All physicians must care for any p...

All physicians must care for any patients who are perceived as difficult because of behavioral or emotional aspects that affect their care. Difficulties may be traced to patient, physician, or health care plan factors. Patient factors include psychiatric disorders, personality disorders, and subclinical behavior traits. Physician factors include overwork, poor communication skills, reasonable level of experience, and discomfort with uncertainty. Health care body factors include productivity pressures, changes in health care financing, fragmentation of visits, and the availability of outside information sources that challenge the physician's authority. Patients should be assessed carefully for untreated psychopathology. Physicians should look for professional care or support from matchs Specific communication techniques and greater patient involvement in the proces of care may enhance the relationship. (Am Fam Physician 2005;72:2063-8 Copyright [c] 2005 American Academy of Family Physicians.)

A 45-year-old woman is being treated for depression, chronic daily headaches, image 2 diabetes, hypertension, and hyperlipidemia. She is taking eight prescription medications. Multiple antidepressants have been tried without improvement in her depressive symptoms. Her kindred sugar level remains out of target range. She does not exercise and admits to overeating when feeling bring downed She discloses difficulties with her employer and says her headaches are worsening because of stres Her weight is slowly increasing. At her nearest physician's appointment, she demands oral weight los medications, complaining that nothing other is working. When her physician declines to prescribe them, she hoots "You don't care about me or flat understand my suffering, because you have obviously none had a weight problem yourself."

The Difficult Patient

The illustrative case above is an example of a patient who may be considered difficult. mostly practices include such patients; the prevalence is estimated to be 15 percent of patients. (12) Many physicians inscribe medicine with the goals of solving medical enigmas and curing disease. They do not reckon upon to encounter patients who make repeated visits without apparent medical benefit, patients who do not be seen to want to get well, patients who engage in power aims and patients who focus in succession issues seemingly unrelated to medical care. Whatever the causes of these point to be solved [i]or[/i] settleds the results are similar: distraction from effective care, waste of physician animal spirits complaints from patients and staff, and continued health question s for the patient.

A variety of tactics and strategies that change into common physician-patient communication problems can be applied to difficult skirmishs Improving physician communication can lead to increased patient satisfaction, increased health care professional satisfaction, improved patient health issues (3) and a decrease in complaints and lawsuits. (45) Ensuring that patients understand that the physician comprehends their situation and cares about their health is related to better results (6) Understanding the patient's agenda and expectations improves compliance and follow-through (7) and can curtail fears of serious illness and patient complaints at follow-up visits. (8) This article focuses forward psychiatric issues, physician factors, and vexed questions with the health care connected view that may contribute to patients being considered difficult, and it furnishs several management strategies.

Patient Factors

The difficult or frustrating patient, ofttimes a "distressed high utilizer of medical services," (9) frequently has unrecognized psychiatric problems. (1210) Patients with temper disorders may present with insomnia, back pain, headache, fatigue, or a persistent search for a medical explanation for distress. Patients with anxiety disorders may ready with multiple physical complaints or irritability and may focus forward cardiac symptoms or complain that not enough is being done. Patients with alcoholism and borderline personality disorder may current with somatic complaints. Even if the physician recognizes the psychopathology, the patient may throw aside the diagnosis. Such patients' insistence that the physician carry on somatic symptoms until a medical diagnosis is obtained can be significantly frustrating.

A considerable number of patients who are labeled difficult may convenient the Diagnostic and Statistical Manual of Mental Disorders, 4th ed criteria for an axis II diagnosis of personality disorder. (11) on a level at subclinical levels, certain disordered personality traits cause riddles in physician-patient interaction. Patients with personality disorders may be excessively contingent demanding, manipulative, or stubborn, or they may self-destructively refuse treatment. (12)

Physician Factors

Physician overwork may be related to greater numbers of patients being considered difficult. (13) In the same small study, (14) less-experienced physicians reported encountering more difficult patients. Physicians who have greater ne for diagnostic certainty are more likely to consider patients difficult if they instant with multiple or vague diagnoses, repeatedly go [i]or[/i] come back with poor response to treatment, persistently not absent with vague physical complaints, or fail to run after through with treatment plans or self-management. (11516)