Difficult Patients or Difficult Doctors : An Analysis of Problematic Consultations

Aim: All physicians must care for some patients who are perceived as difficult because of behavioral or emotional aspects that affect their care. Reasons may be delivered from patient, physician, or health care system. To identify reasons behind perceiving some patients as “difficult” from a family doctor’s point of view; propose solutions for dealing with, and ultimately accepting and understanding them. Method: Cross sectional descriptive study. Participants: Data was collected from seventy board-certified family doctors currently working in primary care services. A structured questionnaire with answers scored on a 2 point scale (agree/disagree) was used to assess the perception of difficult patients. Twenty questions were related to patients, 8 were related to doctors, and 8 were related to administrative system. Results: The majority of doctors agreed that patient characteristics that render them difficult included psychological disorders (95.7%), life stresses (95.7%), social isolation (87.1%), multiple physical problems (78.6%), chronic diseases (82.9%), inability to communicate own needs (80.0%) and unrealistic expectations of the patient (77.1%). Most participants considered greater work loads (81.4%), lack of job satisfaction (72.9%), psychic condition of the doctor (68.6%), lack of training in counseling (78.6%) and communication skills (74.3%) were the main physicians reasons behind perceiving patients as difficult. Factors related to the administrative system were mainly absence of strategies to deal with difficult patients (91.4%), lack of a legal policy in the clinic (82.9%), free health services (82.9%), improper appointment system (81.4%), failing of registration to a single doctor (80.0%), unavailability of social services (72.9%), and untrained receptionists (71.4%). Conclusion: Our study demonstrated that the “problems” do not lie exclusively with the patients. Doctors should analyze difficult patient encounters to identify the causes behind them. In the pro1 Qadysia Family Practice Training Centre, Capital Health region, Kuwait. 2 Mansouria Family Practice Health Centre, Capital Health region, Kuwait Eur J Gen Med 2009;6(2):87-93 Correspondence: Dr. Maleka Serour P.O. Box 44102, Hawalli, 32056/Kuwait Tel: 00965 6016365, Fax: 00 965 5330002 E-mail: drserour@hotmail.com Maleka Serour1, Heyam Al Othman2, Ghada Al Khalifah1 Difficult Patients or Difficult Doctors European Journal of General Medicine 88 INTRODUCTION Almost all doctors encounter patients who are perceived as difficult because of behavioral or emotional aspects, which can interfere with the doctors’ ability to provide optimal care. About 1 out of 6 outpatient visits is considered difficult by clinicians (1,2). Groves (1978) was one of the first to describe and classify difficult patients (3). He defines 4 types: “dependent clingers, entitled demanders, manipulative help-rejecters, and self-destructive deniers.” Ensuing studies defined other types of difficult patients as the somatizers, the frequent attenders and patients with social and psychological problems (2,4). Difficult patients provoke a variety of unpleasant reactions in their doctors, which can lead to deterioration in the doctor-patient relationship, such as frustration, anger, exasperation, defeat, rejection and even despair. During the consultation there may be conflicts and reactions triggered by the characteristics and behavior of the patient, the doctors’ personality, work style and beliefs, cultural gaps between the doctor and his patient, and external circumstances that affect the encounter (4-6). Understanding reasons behind these undesirable consultations with difficult patients may ease the communication and help doctors accept their feelings in future encounters as commitments to such patients may be long term. Numerous articles were written about the characteristics of difficult patients and difficult doctor-patient relationships, many of which written by psychiatrists. The majority discussed patients’ characteristics. We carried out this study to investigate the diverse reasons of difficult doctor patient relationships, as well as try to propose solutions for this problem. MATERIAL AND METHODS One hundred and two Board-certified family doctors (RCGP/Kuwait) who are currently working in contact with patients in primary care services all over Kuwait were chosen to participate in this study. The study was conducted as a cross-sectional descriptive survey. A self administered questionnaire was mailed to the chosen doctors accompanied by a note inviting them to participate in our study, of which seventy replied (68.6%). The questionnaire was designed, based on literatures on the subject and the researcher’s experience of the patients’ characteristics and the administrative system. It was ‘pilot’ tested with nine family practitioners after which minor changes were applied. The questionnaire consisted of 46 close-ended questions. Ten of these questions assessed socio-demographic data, such as sex, age, years of experience in the general practice, marital status, average number of patients seen daily, and other work responsibilities. Patients’ characteristics which can make them difficult were selected from the medical literature (3,7). They were assessed using 20 structured questions and their answers were scored on a 2 points scale (agree and disagree). Factors relating to the doctors and the system were acquired from the results of other studies (8,9) and (10,11,12) respectively. Both were assessed using 8 structured questions each, and their answers were scored on a 2 point scale (agree, disagree). Questions on patients, doctors and system factors had an internal consistency reliability (Cronbach α) of 0.822, 0.788 and.0.717 correspondingly in the current study.


