Changing How We Think About Difficult Patients

This transcript of their discussion has been edited for clarity and length.

Mike Sacopulos: My guest today is Joan Naidorf. She is a board-certified emergency medicine physician. Dr. Naidorf is the author of the recently released Changing How We Think About Difficult Patients: A Guide for Physicians and Healthcare Professionals , published this year by the American Association for Physician Leadership.

Dr. Naidorf, welcome to SoundPractice. The obvious question is, what is a difficult patient?

Joan Naidorf: Difficult patients are people who don’t follow the rules that we set out. They don’t do what we suggest, they don’t keep appointments, they don’t fill the prescriptions or take the medicines that we suggest. In general, they don’t want to go along with the plan that we set out for them. So, it is a very subjective rule of what “difficult” is that every nurse or physician or a healthcare professional has, and not everybody follows the same plan.

For example, patients would come into the emergency department and say, “I have this sort of ache or pain,” and I would start suggesting what the treatment would be. And after a workup they’d say, “Well, I don’t want to take any medicine.” My response then would be, “What would you like me to do for you then?” And we have to come up with a plan. But when the patient says upfront that they don’t want to go along with the plan, that person is going to be viewed as difficult by their healthcare professional.

MS: And I assume that patients can be difficult to certain providers, but not others. Is that fair?

JN: One of my personal problem types of patients are people who would come in with an active nosebleed. It is very upsetting to them. They don’t know what’s going on. There’s usually blood going everywhere. They’re very anxious, they’re spitting and coughing, and it’s very hard to get them to calm down and let us do what we need to do to them or for them. And I was speaking about this issue with one of my colleagues who happened to be an ENT doctor. He said that he loves nose bleeds. Those are his favorite patients. Well, there you go right there. So, for that physician who’s trained in that, he’s got all the right equipment. He knows exactly what to do and how to calm people down.

The ENT has the right apron and masks so that he doesn’t get blood all over him. He’s confident he can fix the problem. So, that goes to show you that one of the things I talk about in the book is . . . It’s not the patient’s diagnosis or the patient himself that’s the issue here, because we all have different thoughts about different problems, it is our thoughts that matter, and we can change our thoughts. We can work our way to having better thoughts about difficult patients or the patients whom we consider to be difficult.

Some patients are just flat-out hateful. In the book, I talk about one of the original articles on the subject, the one Dr. James Groves wrote. He’s a psychiatrist on the general consultation service at Massachusetts General Hospital. He wrote an article in 1978 called “Taking Care of the Hateful Patient.” And he came up with four stereotypical types of patients that doctors dreaded seeing. I think it’s important to become familiar with the four categories, because just becoming aware of them and seeing that this is a patient type that we all struggle with makes it a lot better. And I can quickly go through the four categories just so we get a little taste of what Dr. Groves was writing about.

The first type was called the dependent clinger. They’re excessively needy, and they require endless attention and reassurance. They make inappropriate requests for reassurance and repeated pleas for an explanation, affection, pain relievers, sedatives, and more. These people use flattery and childish behavior to get the physician to give them endless attention and reassurance. It’s important to know that you’re seeing this type of person because there’s a certain way that physicians have to deal with it. They have to set limits on the patient’s expectations.

The second type is called the entitled demander. And we all see this type of patient as well. It’s a person who uses intimidation and threats to get the treatment that they think they’re entitled to get. And they think that they’re entitled to get special treatment, and they try to control the doctor’s behavior or the nurse’s behavior and this type of behavior is born out of a fear of abandonment. We need to reassure these people that they are entitled to great medical care, and we try to give everybody the best medical care.

The third type is called a manipulative help rejector. These are people who never seem to get better. They’re looking for a physician to give them some sort of emotional attention. And sometimes when we get them better from one problem, another symptom or illness comes up, because they’re afraid if they don’t have some sort of illness that they won’t have the relationship with the physician.

The fourth category is called the self-destructive denier. These are people who disregard the necessary treatment. They have very self-injurious behavior, such as smoking or drinking or drug addiction. I think some of us view people who refuse to take vaccines right now to be kind of self-destructive deniers. And it’s very difficult for physicians and nurses not to feel dread and dislike for people whom we view as going against our wishes and hurting themselves.

