Strategies For Dealing With Difficult Patients

Difficult patients can present to your office with attitudes ranging from anger to stony silence to incessant complaining. This author presents a guide to defusing the situation and treating difficult patients in an empathetic way that provides them better care and makes your day easier.

If you are now, have ever been, or plan to be a difficult person, raise your hand.

Face it, we all have those occasional patients who manage to annoy us to the point of actually stressing us out. Often, when we verbally tangle with a patient in the office, we have trouble letting it go. If we don’t let it go, we drag that irritated attitude home and spew the remaining aggression on our families, friends, fellow commuters, or an unsuspecting pet.

That is not good for us—and it certainly isn’t fair to recipients of that hostility.

Is The Patient ‘Difficult’ Or ‘Different’?

I think we all already know that difficult people are everywhere. It is highly unlikely that we will go through life and never encounter them. Difficult people are disguised as our patients, coworkers, employers, family, friends, partners, service people, acquaintances or strangers … literally, people you come into contact with every single day.

Keep in mind that the word “difficult” is subjective. In other words, personalities that are difficult for one individual might not seem difficult to another, which usually accounts for many a personality conflict. What one finds challenging and internalizes, another might easily brush off. It is important to understand it is not the person we find annoying as much as it is the behavior. The way difficult people act rubs us the wrong way. Sometimes, we tend to label people as “difficult” just because they think differently from us or fail to see things our way, which of course is the right way. Right? Wrong.

We are all motivated by different things; needs, fears, perspectives, values and cultures. Gender-thinking and right/left brain dominance also play a role. This combination of dynamics is responsible for how we communicate. People who seek control or require recognition communicate one way, while others who focus on a need for affection and respect communicate differently. Some people avoid confrontation for fear of hurting an individual’s feelings while others might think it is prudent to say exactly what is on their mind and not dwell on the potential emotional impact.

If we were to describe some familiar labels that we might consider “difficult,” words like selfish, negative, pot-stirrer, irresponsible, arrogant/rude, unmotivated, insubordinate, disrespectful, foot dragger, gossiper and bully might come to mind. People don’t generally think of themselves as difficult; however, if you have ever been guilty of even one of these labels, someone might perceive you as, well, difficult.

Bottom line: we could all be somebody’s worst nightmare at some point, whether intentional, inadvertent, or maybe due to a bad hair day. It’s just who we are. Perhaps our 3-year-old grandson said it best. Following a minor meltdown, I questioned him as to why he was misbehaving. He turned to me with shrugged shoulders and the most sincere facial expression and said, “Mimi, sometimes I do and sometimes I don’t. That’s just the way I am.” Hard to argue with innocence and honesty.

So while expectations are that patients and coworkers will always conduct themselves in a civilized manner, we have expert testimony that “sometimes they do and sometimes they don’t.” Our goal as professionals, (and for self-preservation) should be to treat all individuals with compassion and respect, (maybe with some extra consideration for our patients). Regardless of how difficult patients may seem, the truth is, none of us can know what someone else is going through.

There are two things you should know. One, we cannot fix these people. Two, it requires effort to compel difficult patients to like us. If we simply make the effort to understand personality types and learn to appreciate each other for strengths and qualities instead of weaknesses, we just might minimize some of those potential combative situations.

Hopefully, by article’s end, you can identify who the “difficult” people are in your life. Then apply some of the coping these strategies to help you deal rationally, sensitively, and most important, effectively with them, if for no other reason than personal harmony.

A Closer Look At The Full Range Of Patients You See

We basically deal with four types of patients on a daily basis:

• Fans (those who are happy and quick to tell us)
• Silent supporters (we know they are happy, but never tell us)
• Complainers (unhappy and cannot wait to tell us)
• Deserters (unhappy and just leave, never to return).

We love our fans and even our silent supporters. We have succeeded in making them happy (even though we may not always hear about it). We should value feedback from our disgruntled, the complainers, who often provide relevant data to make needed improvements. It is the deserters we should fear most and in fact, they can cause the most harm. If these unhappy, dissatisfied patients quietly leave our office (with a grudge), it is likely they will tell their family and 10 to 12 other potential patients (and their families) about the crazy, bad experience at your office and you may only learn about it on Yelp.