INTRODUCTION
Almost all doctors encounter patients who are perceived as difficult because of behavioral or emotional aspects, which can interfere with the doctors' ability to provide optimal care.About 1 out of 6 outpatient visits is considered difficult by clinicians (1,2).Groves (1978) was one of the first to describe and classify difficult patients (3).He defines 4 types: "dependent clingers, entitled demanders, manipulative help-rejecters, and self-destructive deniers."Ensuing studies defined other types of difficult patients as the somatizers, the frequent attenders and patients with social and psychological problems (2,4).
Difficult patients provoke a variety of unpleasant reactions in their doctors, which can lead to deterioration in the doctor-patient relationship, such as frustration, anger, exasperation, defeat, rejection and even despair.
During the consultation there may be conflicts and reactions triggered by the characteristics and behavior of the patient, the doctors' personality, work style and beliefs, cultural gaps between the doctor and his patient, and external circumstances that affect the encounter (4)(5)(6).
Understanding reasons behind these undesirable consultations with difficult patients may ease the communication and help doctors accept their feelings in future encounters as commitments to such patients may be long term.Numerous articles were written about the characteristics of difficult patients and difficult doctor-patient relationships, many of which written by psychiatrists.The majority discussed patients' characteristics.We carried out this study to investigate the diverse reasons of difficult doctor patient relationships, as well as try to propose solutions for this problem.

MATERIAL AND METHODS
One hundred and two Board-certified family doctors (RCGP/Kuwait) who are currently working in contact with patients in primary care services all over Kuwait were chosen to participate in this study.The study was conducted as a cross-sectional descriptive survey.
A self administered questionnaire was mailed to the chosen doctors accompanied by a note inviting them to participate in our study, of which seventy replied (68.6%).
The questionnaire was designed, based on literatures on the subject and the researcher's experience of the patients' characteristics and the administrative system.It was 'pilot' tested with nine family practitioners after which minor changes were applied.
The questionnaire consisted of 46 close-ended questions.Ten of these questions assessed socio-demographic data, such as sex, age, years of experience in the general practice, marital status, average number of patients seen daily, and other work responsibilities.Patients' characteristics which can make them difficult were selected from the medical literature (3,7).They were assessed using 20 structured questions and their answers were scored on a 2 points scale (agree and disagree).
Factors relating to the doctors and the system were acquired from the results of other studies (8,9) and (10,11,12) respectively.Both were assessed using 8 structured questions each, and their answers were scored on a 2 point scale (agree, disagree).Questions on patients, doctors and system factors had an internal consistency reliability (Cronbach α) of 0.822, 0.788 and.0.717 correspondingly in the current study.

Additional Analysis
We used Pearson's chi-square tests which showed no significant correlation between doctors' variables (gender and work load), and their perception of reasons causing patients to be difficult

Statistical Analysis
Various descriptive statistics (mean and SD) were used to describe the quantitative variables.Chi square test was used to find the significant difference between qualitative variables.Level for significance as p< 0.05 was used.The statistical package for Social Sciences (SPSS) version 14 was used for data processing.cess they will possibly overcome their negative feelings and discover some of their educational needs.

