Monday, August 31, 2009

The Difficult Patient


I am willing to bet that patients do not know that the medical community talks formally about "The Difficult Patient". Courses are taught on how to handle these patients and there is even an ethics study on Medscape about it. So what is the difficult patient?

Every practice encounters them and they come in many varieties. They are the patients who abuse the staff, miss appointments repeatedly, "lose" their prescriptions for pain medication and then demand instant refills. They may not follow up with important tests or stop taking needed medication and then show up with acute medical problems. Some doctors have a low tolerance for patients who are not "compliant" but even the sainted physicians experience "difficult patients".

So when the therapeutic relationship is damaged, doctors are taught the ethical ways of firing a patient from the practice. Once a relationship has been established, a physician may not abandon a patient. Medical ethics demand that a physician may discharge a patient from the practice only after attempts to resolve the matter have failed. Adequate replacement care must be available and the patient's health should not be jeopardized in the process. The physician must ensure that the reasons for discharging a patient are justifiable and ethical.

Once the doctor- patient relationship has broken down, the doctor must make sure:
  • She has done everything possible to address the patient's problems
  • She has informed the patient of the consequences of his actions, both for his own health and his relationship with the physician; and
  • She must tell the patient that he would better off with another physician and help the patient find another doctor.
Ending a doctor- patient relationship should be a rare event. Like any relationship, there should be discussions that take place openly long before things get bad enough for the doctor to "fire" the patient.

Of course, an unhappy patient needs only to leave a practice and move on. But all physicians know that one disgruntled patient will tell 20 friends about his bad experience.

14 comments:

Anonymous said...

I can't believe that patients act like this and I never knew there was a difficult patient. Interesting

KM said...

I have experienced the kind of patients you are describing in practices where I have worked. Years ago in a previous doctors office care was declined by the doctor and the legal amount of time was given for that patient to find another physician. The difficult part was in the interim time before the transition was made, the patient left messages with requests for meds. or wanting office visits the doctor would only communicate through me to turn down what she wanted and only see her if there was a injury or illness.
So I had to deal with the emotional patient after the denial letter was sent and was really put in the middle.

tracy said...

i try very hard to be a "good patient" with physicans...whatever that is.
Registered Dieticians must have a whole other set of rules...in the midst of being treated for bulimia and not havimg much sucess, the dietician, decided to "fire" me without warning...giving me no references,and as i said, no warning that this was coming. i immeadiatly revoked her priviledge to speak with my psychiatrist and she went ahead and did that anyway...after i withdrew permission. i have often wondered if that did not somehow break some code of ethics....sigh.
"Difficult Dietician Patient" , i guess.

tracy said...

PS She did none of the above three actions.

ERP said...

I see people in the ED that are so pathologically "difficult" I cannot any sane MD would have them as a patient. I can barely tolerate them for 5 minutes. God bless those doctors and their patience.

Allen said...

A normal person doesn't know much about difficult patient. So. he can act like this!!

4d ultrasounds said...

I am looking forward for your next post, I will try to get the hang of it!

Anonymous said...

There are no difficult patients; only difficult encounters. Calling a patient "difficult" just sets you up to have a difficult encounter. Mindset matters.
BTW, there are a lot of difficult doctors out there, too.

Johnson said...

I found your post via the "MD Whistleblower" post about doctors firing patients. That post had a different inference than yours does (and implies patients can be fired for any reason or no real reason), and yours is more clear-cut - more what I expected and hoped to find. So thank you!

I was recently fired by my doctor out of the blue, with no reason given, *after more than a decade*. No bill payment problems or recent contact with the office for me to have been "abusive" towards staff. I can't imagine what kind of non-compliance I might be guilty of to warrant this, because over all of the past years I've always been honest about things I disagreed with and we worked together, so I don't think that's an issue.

The doc offered no suggestions or referrals to other doctors, etc., leaving me 'out in the cold', so to speak. This happened right after I had to go to the ER on the advice of an Urgent Care doctor during off-hours. I'm currently unable to work and it's not like you can get in to see a neurologist right away, so who knows how long it will be before I can even be diagnosed. I'm sick, and the timing is...interesting.

I had already decided I'd be leaving my doctor prior to him/her firing me (I'm being purposely vague to avoid identifying the doctor or myself). Long story, but there have been behavioral changes in my doc, noticed not only by myself but everyone in the clinic as well as patients, some of whom leave the exam room crying never to return (according to staff members). Exam discussions became 1-sided (or 90/10), with him/her ranting about colleagues, patients, and sometimes even naming the patients, who annoy or piss him/her off. It's not uncommon for him/her to walk out, thereby ending the appointment, while the patient is asking a question or relaying relevant information. There have been "mistakes" like omitting pertinent tests during bloodwork, mis-reporting important diagnostic results, etc. I won't even start with the rudeness and disrespectful way that s/he speaks to patients one moment, and then might be professional another moment.