MS: Of those four categories, are some more prevalent, more common than others?

JN: Some of the clinginess and the dependence is one of the natural responses to illness that we see. Normal patients who are ill or injured regress to a little bit more childlike state, which we consider to be helpful because we want people to follow our advice. They become a little more childlike and they look to us and the physicians in a very paternal, or, in my case, maternal role. And we want them to listen to us as a child would listen to a parent. So I think that’s probably the most common. I wrote a lot in the book about, which is not just in the emergency setting, but we see an awful lot of patients, a lot of our repeat visitors who have drug or alcohol problems. And it’s a constant source of issues in the emergency department.

MS: So, just to be clear, these are not your categories. You’ve used them because they date back to Dr. Groves’ categorizations. Is that correct?

JN: Those were his categorizations. This article came out in 1978. I just want to make sure you understand that was before I was in medical school. At the time of its publication, this was a taboo subject. Nobody ever talked about not liking their patients, but Dr. Groves said—and there was a lot of response to this over the years—that these thoughts and feelings that we had regarding these patients were very useful clues to us as to how we’re thinking, and those type of thoughts and feelings were not to be ignored. And because sometimes we find ourselves being annoyed or frustrated with people before we even realize that we’re having those feelings. But there always is a thought preceding it. And if we can drill down on that and get more curious, it’s quite helpful.

MS: Are there other more useful categories than the four that you set out?

JN: I always like to try to be curious about everybody’s illness. In my practice, in the emergency department, I’d like to categorize people whom I thought had problems that were real emergencies or urgencies, versus minor, annoying, or more chronic problems that could wait, because the emergencies or urgencies I needed to get on and get the plan rolling as urgently as possible. I think that another way for physicians and healthcare professionals is to think about patients or the people whom they can help versus the ones that would probably be better if they went elsewhere.

We should validate that they have the problems, but they might be better served in another setting or with another provider who falls more under their specialty, because sometimes patients show up at the wrong type of specialist when some generalist is not the person they want to see. They do need to see a specialist.

MS: Whose fault is it that the patients are being perceived as difficult?

JN: Well, I don’t like using the words “fault” or “blame” because I don’t think that we should blame patients for the way that we’re acting, but I think that the responsibility for what physicians and nurses think lies squarely with us. If we think that we can’t get something done or we can’t be happy, or we can’t solve the problem, unless the patient does exactly what we think or say or changes their behavior, then we’re never going to be happy.

The only thing we can change is how we think. So we need to be responsible for our experience and how we think about patients. As physicians, we’re always looking for the worst possible diagnosis. We’re always on guard that there’s a, what we call a zebra; some sort of unusual diagnosis that is causing a person’s problem.

Our groupthink, in the medical profession, is extremely negative. And we’re taught to think that way on rounds in the hospital. Our senior resident would make disparaging remarks about the patients in the break room, in the emergency department. Everybody’s talking in a very negative way about various people and their problems. And when you’re brought up in that environment, you just think that that’s the truth. But the truth is that everybody’s adopted a very negative way of thinking. And once you become more aware of it, try to call people’s attention to how you’re falling into these traps. Once you become more aware of it, you can put a little pause between those thoughts and how you feel and think. How can I think about this person differently?

MS: Do you think that the negative thoughts or views that are expressed are just a way for providers to protect themselves psychologically from a lot of trauma and death that’s in front of them?

JN: I do think that that’s part of it. I think we have been taught as part of our training to distance ourselves emotionally from some of the terrible things that we’re seeing. I think part of it is gallows humor. Unfortunately, in some offices and also in the emergency department, some of which are very open settings, the patients can hear what we’re saying, and sometimes they’re hearing very negative talk. And part of our gallows humor is unpalatable.

MS: You write about the “think, feel, act” cycle. Can you tell me a little bit about that?

