagement and activation tool. Appointment time management strategies can help physicians control internet content discussions so that they don’t run over the appointment time. Managing patients who self-diagnose via the internet can help reduce physician burnout as well as provide an improved patient experience and better treatment results.
Particularly in a busy practice with tightly scheduled appointments, very needy patients can become overwhelming. The disproportionate need for reassurance in some patients can contribute to physician burnout. Various strategies can be used to reduce the stress associated with managing overly needy patients, including improving reassurance skills, establishing appropriate patient expectations, setting boundaries on your availability, and better management of appointment time. Establishing more control during these encounters can reduce the stress and frustration that feed physician burnout.
Rehabilitating and Terminating Treatment of a Challenging Patient
Preparation is the key to successfully addressing challenging patients in office practice. Setting expectations for patient behavior at the beginning of the physician-patient relationship can signal to patients that violent, disrespectful, aggressive, overly needy, and drug-seeking behavior will not be tolerated. Patient rights and responsibilities statements or patient brochures are two ways to communicate behavior expectations and help prevent disruptive patient behavior from causing physician burnout.
While appropriate termination of treatment is an option for repeated or extremely disruptive patients, not all challenging patients need to be dismissed from the practice. Some patients may need a reminder in the form of patient behavior agreements or written warnings following an incident. Once a patient is informed of behavioral expectations and the consequences of violating expectations, they may cease being problematic. If the patient’s behavior continues to be problematic, strong policies and documentation can facilitate termination of treatment in a manner that minimizes the risk of an abandonment claim. If a patient does file such a claim, evidence of policies and documentation can help successfully defend the allegation. Consider the following strategies:8
- Inform patients and visitors of behavioral expectations in waiting rooms with communications tools like placards and handouts, patient rights and responsibilities statements, and practice brochures.
- The notices should outline the types of behavior expected and also the types of behavior for which the office has a zero-tolerance policy.
- They should also describe the use of behavioral agreements or behavioral warning protocols, and that patients who break the rules may be terminated from treatment.
- Create behavioral rehabilitation policies and protocols, including warnings or behavior agreement protocols and termination policies.
- Intervene early, before problems escalate.
- Establish the number of times the patient will receive warnings or can violate a behavior agreement before termination may be initiated.
- Train staff on patient behavioral policies and protocols.
- Start behavioral rehabilitation with a patient meeting to explain your expectations.
- Clearly identify the patient’s inappropriate behavior.
- Explain why the identified behavior is not acceptable according to office policy.
- Describe your expectations for future interactions with the patient and the consequences of the patient’s failure to meet expectations.
- Create a warning or patient behavior agreement that memorializes the expectations and the patient’s acceptance of them.
- Have the patient sign and date the agreement and provide the patient with a copy.
- Document the details of the rehabilitation encounter in the patient’s medical record, including whether the patient has accepted or rejected the rehabilitation plan.
- Communicate the rehabilitation plan and expectations to staff, along with clear directions about how non-compliant behavior should be handled and documented.
Termination of Treatment Resources
Patient Behavior Tools
- Sample Patient and Care Team Partnership Agreement (Regions Hospital)
- Sample Patient Rights and Responsibility Language (ProAssurance)*
- Quality and Risk Management in Healthcare Organizations Resource Document (ProAssurance)*
Termination of the Patient Relationship
- Termination of the Physician-Patient Relationship: Case Studies and Best Practices (ProAssurance)
- Physician-Patient Relationship: Establishing and Terminating the Relationship (ProAssurance)*
Service Recovery and Unanticipated Outcome Resources
- CAHPS Ambulatory Care Improvement Guide, Strategy 6P: Service Recovery Programs
- Service Recovery in Healthcare (Beryl Institute)
- Responding to Unanticipated Outcomes: First Conversations (NORCAL)
- Communication and Optimal Resolution (CANDOR) Toolkit (AHRQ)
Challenging patient encounters that damage or strain the physician-patient relationship present the physician with a decision to attempt rehabilitating the patient relationship or terminating treatment. Different kinds of challenging patients require different management and follow-up strategies. For example, de-escalation strategies may be too dangerous if the patient has a weapon. In those cases, call police or security. Immediate termination of treatment is also appropriate.
On the other hand, patients who are challenging because of a perceived service failure might be successfully calmed to a degree that the basis for their anger can be discovered and remedied. In that case, the appropriate follow-up might be a behavior warning or a patient behavior agreement. Sometimes, challenging patient behaviors destroy the therapeutic relationship. Termination of treatment with proper notice may also be appropriate in those cases.
* This content is available to insureds in the secure ProAssurance portal.
1. Elizabeth S. Goldsmith, Erin E. Krebs. “Roles of Physicians and Health Care Systems in ‘Difficult’ Clinical Encounters.” AMA Journal of Ethics, 2017;19(4):381-390.
2. Rosemarie Cannarella Lorenzetti, et al. “Managing Difficult Encounters: Understanding Physician, Patient, and Situational Factors.” American Family Physician, 3/15/2013; 87(6)419-425.
3. Leonard J. Haas, et al. “Management of the Difficult Patient.” American Family Physician, 11/15/2005; 72(10):2063-2068.
4. Dov Steinmetz, Hava Tabenkin. “The ‘Difficult Patient’ as Perceived by Family Physicians.” Family Practice (2001) 18 (5): 495-500.
5. Cora Collette Breuner, Megan A. Moreno. “Approaches to the Difficult Patient/Parent Encounter.” Pediatrics. 1/1/2011;127(1):163-169.
6. Medical Protection Society. “The Challenging Patient.” Casebook. May 2009;17(2):12-14. (resource not available online)
7. Eric D. Morgan, et al. “Continuity of Care and Patient Satisfaction in a Family Practice Clinic.” The Journal of the American Board of Family Practice. September 2004;17(5):341-6.
8. NORCAL Mutual Insurance Company. “Termination of the Physician-Patient Relationship: Breaking Up is Hard to Do.” Claims Rx. April 2020.