There are patients in every practice who give the doctor and staff a feeling of “heartsink” every time their names are seen on the day’s appointment list and evoke feelings of exasperation, defeat, guilt, negativity, and sometimes active dislike.¹ Important factors in the assessment of difficult patients include identifying past or current history of abuse, depression, psychosocial stress, occupational stress, and not having sufficient coping skills. Patients whom physicians find to be difficult are also high users of health care services, and they may be dissatisfied with the care they receive.

Difficult patients often fail to respond to nerve blocks, medications, or physical therapy, and they may be noncompliant with treatment, harbor objections to their physicians’ approaches to their care, or be resistant to forming an effective alliance with their medical providers. Individuals with chronic pain may be difficult because of the psychosocial stressors that arise from having chronic pain, and these psychological symptoms, in turn, may lead to a preoccupation with physical symptoms, feelings of worthlessness, loneliness, fear of abandonment, and becoming socially isolated.

Particularly in Western societies, being sick implies certain expectations, including rights and duties.² The perceived “rights” of being sick include being temporarily exempt from “normal” social roles, with the more severe the sickness, the greater the exemption, and that the sick person is not held responsible for his or her condition (beyond the patient’s control or absence of blame). The duties of a patient, which are quite applicable to those in pain, include the obligation to try to “get well,” to seek help from a professional, and to cooperate in the process of “trying to recover.” Patients with chronic pain who do not fulfill or comply with the social expectations of the sick role run the risk of being perceived as malingering or difficult by their clinicians and becoming isolated from friends and families.³

Because physicians are under increasing time pressures, patients with pain who exhibit vague symptoms and who are unresponsive to many different interventions for pain can be particularly frustrating, especially when the burden of providing treatment is shouldered by a lone individual rather than by an interdisciplinary team. Not all patients with difficult behavior exhibit significant psychopathology, such as major depression, anxiety, or a personality disorder. Patients who are otherwise “normal” can also be perceived as difficult when they arrive at a pain center for treatment with unrealistic expectations. They may have had problems in previous health care settings in which they were accused of exaggerating their pain and may suffer from a lack of sleep, poor eating habits, and long commutes on public transportation to their appointments, which can also contribute to outbursts, hostility, and unstable behavior. They may feel that their physicians are dismissive or skeptical of their pain rather than understanding and sympathetic. Even comparatively well-adjusted patients can have the idea that their pain physicians should be able to eliminate all of their pain and that failure to do so is tantamount to withholding treatment.

Difficult patients drain clinic time and financial resources. They tax staff relationships and deplete emotional energy. Staff members report feeling “beat up” after interacting with these patients, which leads to low morale and high staff turnover. Difficult patients can keep staff members on edge for fear of an outburst, and staff members report feeling helpless and vengeful in the wake of such encounters. The fears of clinic staff may be justified because epidemiologic evidence indicates that health care workers are at a higher risk than other occupations for becoming victims of assaults by their patients.^4,5 Gerberich and colleagues⁴ and Bruns and colleagues⁵ determined that the primary risk factor for being assaulted at work was “working with unstable or volatile persons in health care, social service, or criminal justice settings.”

According to the National Institute of Occupational Safety and Health, 51% of all reported nonfatal workplace assaults were of individuals who worked in a medical setting.⁶

The figures do not reflect verbal, passive aggressive behaviors; bullying; harassment; and implied threats, which are more pervasive than actual assaults. A true estimate of the number of difficult patient–clinician encounters is impossible because many of the incidents go unreported by the clinical staff for fear of retribution or being perceived as weak or incompetent by their peers or supervisors.

Patient-perpetrated violence against physicians or violent ideations is also associated with psychopathologies (e.g., antisocial and narcissistic personality traits), situational variables (litigation, workmen’s compensation), and the perception of the patients’ relationship to their physicians.^7–9

Not all providers view the same patient as difficult, but difficult patients in general tend to have similar things in common. Hahn et al. developed a 30-item Difficult Doctor-Patient Relationship Questionnaire (DDPRQ) for quantifying the characteristics of difficult patients.¹⁰ In the original 30-item DDPRQ, physicians classified up to 20.6% of patient encounters as “difficult,” or evoking a level of physician distress that “transcends the expected and accepted level of difficulty” with patients described as “hateful,” “heartsink,” “problem,” or “difficult.” Half of the physicians “secretly hoped” that difficult patients would not return.

