Johns Hopkins Psychiatry Guide

Caring for "Difficult" Patients

James Aluri, M.A., Margaret S. Chisolm, M.D.
Caring for "Difficult" Patients is a topic covered in the Johns Hopkins Psychiatry Guide.

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DEFINITION

EPIGRAPH

It is usual to encounter, in any large mental hospital, a group of patients who are considered by the staff to be difficult. This opinion is slowly formed but, once established and repeatedly expressed in nursing reports and medical records, it rarely alters and may have a powerful influence on the patient’s career in [the] hospital.[1]

  • Patients who might be described as "difficult" have mostly been defined by the negative emotional response that they trigger in clinical staff.
  • These patients have been described as those who:
    • “Exasperate,” “overwhelm,” or “distress” their physicians[2]
    • Cause a clinician’s “heart to sink”[2]
    • Inspire feelings of “dread” in physicians[3]
  • Others have advocated for alternative understandings of the "difficult patient" label.
    • “…someone who perceives himself as wronged in the medical encounter—perceives being treated unfairly, disrespectfully, dismissively, condescendingly, or offensively…”[4]
    • Some think of the relationship as difficult, rather than the patient[5]
    • Patients and families who do not passively agree with the physician or do not let the clinical team entirely dictate “what happens and when”[6]

EPIDEMIOLOGY

  • Several studies have found the prevalence of "difficult encounters" or "difficult patients" to be in the range of 10-20%.[7][8][9]
  • A variety of associations have been noted that give rise to labeling patients as "difficult."
    • Patient characteristics:
    • Physician characteristics:
      • Overworked/working more hours per week[12][14]
      • Poor communication skills[12]
      • Less experience/being younger[13][14]
    • Health care systems factors:
      • The pressure on clinical staff to meet productivity benchmarks[12]
      • Financial concerns[12]
      • Fragmented visits[12]
      • Patients’ increasing access to their medical records or internet-derived information that can lead them to challenge physician’s opinions[12][15]
  • Prevalence in various hospital settings
    • This group of patients have been described mostly in the context of general practice[2][8][9] and psychiatry.[1][16]
    • The increased comorbidity of psychiatric conditions among patients categorized as "difficult" by their physicians (see the bullet Patient Characteristics above) can give a "difficult patient" stigma to patients who have a psychiatric diagnosis in their one-liner when they are encountered in other healthcare contexts.
  • The evidence is not conclusive whether patients viewed as "difficult" receive worse care.
    • Some suggest that these patients receive worse care.[17][18][19]
    • Others did not find an association between being viewed as "difficult" and management decisions.[20]
    • Even if clinical outcomes are not directly affected, the emotional responses that some patients engender can contribute to division among staff.[21]

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Last updated: October 29, 2017

Citation

TY - ELEC T1 - Caring for "Difficult" Patients ID - 787366 A1 - Aluri,James,M.A. AU - Chisolm,Margaret ,M.D. Y1 - 2017/10/29/ PB - Johns Hopkins Psychiatry Guide UR - https://www.unboundmedicine.com/medline/view/Johns_Hopkins_Psychiatry_Guide/787366/all/Caring_for_"Difficult"_Patients ER -