Taming the difficult patient

You were warned about them in med school: the patients who make threatening noises about lawsuits at the slightest provocation. The folks who know exactly what's wrong with them and how you should treat it. People who make you wonder why you didn't listen to Uncle Fred and become an actuary.

Yes-disagreeable, noncompliant, arrogant, and anxious patients come with the territory. But that doesn't mean you have to grit your teeth and put up with them. Most veteran physicians have developed ways of handling troublesome patients-although "handling" sometimes means showing hard-core irritants the door. So the next time you're on the receiving end of a patient's diatribe, don't get angry-get serious about determining what the trouble is and taking corrective action.

Here's a look at four patient "types" every clinician will recognize, along with tips from your colleagues on how to deal with them.

Urologist Stephen Leslie of Lorain, Ohio, once sparred with a 65-year-old man who wanted a testosterone gel that had just been approved by the FDA. Leslie demurred, because he hadn't received official prescribing information, and no local pharmacy had the gel in stock anyway. With that, the patient erupted.

"He ranted and raved in the exam room and out in the hall," Leslie says. "He accused me of malpractice and threatened me with legal action, including letters to the state medical board and anywhere else he could think of. This was the only time in 19 years of practice that I had to call the police about an unruly patient. Fortunately, the man left before they arrived."

As Leslie acknowledges, experiences like the one he describes are atypical. Most irascible patients are open to reason, and will come around if you push the right buttons. For example, neurosurgeon Michael-Gerard Moncman of Altoona, Pa., turned a cantankerous fellow into an ally by getting a staffer to run interference.

"He gave me a particular history, I operated on him, then he changed his history and sought care elsewhere while continuing to see me," Moncman says. ["I learned that in treating this man and people like him, sometimes the best strategy is to figure out who in the office they best interact with and use that person as a buffer."]

"So whenever this man called, we put his favorite staff member on the phone. That way, some of his hostility got defused and we were able to get through the situation very nicely. When all was said and done he admitted, grudgingly, that we had treated him well."

How is the intermediary selected? "Sometimes patients pick them for us," Moncman explains. "They'll call specifically to speak with a certain individual, or they'll express disappointment if someone is out of the office that day. When the intermediary isn't obvious, I may bring up a problem patient during a staff meeting and ask, 'Does anyone have a good relationship with this guy and can reach out and touch him better than I can?' Obviously, I bear ultimate responsibility for the relationship, but if I have someone who can intercede for me, it's a big help."

E. Gene Burns, Jr., a family practitioner in LaPlace, La., sometimes wins over quarrelsome patients by agreeing with them on some point. One of Burns' patients was frustrated about having a procedure denied by an HMO. "Most patients in this position initially show their anger to the physician instead of the HMO," Burns says. "This man, however, was stunned and apologetic when I gave him a copy of a letter I had already sent to the HMO on his behalf."

The refusenik

San Francisco internist Gary G. Kardos remembers a 55-year-old auto mechanic who, upon meeting the doctor, barked, "Just give me a checkup so my wife will get off my back!" Kardos performed a complete physical, then referred the man for several screening tests.