The DDPRQ-10 (Fig. 22-1) requires less than 1 minute to complete, has an R² of 0.96 with the original 30-item instrument (indicating that responses on the short 10-item form are almost perfectly correlated to the original 30-item form), and has an internal consistency reliability (Cronbach a) of 0.88.¹¹ Using the 10-item DDPRQ, a constellation of three characteristics has been associated with patients being perceived as difficult. Compared with not-difficult patients, difficult patients have twice the prevalence of significant psychopathologic disorders (67% vs. 35%; P <0.001). Second, 90% of difficult patients have an abrasive personality style or personality disorder. Third, difficult patients are more likely to have one or more of 16 physical (often somatoform) symptoms as shown in Table 22-1.

Some difficult patients have a history of victimization or abuse, which is associated with significantly greater health care use, levels of depression, somatization, negative temperament, and catastrophizing.¹² For women, having a history of physical or sexual abuse increases the risk of experiencing difficulty in the physician–patient relationship and increases self-reported pain four- to fivefold versus those without a history of abuse.¹²

The role that physical and somatoform symptoms play in the generation of practitioner-experienced difficulty has implications for clinical management. First, clinicians should recognize the need to assess patients with many physical symptoms for common mental disorders by using structured methods. Second, clinicians should strive to understand their patients’ experience of illness and to address their symptom-related concerns.¹³ A patient-centered approach that validates the patient’s experience and enlists the patient’s active participation in setting treatment objectives is critical. Third, health care providers should assess the role that symptoms play in the patient’s family system and should acquire skills in redirecting patients’ attention to underlying psychosocial issues so that the patients can be effectively referred for further therapy when indicated.¹⁴ Understanding that caring for patients experienced as “difficult” can be understood in terms of these three components is a first step in rendering the experience less difficult.

Patients prone to difficult behavior who perceive that the pain physician’s role is to cure them completely tend to react with frustration when pain persists. Difficult pain patients may see themselves as “broken” by pain, and although treatments may lead to partial relief of pain and some improvement in function, pain and disability often persist. Some of the primary tasks a pain clinician may face are to foster realistic expectations for treatment success, to convey that patients are not “broken” by pain, and to encourage patients to appreciate that improvements in their pain allow them to carry on satisfying lives.

Difficult patients have very different coping styles. In a correlational study of lower back and neck pain to coping styles, Carroll et al. found that the highest levels of self-reported disabling pain were seven times more highly associated with those having high passive coping (e.g., remaining inactive and not using self-management strategies for pain control) regardless of the level of active coping.¹⁵ High active coping was more associated with higher education and better general health.¹⁵ In other smaller studies of clinic patients, coping styles that have been identified with more disabling pain include passive coping, catastrophizing, and adversarial attitudes.¹²

James Groves was one of the first clinicians to describe types of difficult patients. He classified these patients as falling into one of four groups: (1) dependent clingers, (2) entitled demanders, (3) manipulative help rejecters, and (4) self-destructive deniers. He recommended treatment strategies for each of these patient types as shown in Table 22-2.¹⁶

WHAT IS THE RELEVANCE OF MOTIVATIONAL INTERVIEWING?

The concept of motivational interviewing evolved from the experience of treating alcoholism.¹⁷ Further refinement defines motivational interviewing as “a collaborative, person-centered form of guiding to elicit and strengthen motivation for change.”^17,18 The fundamentals of motivational interviewing are based on the assumption that people generally have the skill set to adopt change but vary in the degree to which they are ready to engage in new behaviors.

In the precontemplation stage of change, people with chronic pain have not yet begun to consider changing, owing to a purely physical view of their pain. They assume a passive role and rely on the physician to provide the appropriate treatment. The clinician’s role is fostering acknowledgment of risks and problems owing to passivity and inactivity—problems such as increased pain and physical deconditioning. In the contemplation stage, people with chronic pain acknowledge the risks associated with inactivity and passivity. The clinical goal at this stage is to assist the patient to realize that the risks of inactivity outweigh the perceived benefits.

When the patient is ready to become more active (preparation stage), the clinician helps the patient outline appropriate structured physical activities in which the individual is willing to participate. Finally, in the action stage, the clinician helps the individual increase activity. This is followed by maintenance, geared toward the individual’s ongoing motivation and commitment (Table 22-3).

