Difficult Patient* / Multiple Medical Problems*

Difficult Patient

1. When physician-patient interaction is deemed difficult, diagnose personality disorder when it is present in patients.
2. When confronted with difficult patient interactions, seek out and update, when necessary, information about the patient’s life circumstances, current context, and functional status.
3. In a patient with chronic illness, expect difficult interactions from time to time. Be especially compassionate and sensitive at those times.
4. With difficult patients remain vigilant for new symptoms and physical findings to be sure they receive adequate attention (e.g., psychiatric patients, patients with chronic pain).
5. When confronted with difficult patient interactions, identify your own attitudes and your contribution to the situation.
6. When dealing with difficult patients, set clear boundaries.
7. Take steps to end the physician-patient relationship when it is in the patient’s best interests.
8. With a difficult patient, safely establish common ground to determine the patient’s needs (eg. threatening or demanding patients).

Multiple Medical Problems

1. In all patients presenting with multiple medical concerns (e.g., complaints, problems, diagnoses), take an appropriate history to determine the primary reason for the consultation.
2. In all patients presenting with multiple medical concerns, prioritize problems appropriately to develop an agenda that both you and the patient can agree upon (i.e., determine common ground).
3. In a patient with multiple medical complaints (and/or visits), consider underlying depression, anxiety, or abuse (e.g., physical, medication, or drug abuse) as the cause of the symptoms, while continuing to search for other organic pathology.
4. Given a patient with multiple defined medical conditions, periodically assess for secondary depression, as they are particularly at risk for it.
5. Periodically re-address and re-evaluate the management of patients with multiple medical problems in order to:
   • simplify their management (pharmacologic and other).
   • limit polypharmacy.
   • minimize possible drug interactions.
   • update therapeutic choices (e.g., because of changing guidelines or the patient’s situation).
6. In patients with multiple medical problems and recurrent visits for unchanging symptoms, set limits for consultations when appropriate (e.g., limit the duration and frequency of visits).

Difficult patient interactions

• Patient
  • Consider psychiatric: personality disorder, depression, anxiety, abuse (violence, substance), somatization
• Physician:
  • Overwork, poor communication, low level of experience or discomfort with uncertainty
• Healthcare system:
  • Productivity pressures, financing, fragmentation of visits

General Approach

• Agenda
  • Find common ground
  • Set limits and prioritize
  • FIFE
• Active listening
  • Give full attention
  • Reflection and summarizing
• Acknowledge/Validate the emotion and empathize
  • Reinforce that the patient is entitled to good medical care, but that anger should not be misdirected at those trying to help
  • "I can see that you are ____."
  • "You are right - it feels ____ to be in this situation."
• Explore alternative solutions
  • "Is there something else I can do to meet your expectations for this visit?"
• Closure
  • Recognize the complete resolution of issues is limited
  • Celebrate small success
  • Agree on achievable goals, realistic time frames, and follow-up
    • Limit duration and frequency of visits for unchanging symptoms

End physician-patient relationship

• Irreconcilable breakdown of relationship
  • Fraud, theft
  • Threats, abuse to staff
• Give patient adequate notice to find another physician
  • In QC, physician must have reasonable and just cause to end relationship
• Call CMPA for help