Risk Strategies for Managing Difficult Patient Behaviors

Difficult patients represent one of the most challenging situations that doctors and other healthcare professionals encounter. Dealing with these patients can be emotionally and mentally draining — as well as increasingly frustrating — for practitioners and their staff members.

Inappropriate patient behaviors also can compromise the provider–patient relationship, and patients who exhibit these behaviors might be at higher risk for misdiagnosis and poor outcomes.¹ Difficult patients also might be more likely to file lawsuits because of perceived unsatisfactory encounters.

The types of behaviors that difficult patients exhibit can vary widely. For example, these patients (or their family members) might:

• Have unrealistic expectations or demands
• Have a laundry list of clinical issues with no clear basis
• Have a history of doctor shopping and dissatisfaction with care
• Overutilize healthcare services
• Display needy or manipulative tendencies (e.g., threats of complaints or lawsuits)
• Exhibit rude, unpleasant, threatening, or aggressive behaviors that might potentially escalate over time into violence

Many factors can contribute to these types of patient behaviors, such as a complex medical history, psychiatric disorders, drug or alcohol abuse, frustration with the complexity of the healthcare system, social/personal issues, and cultural factors.

Moreover, healthcare providers’ attitudes and behaviors — whether in reaction to the patient’s behavior or as inherent characteristics — can complicate these situations. Feelings of anger, defensiveness, fatigue, and stress might provide the catalyst for adversarial interactions between providers and patients.

Although caring for difficult patients can be burdensome, healthcare practitioners can implement risk strategies to help manage these patients. First, practitioners should quickly assess whether the disruptive behavior could potentially escalate to a violent situation. This assessment should include consideration of whether substance abuse, an acute physical condition, or mental illness might be causing the difficult behavior.

Staff, patient, and visitor safety should be the primary concern if a patient is potentially violent to self or others. Every healthcare facility should have an established security protocol, with verbal or physical triggers that initiate a call for law enforcement support. Further, staff should receive training to help them manage these situations and de-escalate aggressive patient behaviors.

If a patient is not violent, the provider should tell the patient that their behavior is unacceptable and must stop before care can continue. Approaching this conversation from the standpoint of prioritizing quality care and treating the patient as a vital member of the care team can potentially help avoid confrontation.

Other strategies that can help address difficult behavior include:

• Working to clarify expectations (e.g., through the provision of a patient brochure that explains the organization’s policies, procedures, and patient responsibilities)
• Using patient agreements to reinforce expectations and responsibilities
• Addressing cultural or health literacy issues that might manifest as inappropriate behaviors because patients are confused, frustrated, or feel disrespected
• Using patient-centered approaches to get patients more involved in their care, better understand their perspectives, and identify factors that might be influencing their behaviors
• Implementing a complaint process to effectively and consistently manage patient complaints
• Using patient satisfaction surveys to collect critical patient feedback, trend data over time, and identify potential problems

A solution might not be possible in some cases. If discrimination laws are not broken and patients are not abandoned, practitioners might decide the best option is to terminate the provider–patient relationship. To learn more about this process, see MedPro’s Terminating a Provider–Patient Relationship guideline.

Endnote

¹ Schmidt, H. G., van Gog, T., Schuit, S. C. E., Van den Berge, K., Van Daele, P. L. A., Bueving, H., . . . Mamede, S. (2016, March). Do patients’ disruptive behaviours influence the accuracy of a doctor's diagnosis? A randomised experiment. BMJ Quality & Safety. Retrieved from http://qualitysafety.bmj.com/content/early/2016/02/09/bmjqs-2015-004109

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