Motivational interviewing is a framework for preparing individuals for treatment, not the treatment itself.¹⁹ From the clinicians’ perspective, the five strategies to follow for effective motivational interviewing are (1) express empathy, (2) develop discrepancy, (3) avoid argumentation, (4) roll with resistance, and (5) support self-efficacy. Clinicians can encourage progression throughout the stages of change by providing patients with motivational statements, listening with empathy, asking open-ended questions, providing feedback and affirmation, and handling resistance by rolling not arguing. Examples of the types of open-ended questions used in motivational interviewing include:

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  What changes would you most like to talk about?

  
  
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  What have you noticed about …?

  
  
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  How important is it for you to change …?

  
  
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  How confident do you feel about changing …?

  
  
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  How do you see the benefits of …?

  
  
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  How do you see the drawback of …?

  
  
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  What will make the most sense to you?

  
  
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  How might things be different if you …?

  
  
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  In what way …?

  
  
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  Where does this leave you now?

By using a guiding rather than directing style, clinicians can develop strategies to elicit the patient’s own motivation to change and eliciting or encouraging change talk from the patient. The following are examples of directing versus guiding styles:

Directing style: “Your weight is putting your health at serious risk and contributing to your lower back pain. You need to exercise more frequently and to try to lose weight.” (Patient replies with a “yes, but …” argument.)

Guiding style: “Let’s have a look at this together and see what you think. From my perspective, losing some weight and getting more exercise will help your health, but what feels right for you? (Patient often expresses ambivalence at this point.) …. So you can see the value of trying these things, but you don’t see how you can attempt to do it at this point in time. OK. It’s up to you to decide when and how to make any changes. I wonder, what sort of small changes might make sense to you?” (Patient says how small change might be possible.)

Historically, difficult encounters focused on the patient. More recently, however, the importance of the physicians’ attributes has been recognized. Jackson and Kroenke found that the greatest predictor of difficult patient encounters was not the patient but the physician.²⁰ The results from their study revealed that physicians with poorer attitudes toward approaching psychosocial issues averaged almost three times as many (23% vs. 8%) “difficult” encounters than physicians with positive attitudes.²⁰

The Field Guide to the Difficult Patient Interview²¹ states that the strongest predictor of patient adherence is the doctor–patient relationship itself. Having a healthy relationship based on trust, empathy, and confidence in the physician is the first step in preventing patients from becoming difficult. Patients often become difficult because of perceived deficiencies or inequities in the relationships with their physicians, and the physicians become suspicious and perceive patients as difficult when the patients benefit from being ill and when biomedical explanations do not match patients’ experience.²²

Failure to improve may fuel a patient’s frustration, but it seldom proves to be the sole reason for the development of difficult behaviors and interactions. A number of factors can be addressed in an effort to foster a relationship in which the physician is seen as a healer, ally, and guide to improved health, not merely a service provider. Learning to say no in a way that makes the patient believe that he or she is still involved in the decision-making process can make patient encounters less difficult.²³ The physicians’ attributes associated with malpractice suits do not appear to be related to the quality of the medical care.^24,25 The amount of time spent with a patient, having good communication skills, using humor, and even a physician’s tone of voice are all associated with not having a malpractice claim history.^23,24,26 Bruns and Disorbio found that worker’s compensation patients have a higher frequency of violent ideation than other insured patients.⁵ The patient reports being “disabled” by the pain, but when medical evidence suggests otherwise, the relationship may become adversarial, made worse by the fact that the patient cannot leave this physician’s care because of a loss of disability benefits.

Feelings of job dissatisfaction and job stress are problems shared by providers in many countries. A lack of time and heavy workload are cited as the main causes of these feelings of discontent and stress, which in the long term may lead to burnout. Burnout is a syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment that can occur among individuals who work with people in some capacity.²⁷ Emotional exhaustion is a key factor in burnout and may evoke feelings of reduced personal accomplishment and depersonalization. Depersonalization is expressed as a negative, cynical, and distant attitude toward others, including patients.