Another personality type that provokes us now and then are those demanding all our attention. These patients make interruptive, challenging calls and are less adherent, even though they “yes” us to death. Some even outright refuse treatment.

Think difficult patients do not concern you? Alarmingly, many patients who end up suing their doctor do so because of a bad experience, a lack of attention, perceived neglect, or miscommunication. These factors matter, statistically, more than a poor treatment outcome.

It is counterproductive to ignore or write off the difficult people in our lives because when we do, we shut them out and never acquire skills to problem solve, leaving the difficulties to become a recurring theme. So, when dealing with patients who drive us up a wall, the best advice is to take H.E.A.R.T. This humble acronym is a very fundamental, powerful, yet often forgotten approach and simply reminds us to; Hear them out, Empathize, Acknowledge (and Apologize), Respond appropriately, Take responsibility (and Thank them).  

Most people, regardless of personality style, want to be listened to, understood and acknowledged. Often being heard is all it takes to diminish conflict, along with a sincere apology and a caring, sensible solution. Of course, accepting responsibility instead of blaming makes for the bigger person. It may not always work out the way we want, but it is always worth making the effort. Believe it or not, those genuine courtesies we all learned at a very young age—like please and thank you, share and take your turn—still work like magic and we should always exercise them liberally.

Do not be fooled. There are people who have had years of practice being “difficult.” These difficult people have mastered their behavior and for all intents and purposes have reached “expert” status with a limitless appetite for more conflict; a clear advantage over any rookie. Rather than ignite any confrontational behavior by engaging difficult people, fighting back, being accusatory, belittling or patronizing these people (which only intensifies their behavior), take a more preemptive approach to calm negative outbursts.

Also, never assume you know what these individuals are thinking. Instead, learn to be considerate of their perspective. While you might think the way that you do things is always the only way to do them, it is not. Look at it another way: 2+2=4, right? But so does 3+1. Different; not wrong.

In most cases, acting as opposed to reacting is the better way to go. We cannot always control what is happening; however, we can control the way we respond to it. Therein lies our strength and our power. The choices we make are in our hands. We can: Stay and do nothing, move on and leave, change our attitude, or change our reaction.

Do You Know These Difficult People?

• The patient who fully expects to monopolize your time, presenting with two bags of shoes and pages of printed articles from the internet about a foot and ankle condition, preparing to match wits.

• The patient who presents with a shopping list of conditions and wants to discuss every single one in the allotted 15 minutes of time.

• The complainer, who has ongoing grievances about (insert complaint du jour here, such as treatment, care, service, fees, staff, etc.).

• The contrarian, a patient who disagrees just to disagree.

• The talker, bombarding you with unnecessary details unrelated to their treatment.

• The abuser, the surgical patient who excessively demands more painkillers.

• The uncooperative patient who verbally “yesses” you to death, never follows the clinical advice, then complains there has been no improvement in the condition.

• The patient who is aggressive, angry and/or verbally offensive.

I could go on.

Each of these examples demonstrate classic personality traits. Without violating the Health Insurance Portability and Accountability Act (HIPAA) laws by attaching names to the culprits, you might privately concede that each one could be a patient of yours. Your mission, doctor, should you choose to accept it, is to detect the dominant personality of your most challenging patients (connect the dots based on noticeable behavioral patterns). Then apply strategies that will move you (and your staff) toward a more constructive exchange with these patients.

A Guide To The Cast Of Characters

Of course, there are many more “characters” than the eight selected below, but here is a variety of the more common ones that we come across on a daily basis. Included are brief narratives and guidance on how to best deal with various types of people.

The Clam. It is always best to get the Clam to open up, as these are silent people. If these people are disappointed, dissatisfied or disgruntled in any way, it is better if we know so we can make amends before they share their dissatisfaction with anyone outside the practice. By opening such people up, we want to be careful not to pressure them into an unwanted conversation or they are liable to withdraw deeper into their shell. Anyone who owns a cat knows what I’m talking about. The more one prods cats to come out from under the bed, the less chance of success.

