How Not To Be A Difficult Patient

June 6, 2011
Steve Balt, MD

A poster at the APA meeting, "The Difficult Patient in Psychiatric Practice," surveyed psychiatrists about which patients they considered "difficult" and why.

The following was originally posted to the HCPLive network blog Thought Broadcast.

One of the more interesting posters at last month’s American Psychiatric Association Annual Meeting was presented by Ricardo Salazar of the UT San Antonio Health Science Center. 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).

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