Granek et al. interviewed oncologists to determine if they experienced grief at the loss of their patients.²⁸ The results of their interviews revealed that half of the oncologists struggled to manage their feelings of grief, failure, self-doubt, and powerlessness. Even though the oncologists were grieving, they reportedly hid these emotions from colleagues so as to not be considered weak and unprofessional. Their discomfort over their grief led them to recommend more aggressive treatment strategies when palliative care would be a better option. When evaluated for burnout, the most consistent finding was the use of compartmentalization of their grief from other aspects of their lives as a coping strategy to prevent burnout.²⁸

One of the perspectives to explain burnout is found in equity theory. When job demands are high or rewards are low, people may experience an imbalance between their investment and reward. Clinicians who deal with difficult patients are at great risk of experiencing an imbalance between their investment and rewards and which may eventually lead to burnout. Zantinge et al. hypothesized that physicians who were emotionally exhausted and burned out would invest less in their patient contacts; have shorter consultations; be less inclined to encourage their patients to discuss their problems; and behave in a cynical, negative manner toward patients than other physicians.²⁹ Contrary to their expectations, exhausted and burned out physicians had longer consults and discussed more psychosocial or biomedical issues with their patients than other physicians. The exception to these results were the physicians who felt “incompetent” or had feelings of reduced accomplishment.

Gillette recommends that health care professionals continually assess and understand their own strengths and weaknesses and strive to improve their communication skills.³⁰ In fact, self-assessment and lifelong learning were adopted by the American Board of Medical Specialties explicitly as one of four elements in its Maintenance of Certification program.³¹ The American Board of Internal Medicine requires the “capacity of physicians to self-assess” in diplomates who choose to recertify.³²

To determine how accurately physicians self-assess compared with external observations of their competence, Davis et al. (2006) conducted a systematic review of 725 articles, 17 of which met inclusion criteria. Across studies, weak or no associations were found between physicians’ self-rated assessments and external assessments.³³ A number of the 17 studies found that the worst accuracy in self-assessment was among physicians who performed the least well by external assessment, independent of level of training, specialty, or manner of assessment and comparison.

Providing physicians a framework to effectively evaluate their own behavior and emotions and understand how these can affect the outcomes of encounters with difficult patients is important. Physicians also benefit from hiring support staff that are pleasant and adept at dealing with interpersonal problems. Perceived rude, insensitive, and crude behaviors of physicians and the support staff have the potential to complicate care.³⁴

Being conscious of verbal communications, such as properly introducing oneself, speaking without medical jargon, and using a discourse tempo that is not rushed, also helps to create a positive environment for consults. Attention to aspects of verbal and nonverbal communication in the training of medical students or inexperienced clinicians may improve care and draw attention to the physician attributes in the interactions with difficult patients, particularly those with mental health problems.

Not all clinicians are adept at handling difficult patients, but this ability can be improved. Every practitioner faces difficult patients, and a conscious attempt at being empathic will help to avoid personality conflicts. For some patients, scheduling regular visits, encouraging the patient to take an active part in his or her care, and working with the patient’s family may avoid difficult encounters, irrespective of a physician’s unease in dealing with difficult patients. Regular visits convey the message that the patient should deal with pain flares and not respond to them as crises. Such visits establish a set period when the physician will be most available to them, which reassures patients that their physicians care about their progress. Using a guided versus directed interviewing style to encourage change and motivation to participate in their care (e.g., physical rehabilitation) can shift the burden of improvement from being solely on the physician. A patient’s family can reinforce this idea and help monitor compliance.

Intrinsic to the healing process is the perception by patients that their health care providers are listening and genuinely appreciate their suffering. As outlined earlier, difficult patients are often those who have difficulty not only with the level of their pain but also with their pain physician. Coulehan et al. identified ways for a clinician to build empathy and, in turn, defuse problematic encounters with difficult patients. Asking questions such as “Is there anything else?”; using clarifying statements such as “Let me see if I have this right”; and responding with feeling statements such as “I can imagine how this might feel” can be helpful.³⁵

Simple questions can be powerful tools in conveying a physician’s empathy for and appreciation of a patient’s suffering. Questions such as “Is having chronic pain a lot of work for you?”, “How is your life changed because of the pain?”, and “What have you lost as a result of having chronic pain?” acknowledge that the patient is experiencing extreme difficulty and loss and that the patient is trying his or her best to cope effectively. Haas et al. lists specific communication techniques that may help physicians in communicating with difficult patients (Table 22-4).³⁶

Drawing from the principles of medical ethics consultation and mediation services may also be useful.³⁷ For example, (1) Reframe the problem as bilateral and refer to the situation rather than the patient as “difficult.” (2) Express curiosity about the patient. “Why would a reasonable person behave this way?”, “What do they hope for from the medical team, and what do they fear?”, or “What can our team do to help them through this?” (3) Affirm and accept frustrations regarding circumstances over which the provider has no control, such as lack of insurance, social support, or transportation to get to appointments.