On the other hand, if quiet patients feel speaking with you is safe, they will open up, so let them know you are there to help in any way you can and keep your conversation light. Avoid politics and religion or any topic that could be considered provocative, demanding, or put them on the defensive. If that happens, you are likely to lose these patients completely.

Typically, patients will respond to questions with a simple yes or no; however, when that doesn’t work, asking open-ended questions like who, what, when, where, why and how as opposed to closed questions (did, can, are, is, will) can sometimes do the trick.

The Grenade. The Grenade’s approach is very direct and such patients are accustomed to flying off the handle at times to make their point. These patients just want you to take them seriously and unfortunately, they believe raising their voice gives them an advantage. It is important to actively listen to them. Looking patients straight in the eyes when they are speaking tells them you are genuinely concerned.

Another tactic to reduce these patients’ intensity is to employ an exercise called “mirroring,” which helps to minimize the differences between you and other person. Let’s say, for example, you find yourself speaking to someone with a Grenade-type personality who tends to be overly excited and loud. Mirroring allows you to bring their volume or tone down to a normal pitch by starting out speaking on their same level of vocal intensity, then gradually lowering your tone to a more engaging one. This usually encourages patients to follow your lead, inevitably lowering their voice to match yours.

The same is true in the reverse. If a patient appears too soft-spoken, start by matching the patient’s softness and raising the volume to a more acceptable level. (Sounds a little like a poker game. I’ll call your level and raise you two levels.) In all seriousness, it is worth a try. I can confirm, from experience, that it really works.

The Locomotive/Steamroller/Tank. Getting run over by a steamroller, tank or train is hardly in anyone’s best interest. Tank personalities will crush you if you let them. They are very likely to be in your face, critical, superior and extremely intimidating.

These patients’ words are unfiltered, so things they say are often very personal, even hurtful, and can send one into a defensive mode. Having driven tendencies, these people are focused on accomplishment, not emotion. If Tank patients are convinced that control and hostile bullying is the only way to get what they want, these aggressors will use those tactics for their desired results. Can you think of anyone like this?

Maybe your Tank is a patient who insists you incorrectly filed her insurance form and she didn’t get paid as a result. Take an outcome-oriented approach. Get your facts in order and suggest a time when you can both sit down and have a reasonable discussion. Putting things on hold for bit allows patients to calm down and run out of steam (every locomotive does, eventually). Moreover, putting things on hold provides time to do your homework, fully research the problem, regain composure, and present a meaningful solution.

Whatever you do, keep emotions intact. Going on the defensive, explaining or justifying your intentions over and over will get you nowhere. Instead, smile (it sends a message of self-control). Then simply say, “Well, it appears we’ve come to an impasse. We obviously see things differently. I suggest we move on from here.”

The No Person. The No Person needs to get things right. These people are task focused, prefer the status quo, and are also kind of a morale buster. People in their presence can easily get sucked into their negativity.

If we really want to encourage our patients to accept a new treatment plan, we need to approach the plan in a way that gets the resister on board by involving him or her in the process. It is hardly useful to throw new ideas at resisters without also providing certain details, i.e., how to accomplish an idea, how long it will take to implement an idea and see results, what is the expected outcome, what is the financial impact, and who will be responsible.

It takes a good 21 days for any change to take effect, so if a patient rejects your clinical treatment plan right off the bat, you might say, “My recommendation is try this for at least three weeks. If, after that time, the outcome is not as expected, we can look at a different approach.”

The Yes Person. If you thought the No People were hard to get along with, do not underestimate the Yes People, who can be just as exasperating, in a different way.

Yes People will do just what the term suggests. They will “yes” you to death and agree with you in order to please you, causing them to overcommit. Afterwards, in addition to their calculated lack of follow-through, they feel obligated to make up a flimsy excuse for disappointing you. When explaining home or post-op care, for example, they will “yes, doctor” you, only to find out at their next visit that they were totally non-adherent and didn’t follow through. We want to believe these patients, yet history tells us to take things these people say with a grain of salt.

There are several ways to help teach such patients how to better commit: a) get patients’ family on board if they are present, b) have patients repeat their post-op instructions to you before they leave, c) let patients know it is OK to be honest if they are unable or unwilling to do something, and d) explain that you would prefer patients say no rather than leave you with unmet expectations.