I realize I'm lucky to be rid of this doctor, but I guess I had to put this out there because especially considering the circumstances, dropping me like a hot potato with kooties just doesn't sit well with me.

Toni Brayer, MD said...

Johnson: it sounds like you should thank your stars that you were fired from this nutty doctor. Perhaps he is impaired in some way, which explains the strange way he dealt with you. I'm always sorry to hear stories like this and I hope you can find some good care soon. Thanks for writing.

Hello.City said...

I had stage IIIa breast cancer, (cancer free for almost four years!),
and a host of other problems came along with the treatment. Much better than the alternative, and I am most grateful.
On point, I saw my long term primary care doctor one month, the next I was told I was dismissed from the practice. He would not speak with me.
My records show no bad behaviour.
The office was a safe place for me, I had good relationships with many of the clinicians.
I'm devastated and confused. What happened? What did I do? How can I fix it if I don't know what it is? Is it me?
The only thing that changed was our insurance. We chose a plan that his office accepted. If he didn't like it, I would have gladly changed to a plan better for his office.
Just a guess, as I do not know.
I don't think he should have to see a patient that he doesn't want to see.
I do think he has an obligation to tell me why the 180 change in attitude.
Is there any regulatory agency, aside from a lawyer, I am not going down that road, that would compel him to simply explain?
Thank you.

Toni Brayer, MD said...

Hello.City: that is indeed a strange story that makes no sense. I can understand why you feel "unfinished" and confused. Perhaps he/she is ill? Perhaps he/she will be leaving medicine or moving or joining a larger medical group. Ive seen doctors be in practice one day and have closed doors the next day without any communication to patients.

Please write a note to this doctor and ask your question just like you wrote it here. Hopefully you will get an answer that will let you move on and feel OK about it. It certainly doesn't look like it has anything to do with you.

Jennifer Wimbley said...

Out of the blue, my 4 year old daughters pediatrician fired her, citing disrespectful behavior to staff. When did this happen? 2-3 years ago there was an incident where a nurse had to clean up my Childs vomit off the floor in the waiting room, and all the while she talked pure crap about my daughter throwing up on the floor. Yes i did let this nurse know how unprofessional and rude she is/was, and let the doctor know my same feelings. My daughter had a stomach virus. Now all these years later i called her doctor office to find out about getting a kindergarten screening form filled out. Was told to drop off. Dropped off papers on August 20,2014 and paid ten dollars. Received call on August 22,2014 that papers were ready to be picked up. August 23,2014 i receive certified letter citing disrespectful behavior to staff (that was typed on August 21,2014). Now i must have missed this disrespectful situation that happened! There was no incident! The letter also failed to offer to send medical records of give number of help line to find another pediatrician. Did give 30 days though. There has been no meetings about this or about ANY DISRESPECTFUL BEHAVIOR TO STAFF. No warnings. Can they fire my daughter over something that happened years ago and the staff never apologized for their nurses behavior. I feel my daughters rights have been violated and discriminated against. And by the way my child has been seen numerous times after that one incident without any other incidents. Just received vaccines in may.

Jennifer Wimbley said...

Out of the blue, my 4 year old daughters pediatrician fired her, citing disrespectful behavior to staff. When did this happen? 2-3 years ago there was an incident where a nurse had to clean up my Childs vomit off the floor in the waiting room, and all the while she talked pure crap about my daughter throwing up on the floor. Yes i did let this nurse know how unprofessional and rude she is/was, and let the doctor know my same feelings. My daughter had a stomach virus. Now all these years later i called her doctor office to find out about getting a kindergarten screening form filled out. Was told to drop off. Dropped off papers on August 20,2014 and paid ten dollars. Received call on August 22,2014 that papers were ready to be picked up. August 23,2014 i receive certified letter citing disrespectful behavior to staff (that was typed on August 21,2014). Now i must have missed this disrespectful situation that happened! There was no incident! The letter also failed to offer to send medical records of give number of help line to find another pediatrician. Did give 30 days though. There has been no meetings about this or about ANY DISRESPECTFUL BEHAVIOR TO STAFF. No warnings. Can they fire my daughter over something that happened years ago and the staff never apologized for their nurses behavior. I feel my daughters rights have been violated and discriminated against. And by the way my child has been seen numerous times after that one incident without any other incidents. Just received vaccines in may.