One of the more interesting posters at last month’s American Psychiatric Association Annual Meeting was presented by Ricardo Salazar of UT San Antonio and the South Texas Psychiatric Practice-Based Research Network (PBRN). The topic was “the Difficult Patient in Psychiatric Practice” and it surveyed psychiatrists about which patients they considered “difficult” and why.
It might sound somewhat disrespectful (and maybe a little naïve) to label a patient as “difficult.” However, doctors are people too, and it would be even more naïve to think that doctors don’t have their own reactions to (and opinions of) the patients they treat—something referred to in psychoanalytic theory as “countertransference.” Let’s face it: doctors simply don’t like dealing with some patients. (That’s why some choose private practice, to cherry-pick those whom they do like.)
Nevertheless, I think this topic needs more attention, particularly in today’s environment. Much of what we do in mental health (both psychopharmacologically and in therapy) has a questionable evidence base, and yet the experience of clinicians and of patients is that our interventions frequently work. I maintain that clinical benefit often results more from the interpersonal relationship between a patient and a doctor who listens and seems to understand, than from the pill that a doctor prescribes or the specific protocol that a therapist follows. (This is yet another reason why quick-throughput psychiatry, dictated by brain scans, blood tests, and checklists, is bound to fail for most patients.)
Anyway, Dr Salazar’s study used a scale called the “Difficult Doctor-Patient Relationship Questionnaire (DDPRQ-10),” developed by Steven Hahn and colleagues in 1994. I had not heard of this scale before. Here are some sample questions:
1. How much are you looking forward to this patient’s next visit after today?
3. How manipulative is this patient?
4. To what extent are you frustrated by this patient’s vague complaints?
6. Do you find yourself secretly hoping this patient will not return?
8. How time-consuming is caring for this patient?
As a patient, I might find some of these questions mildly offensive (“does my doctor secretly hope I won’t return??”), but as a doctor I must admit that some days I look at my schedule and see a name that makes me dread that hour. (If you’re a doctor and you’re reading this and you do not agree, you’re either fooling yourself, you’re perfect, or you’re IBM’s Watson.) Recognizing those feelings, however, often helps me to prepare for the session—and examine my own biases and faults—and such appointments often turn out to be the most satisfying (at least for the patient).
Salazar’s study showed that, on average, psychiatrists considered approximately 15% of their patients to be “difficult.” The most common diagnoses among the “difficult” patients were schizophrenia (32%), bipolar disorder (19%), cognitive disorder (24%), and personality disorder (32%). Patients with depression (11%) or anxiety (9%)—and, interestingly, patients who were in psychotherapy (11%)—were considered less difficult. Not surprisingly, patients with alcohol and substance use disorders were also labeled difficult (23%), but patients with somatization (defined in this study as “unexplained physical complaints”) were less so (10%).
A fascinating review of 94 studies published between 1979 and 2004 described four reasons why patients may be considered “difficult”: (1) chronicity– i.e., patients fail to improve over time; (2) severe, unmet dependency needs which patients then project onto the caregiver; (3) severe character pathology (especially borderline, narcissistic, and paranoid types); and (4) an inability to “reflect” (which the authors attribute to a history of insecure attachment early in life). The authors also described three types of difficult patients: the “unwilling care avoider” who doesn’t see himself as sick; the “ambivalent care seeker” who is often demanding and dependent, but is frequently self-destructive and self-sabotaging; and the “demanding care claimer” who is aggressive, attention-seeking and manipulative, but who sees himself as a patient only when necessary to achieve his own goals (legal, financial, or otherwise).
Of course, every patient interaction is a two-way street. Regarding psychiatrists, the Salazar study found that young (<40 yrs old) psychiatrists, and those working in a group practice, claimed to have more difficult patients. Another large study published in 2006 examined 1391 physicians to identify which features of doctors underlie their perceptions of patients as “frustrating.” They found that high frustration was associated with doctors who were younger (<40 yrs old), worked >55 hrs/week, had symptoms of depression, stress, or anxiety (yes, that’s in the doctor, not the patient), and had “a greater number of patients with psychosocial problems or substance abuse.” Two-way street, indeed.
It’s commonly said that “there’s no such thing as a stupid question.” By the same token, I would posit that there’s no such thing as a difficult patient. To be sure, some patients present with difficult problems, challenging histories, poor interpersonal skills, and needs that simply can’t be met with the interventions available to the physician. But every patient suffers in his or her own way. Doctors bring their own baggage to the interaction, too, in the form of strong opinions, personal biases, lack of knowledge, or—conversely—the perception that we know what’s going on, when in reality we do not.
When you add in the extrinsic factors that make the interaction even more strained—shorter appointments, care that is dictated by some third party rather than the doctor or the patient, poorly designed electronic medical record systems, or financial conflicts of interest that violate the doctor-patient trust—the “difficulties” just keep piling up.
It’s important that we look at every aspect of the doctor-patient interaction in order to improve the quality and efficacy of the care we provide. Patients should not need to worry about whether they’re perceived as “difficult” or “frustrating.” And when these perceptions do exist, we must critically examine the impact it has on their care, and what it says about the professionals we call upon to treat them.