The Know-It-All Vs. The Think-They-Know-It-All. While both claim to be an expert on everything, there is a stark difference between Know-It-Alls and Think-They-Know-It-Alls. Although Know-It-Alls are far from perfect and difficult to take in large doses, they are mostly well-informed and competent. Conversely, the Think-They-Know-It-Alls are just filled with hot air and love to bloviate. Warning: If you ask either for their opinion, you will receive it in large quantities.

The Know-It-All patient has likely done a fair amount of research on the internet about the condition and is compelled to not only inform you about it, but comment on how to best treat it. Is that a challenge? Do you ever wonder why these patients felt the need to make an appointment in the first place?

The Micromanager. Anyone who has ever worked with or for a Micromanager would be hard pressed not to instantly recognize the discouraging behavior. Micromanagers are neck breathers and resent being questioned. Besides not really trusting their employees’ abilities or desire to work, Micromanagers feel it necessary to oversee their every move constantly.

Since Micromanagers have a love/love relationship with efficiency, productivity and performance, anything standing in the way or any kind of bottleneck that prevents their expected progress is their nemesis. The problem, however, is that they are usually the ones who are the very bottleneck they despise (although Micromanagers would never admit it). Since no employee dares to do or say anything without first getting approval or permission for fear of being criticized or ridiculed or overstepping boundaries, things that employees should and could easily accomplish, do not happen.

You all know I am the biggest champion of proper training. However, there is a distinction between training and subjugating. One is lifting up, the other is not.

No one likes to be micromanaged. Working for someone who needs to essentially choreograph every single task, then laboring almost under surveillance to do the work exactly as instructed is frustrating, demoralizing and dispiriting. Yet Micromanagers’ determined and laser-focused tendencies kick in and they almost cannot help themselves. If you are one who feels pressured in this way, the best thing you can do is let people with this overpowering personality know how their behavior makes you feel. Implausible as it seems, there is a good chance that if you don’t tell Micromanagers, they might never know.

The Complainer. I saved the best until last: the Complainer, a.k.a. whiner or cry baby. What can I say about the Debbie (or David) Downers of the world that Saturday Night Live hasn’t already successfully satirized? They always seem to have that “woe is me” attitude and are toxic to be around.

From Guy Winch, PhD, at Psychology Today: “The optimists see a glass half full; the pessimists see a glass half empty. Chronic complainers see a glass that is slightly chipped holding water that isn’t cold enough, probably because it’s tap water when I asked for bottled water and wait, there’s a smudge on the rim, too, which means the glass wasn’t cleaned properly and now I’ll probably end up with some kind of virus. Why do these things always happen to me?!”¹

While it is critically important to listen to any legitimate complaint, be careful not to get drawn into useless whining. Arguing, agreeing, apologizing or asking why patients are complaining only gives patients permission to open the floodgates for more of the same. Warning: it could be worse. It could even trigger Complainers to start all over again from the beginning.

Complainers have difficulty being positive. So one way of neutralizing the negativity is to shower them with optimism and validate their opinions. After a complaining rant, reassure them and build up their self-confidence with, “Everything’s fine, no worries” or “You’re really good at this” or “I’m certain this will work out.” Rinse, lather and repeat that positivity as needed. If you’ve absolutely tolerated all that you could, walk away. However, it is more likely that an ambush of non-stop positivity will calm these patients enough to leave you alone.

In Conclusion

Instead of stressing when someone pushes your buttons, learn how to handle people who think and act differently than you do. It all starts with being a good communicator. The more you polish your own communication skills, the more competent and confident (and comfortable) you will become.

Rather than judge people, challenge yourself to study them. See people in a whole new light and try to understand why they behave the way they do. If you understand what makes them tick you can effectively defuse those time bombs before they detonate. Remember, people are not difficult as much as they are different. Different is good.

Ms. Homisak is the President of SOS Healthcare Management Solutions, based in Federal Way, WA.

Reference

1.     Winch G. How to deal with chronic complainers. Psychology Today. Available at https://www.psychologytoday.com/us/blog/the-squeaky-wheel/201107/how-deal-chronic-complainers . Published July 15, 2011.