Despite a physician’s best efforts, significant psychopathology may make patients unavoidably difficult. The main areas of psychopathology associated with chronic pain patients include personality, affective, somatoform, and substance abuse disorders.

Psychopathology affects between 30% and 50% of patients seen in academic and community pain centers.^38,39 Recently, Knaster and colleagues found that more than half of the patients seeking treatment for chronic pain fulfilled the criteria for at least one psychiatric disorder during the past 12 months. The diagnoses included a wide range of psychiatric disorders; mood disorder was diagnosed in 45% and an anxiety disorder in 25% of the patients. The lifetime prevalence of any psychiatric disorder was 75%.⁴⁰ Among patients attending pain clinics, 30% to 50% have a major depressive or anxiety disorder.^41–43 Common symptoms are low mood, increased worry, and irritability. Although such symptoms are most apparent to the spouse or family members, they may emerge in the clinician–patient encounter.

Goral et al. found that two-thirds of chronic pain patients with depression and anxiety disorders had sleep problems compared with one-third of chronic pain patients with no comorbid psychiatric disorders.⁴⁴ Longer duration and higher severity of pain were also significantly associated with having depressive or anxiety disorders.⁴⁴ Gerrits et al. found that patients having a high number of reported pain sites, pain of the joints and longer duration of joint pain (90+ days), daily use of prescription medication, and more severe pain at baseline were at a significantly increased risk of still having a depressive or anxiety disorder at a 2-year posttreatment follow-up.⁴⁵ Arthritis or reported pain in the joints in particular has been associated with psychiatric disorders, including depression and anxiety.^45,46 In their review of the prevalence of major depression in patients with chronic pain, those with pain lasting longer than 6 months were more than four times as likely to have a depressive disorder as those without chronic pain; 65% of patients with depression experienced one or more pain complaints, and depression was present in 5% to 85% of patients.⁴⁷ At least 75% of primary care patients with depression present with physical complaints only. However, pain symptoms are rarely attributed to depression or other psychiatric illness. These physical complaints may be due to amplification of chronic physical disease and remain medically unexplained after extensive workup. As a result, patients with depression who present with physical symptoms such as pain are particularly likely to receive an inaccurate diagnosis.

Screening chronic pain patients for psychiatric comorbidity in secondary care is important because psychopathology may have serious consequences for prognosis, outcome, and health care utilization. Untreated or undertreated psychopathology is the single most important factor in poor pain treatment outcome regardless of the treatment modality.^48,49 Pain patients with comorbid psychiatric disorders report higher pain ratings and show greater pain-related disability than do other patients. Furthermore, patients with psychiatric comorbidities more often have a poor response to pain medications, neural blocks, and physical rehabilitation than do those without psychopathology. The evidence suggests that a reciprocal relationship may exist; the presence of persistent pain significantly increases the risk of future depression or major depression or anxiety and vice versa.¹² Depressed or anxious patients may “lash out” at their pain physicians, blaming them for overwhelming pain and failure of treatment. Although a patient may be adjusting to pain and making reasonable attempts at functional improvement when first evaluated, the development of an affective disorder may manifest as poor motivation to remain active and a perceived intensification of pain in the absence of changes in pain pathology. Suggestions by the pain physician that the patient’s pain cannot be “cured” may be met by frustration and anguish over the anticipation of a life with unbearable pain.

Individuals with personality disorders may present with a pattern of maladaptive emotional and cognitive reactions to daily events or challenging circumstances. Patients who appear odd or eccentric may meet the criteria for paranoid, schizoid, or schizotypal disorders. Patients who appear dramatic, emotional, or erratic may have an antisocial, borderline, histrionic, or narcissistic personality disorder. Patients who appear to be extremely anxious or fearful may have an avoidant, dependent, or obsessive-compulsive personality disorder.