Understand the four types of 'difficult' patients

The debut issue of Neurology: Clinical Practice, launched Nov. 2, takes a deep look at the complexities of difficult interactions between neurologists. Although the neuropsychiatric problems often seen in this specialty may make for more intense situations than might be seen in your practice, the four main types of patient "maladaptive coping styles" identified by the article may ring all too familiar.

Consider whether any of your needy or demanding patients fit into any of these categories and how the following insights might help you respond more effectively:

1. Dependent clingers. Early in the medical relationship, these are the patients who pour on the praise. They've finally found a doctor who can help them! They flatter their physicians into providing special privileges, such as access by personal phone, email or permission for after-hours communications. But soon, the patient's over-the-top gratitude becomes replaced by ever-increasing demands, according to authors David B. Arciniegas, MD, and Thomas P. Beresford, MD. "The intensity and frequency of these demands are proportional to the patient's [often unconscious] feelings of powerlessness and fears of abandonment," they write.

To avoid getting to the point where they dread any interaction with these patients, physicians need to reestablish firm interpersonal boundaries. Recognizing the reasons behind the behavior, it's also important to reassure the patient that he or she will not be abandoned, perhaps by scheduling brief follow-up visits at regular intervals. Providing clingy patients with written instructions between visits can help them feel more secure and connected to their physician.

2. The entitled demander. This type of patient likes to tell you what types of tests to order and medications to prescribe--and may threaten legal action if denied.

Under the aggressive façade, these patients often also feel helpless and powerless. Rather than argue, try a 'supportive-empathic-truth statement' such as the following: "In order to provide you with the best possible medical care, we must work together in a respectful and collaborative manner. Let's discuss how we can do this most effectively." (Note that it is permissible to bill based on face-time if criteria are met.)

3. The manipulative help-rejecting complainer. This type of patient drags physicians through an endless cycles of help-seeking and help-rejecting. Nothing the doctor does is ever satisfactory, though they keep coming back with new requests.

No matter how upsetting these patients' passive aggression may be (a behavior often stemming from abuse or trauma), make it clear that you are genuinely on their side and open to collaboration. Then agree only to truly necessary interventions and treatments; perform only what's mutually agreed upon.

4. The self-destructive denier. This is the patient that knowingly continues behaviors that are dangerous to their health--drinking with a bad liver, smoking after being diagnosed with lung disease and other infuriating methods of apparent "suicide by treatment nonadherence."

Again, these daredevil patients frequently feel hopeless and often suffer from undiagnosed depression or anxiety disorders, the article states. The best way to ameliorate these issues is to concurrently care for the patient with a mental-health professional.

To learn more:
- read the article in Neurology: Clinical Practice

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