JN: The “think, feel, act” cycle is an awareness tool. It’s a way of considering how we humans react to various circumstances or events that happen outside of ourselves. So I use an example in our book, the example of what happens when a patient arrives in the office or the emergency department. This is a neutral event. In other words, there’s nothing bad or good about it until a human has thought about it. As I mentioned, a lot of us are predisposed to have very negative thoughts about some of the patients. I gave an example in the book of a crying child coming into the emergency department. And for those of us who like to see kids, we think that’s great. We get to see a kid and will interact with them.

And at the end, we’ll get smiles and giggles, and that’s wonderful. But then there are a few of us (and this is how I started out because I didn’t understand what was going on with the kids) that dread the interaction because they were just crying. They can’t tell us what’s wrong with them. The parents are overly demanding and some of us just dread seeing the kids. It’s not the patient, it’s our thoughts about it.

That’s the “thought” part of the “think, feel, act.” The thoughts that we have cause us to have certain feelings or emotions, whether we’re a little bit afraid of what’s happening or we’re annoyed or angry. So when we’re having these feelings, we need to think back at how what we thought caused them. And then determine by how we’re feeling—we have an action or some sort of reaction in the medical setting, we’re ordering lab tests, we’re doing procedures, we’re ordering x-rays, and we’re deciding whether someone has a problem that they can follow up within an outpatient setting, or they need to be admitted to the hospital. By looking at this “think, feel, act” cycle, we can help view our thoughts about patients in this setting. And if we want to have better feelings, we can improve our thoughts. And we provide patient care professionals the tools to have more intentional thoughts about their patients.

MS: Do you believe that that results in better medicine?

JN: I think it does because I think that your thoughts matter. And when you think and have better, more compassionate thoughts about your patients, you will listen to them longer. You will spend more time with them. Your patient’s interaction with you will be kinder, more cooperative. And if you have some of those ingredients, you will have better results, and you’ll certainly do things like get better survey results and evaluations, and you won’t have people leave in an angry huff or what we call in the emergency department when someone disagrees with us and they don’t want to follow our plans, sometimes we ask them to sign out “against medical advice.” Well, if we could change the way we think about what the people are asking, we could get them, we could collaborate on some sort of plan. I’d rather have them treated or half treated than not treated at all, but you have to be a little bit flexible on that.

MS: I’m interested in thought distortions. What can you tell me about thought distortions?

JN: Well, thought distortions, or the way I use that word, are certain ways that we go about thinking. I’m talking about how we think about our patients, and they’re distortions in that they’re not accurate or factual. One of them is personalization. And I talk about personalization as a way that some of us tend to look and take too much responsibility or too much blame for whatever is happening with the patient at that time when there’s no objective reason to do so. This is a problem because everyone is going to die at one time or another. And if you’re the last person to see that patient before they die and you take on that responsibility or feel the guilt or shame that the person died while you were taking care of them, it’s not appropriate, because every one of us is going to be the last physician or nurse at the bedside of someone who is dying.

Sometimes that is exactly the thing that’s supposed to happen. We’re supposed to shepherd them through the end of life. So personalization is one of the thought distortions I talk about. I talk about “all or nothing” thinking, which is viewing issues in the extreme. I think some headstrong physicians feel this way, you either do it my way or you have to sign out against medical advice. I don’t think this is helpful. There is not just black or white or all or nothing. There are about 20 or 30 options in between. We have to ask the right questions to come up with the correct thoughts and not think with these distorted views.

MS: It sounds like much of this is trying to better understand where the patient is coming from and that one size of medicine does not fit all. Is that a fair critique?

JN: Yes, absolutely, because I think that one of the things, as I reviewed a lot of this literature and thought about it when I first came up with this idea, when I first started in the practice of emergency medicine, and I found some of these issues so troubling. You see 20 patients and 19 interactions go beautifully. And the one that goes badly just torpedoes your whole day. To try to understand how things went wrong, what are these people thinking? They’re usually thinking that they have the correct solution to get themselves better or, if they’re parents, to get their children better. I think the onus is on us to try to understand where they’re coming from better. Part of the first few chapters of my book talks about various stresses and fears that all patients have when they become ill. It is so much more helpful to understand where people are coming from.

