AMA Journal of Ethics®

Illuminating the art of medicine

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AMA Journal of Ethics®

Illuminating the art of medicine

Virtual Mentor. April 2003, Volume 5, Number 4.

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Who Is Being Difficult? Addressing the Determinants of Difficult Patient-Physician Relationships

The author analyzes various research that illustrate how strained physician-patient relationships can be improved.

Michelle Lim

Both the patient and physician bring to the medical encounter social and personal characteristics that contribute to defining the nature of the patient-physician relationship. When patient or physician or both feel frustrated with the medical encounter, the situation may lead to poorer health outcomes. In a 1989 article in the Journal of Family Practice, Thomas L. Schwenk, MD, et al cite several studies that address the difficult patient-physician relationship by looking at characteristics of patients who have been labeled difficult by physicians [1-5]. These so-called difficult patients are seen as demanding, non-compliant, manipulative, and self-destructive [6]. But focusing on just the patient member of the dyad gives the illusion that the patient is the wrongdoer in the relationship. A physician who wishes to ease the troubled relationship, may turn to a catalog of psychological conditions as explanations for the patients' behaviors. This solution is limited and does not consider the influence of the physicians' roles in the relationships.

Schwenk et al also illustrate how differing physician and patient expectations can produce mutually negative outcomes in the medical encounter [7]. In "Physician and Patient Determinants of Difficult Physician-Patient Relationships," the authors explain that among the family physicians they surveyed the primary motivations for practicing medicine were the desire to help people and the attraction to the problem-solving challenges specific to medicine. When these goals are not met in dealing with a particular patient, the physician is apt to think of that patient as "difficult."

They found that the complexity and ambiguity of the medical problem (medical uncertainty) and the perceived abrasive behavioral style of the patient (interpersonal difficulty) also contribute to the description of "difficult patients" [8]. They conclude that when a patient's medical problems or personality make it difficult for the physician to experience professional satisfaction, the physician views the patient as difficult. Physician and patient dissatisfaction coupled with the unmet expectations produce the difficult patient-physician relationship [9].

Other studies extend the story to the patient's point of view [6,10-12]. These studies suggest that patients' unmet expectations and their dissatisfaction with physicians' clinical behaviors are primary causes of their frustrations with the patient-physician relationship. Greiner points out 2 traditional physician views that present barriers to an ideal patient-physician relationship: the concept of the difficult patient and a biomedical view of medicine that tends to exclude social conditions. He suggests that physicians have definitive opinions about what is "medically appropriate," leaving little room for patient questioning and negotiation. This inflexibility in the medical encounter leaves already vulnerable patients in an even more handicapped position. Patient attempts to negotiate often result in expressed animosity on the part of health care providers [13]. A setting like this leaves patients thinking they cannot be active participants in their health care.

A study by Robert Bell et al found that patients with at least 1 unmet expectation reported less satisfaction with their medical visits, less improvement in their health status, and weaker intentions to adhere to physician recommendations. By the same token, physicians saw these patient visits as frustrating and more effortful [10]. These encounters may be filled with misunderstanding from both sides. Judith Hall, PhD et al surveyed diabetic patients and their primary care physicians in an effort to assess physicians' awareness of their patients' emotions, satisfaction, and opinion about the quality of their communication [11]. They found that physicians tended to see patients' responses as more negative than they actually were. The authors requested that patients rate their opinions regarding quality of communication, satisfaction, and experience of 6 emotions (anger, worry, disappointment, pleasure, cheerfulness, relief). The physicians were asked to estimate the patients' views for each of the questions [14]. Hall et al conclude that physicians had limited accuracy in estimating their patients' opinions and feelings. Moreover, in focusing on the negative signals, physicians may be guilty of failing to properly read affective responses from their patients [15].

Taken together, these studies suggest that a difficult patient-physician relationship emerges from the conflicting expectations and misunderstood behaviors by both patient and physician. They also suggest that focusing on the concept of the difficult patient and the catalog of psychological characteristics of so-called difficult patients is not an effective solution for dealing with an unsatisfactory patient-physician relationship. Rather than categorizing patients as "difficult," the authors of these studies emphasize the value of partnership and teamwork in remedying a broken patient-physician relationship. They also call on physicians to respond with more empathy to their patients' needs and keep open minds when dealing with patient requests.

Herbert Adler believes that a collaborative relationship is also a therapeutic alliance that produces mutual benefits for the patient and physician. He proposes that, in crafting the patient-physician relationship, both patient and physician are collaborative partners "engaged in a common struggle against [the patient's] malady" [12]. "The secret of care of the patient is caring for the patient," [16] Adler cites, adding that "caring" is "responsive listening" [17]. A successful patient-physician relationship is one of flexibility, continuity, and mutual respect. By looking beyond the medical conditions of the patient, physicians can work side-by-side with their patients to devise more successful strategies for clinical negotiation and thus effective treatment.

Questions for Discussion

  1. Given already limited time and financial constraints in the medical setting, do you think the authors' suggestions for remedying the troubled patient-physician relationship are realistic expectations for physicians? What steps would you suggest physicians need to take to better understand their patients needs and expectations?
  2. How would you, as a clinician, deal with conflicts between patient expectations and what you believe to be medically appropriate? What would you define as a "successful strategy" for clinical negotiation? How would you incorporate and maintain empathic responses and the feeling of collaboration when dealing with confrontation?


References

  1. Crutcher JE, Bass MJ. The difficult patient and the troubled physician.J Fam Prac. 1980;11:933-938.
  2. Groves JE. Taking care of the hateful patient. N Eng J Med.1978;298:883-887.
  3. John C, Schwenk TL, Roi LD, Cohen M. Medical care and demographic characteristics of "difficult" patients. J Fam Prac. 1987;24:607-610.
  4. Malcom R, Foster HK, Smith C. The problem patient as perceived by family physicians. J Fam Prac. 1977;5:361-364.
  5. Reis RK, Bokan JA, Katon WJ, Kleinman RA. The medical care abuser: differential diagnosis and management. J Fam Prac.1981;13:257-265.
  6. Greiner KA. Patient-provider relations—understanding the social and cultural circumstances of difficult patients. Bioethics Forum. 2000;16:7.
  7. Schwenk TL, et al. Physician and patient determinants of difficult physician-patient relationships. J Fam Prac. 1989;28:63.
  8. Schwenk, 61.
  9. Schwenk, 62.
  10. Bell RA, et al. Unmet expectations for care and the patient-physician relationship. J Gen Intern Med. 2002;17:817.
  11. Hall JA, et al. Inaccuracies in physicians' perceptions of their patients. Medical Care. 1999;37:1164.
  12. Adler HM. The sociophysiology of caring in the doctor-patient relationship. J Gen Intern Med. 2002;17:877.
  13. Griener, 8.
  14. Hall, 1165-1167.
  15. Hall, 1168.
  16. Adler, 877.
  17. Adler, 874.

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