MS: At what point is it best just to move the patient onto another provider? At what point do you just surrender?

JN: That’s an excellent question. In some cases, you have to enlist help. In an emergency department, if there’s more than one provider, you can ask one of your colleagues to help. In an office setting, you don’t always have that, or if there’s single coverage, you don’t always have that. But you usually can enlist the help of the nurses or other personnel. I think one of the things I talk about is walking away and giving someone time to cool off and give them time to think about it. Sometimes, if it’s an anger issue, a few moments to calm down is what they need. There are no hard and fast rules about that. You always have to protect yourself because there are issues, and they are real.

MS: Do you think people are becoming or have become angrier and more violent during this time of the pandemic?

JN: I think that is true. I think they have. I think that there are a lot of people who are being exposed to one way of thinking—I would call it misinformation—about the effects of this illness or the effects or the issue of vaccinations and feel that in that entitled demander part that they’re entitled to a certain treatment even though the physician feels it’s not indicated. In fact, it should not be given. It could harm a person. Unfortunately, we are seeing a lot of anger and misunderstanding surrounding that.

MS: Have you seen this in the past? Has there been, for maybe lack of a better term, politicization, making it more political in the emergency department?

JN: Well, I think what I saw previously, that was troubling for me, was patients being shamed for illness. For example, during the time that I was in medical school, we started seeing young people die of HIV/AIDS and did not know what it was at first and didn’t know how it was being transmitted. There was this tremendous victimization of the various people who were getting it. At first, they were concerned about people of Haitian descent. Then concern about men who were homosexual. There was this vast morality judgment being made, and it was uncalled for and inappropriate. That was bias against some patients. I think some people feel that that sort of thing is going on now with people who are being labeled as having underlying conditions. And these people don’t choose to have some sort of underlying condition or autoimmune disease or obesity, and they’re being blamed for the illness. And I think it’s inappropriate. I think it’s one of those thought distortions that physicians and the rest of society have that we have to need to open our minds and be more curious about.

MS: As we wrap up our time together, I was hoping that maybe you could tell me how providers choose thoughts so that difficult patients don’t seem so difficult. Maybe walk me through a scenario of a difficult patient and how you would approach that situation.

JN: One of the people whom we would see a lot was someone very angry and oppositional—a patient with chronic obstructive pulmonary disease. Usually, these people were smokers for a lot of their life. When they were young, people like my father, who was a service member in World War II, cigarettes were given to the soldiers, and this is just something that they did. They turned a whole generation into smokers before we knew how harmful that was. Instead of blaming the patients for that, when we see those people, we need to ask better questions and be more curious. Could I be wrong about what I’m thinking about them? This is a question that we have to ask ourselves when we’re dealing with a difficult patient.

Can I give this person the benefit of the doubt? Is this angry person somebody’s father or mother? Those things are true. This is a person who may be an angry man with COPD, but he’s somebody’s father. If my father came into the emergency department, even though he might be grumpy, I’d like everybody to give him the benefit of doubt and give him the best care. Another question we could ask or way to consider to change our thoughts and think more intentionally about these people is, is some of their behavior a symptom of their disease? The answer is often, yes, anger is a part of this, a chronic disease. They’re thinking, “Why me? Why did this happen to me? I was always doing what I was supposed to be doing.” And they’re grumpy or angry about having to be on oxygen all the time. It feels terrible.

Can you even imagine how awful it must feel not to be able to catch your breath? So if you think about someone more in those terms, I think that you will have more compassion for them and you’ll not view them as difficult. Are you challenged by them? Yes, you are. But you’re up to the challenge. You can find a way to bridge the gap with that person and come up with a solution to get better results, better treatment, get them feeling better.

MS: The book is Changing How We Think About Difficult Patients . This is certainly a book that will make you a better physician and I think make your life better in the practice of medicine. It’s an important book. And I certainly recommend it to all who’s listening. Dr. Joan Naidorf, thank you so much for being on Sound Practice and for writing this book.

JN: You’re welcome. I hope that everybody will give it a read. It’s a short book, but one with a significant impact on your day-to-day practice of medicine.