RESULTS
The mean age of the participating doctors was 38.79±5.84(range 30-53).
Table 1 shows characteristics of the participating doctors.Twenty eight out of seventy (40.0%) participating doctors had experience in the practice more than 10 years.The majority were female (78.6%) and married (91.4%).Slightly less than half of them (45.7 %) were consulted by more than 40 patients daily.Less than half of them (42.9%) had additional work responsibilities as trainers or being in charge of clinics.Their number was significantly high in those with more experience in the practice (71.4% vs. 28.6%).Those who are consulted by difficult patients on a weekly basis (42.9%) were more than those who are consulted by them daily (22.9%), monthly or more (34.3%).
Table 2 shows the number of doctors who agreed about certain patient characteristics which can render them difficult.Psychological factors (depression, anxiety and personality disorders) in addition to life stresses were major factors (95.7%) causing patients to be difficult.Most of them agreed that social isolation (87.1%), patients with multiple physical problems (78.6%),having a chronic disease (82.9%), and inability to communicate own needs (80.0%), unrealistic expectation of patient (77.1%) which was more significant (p< 0.05) in doctors with experience more than 10 years in the practice, and previous bad experience with health providers (82.9%) can make patients difficult.More than half of them agreed that being single (58.6%), terminally ill (67.1%), physically crippled (61.4%), and mentally handicapped (67.1%) were reasons for patients to be difficult.
Table 3 shows factors related to doctors' that lead them to perceive some patients as difficult.The majority of the sample (81.4%) agreed that greater work load was an important factor.Other reasons included lack of job satisfaction (72.9%), lack of training in counseling skills (78.6%), deficiency in communication skills training (74.3%) and psychic condition of the doctor (68.6%).More than half of studied doctors agreed that doctors' social life stress (58.6%) affected their perception.Doctor's illness (54.7%) and lack of interest in dealing with some medical problems (45.7%) were noticed to be less important factors.the absence of strategies to deal with difficult patients (91.4%), lack of a legal policy in the clinic (82.9%), improper appointment system (81.4%) and free health services (82.9%) caused patients to become difficult.Most of them agreed that unavail-ability of social workers in the clinic (72.9%), poor team work (70.0%), no registration to a single doctor (80.0%) and untrained receptionists (71.4%) were also important reasons.The key finding of this study was the consensus of the participating practitioners that there is a diverse number of reasons causing patients to be difficult, rather than only patients' characteristics.

DISCUSSION
Patients with psychiatric problems came at the top of the list of all factors that cause patients to be perceived as difficult by their doctors which was in consistence with other studies (13,9).These patients need a lot of counseling and versatile communication skills in addition to the support of social workers.Doctors may find these requirements time consuming in their busy practice and they may not be trained enough to acquire these skills.Family doctors may be in need to refresh their training in psychiatry (14,15) by attending appropriate continuous professional educational programs.It also highlights the importance of availability of social workers in the practice, or easy access to their services.
The main social characteristic of difficult patients agreed by doctors was social isolation, which had been proven in previous studies to increase the risk of depression (16).Patients with frequent life stresses reported a high range of anxiety, depression, and psychosomatic symptoms (17,18).This explains why these patients are perceived as difficult.
Patients with chronic health problems and those with multiple physical problems were considered by a large number of doctors as difficult which was consistent with other reports (19,20).These patients pay extra visits to their doctors and are more vulnerable to psychiatric problems (21,22).These factors were viewed by physicians as an additional load during consultations.Availability of local protocols for the management of various chronic problems, enhancing clinical skills by prioritizing dealing with patients' problems and regular case discussion with the team can help doctors in managing and dealing with these patients.
Terminally ill patients are at risk of developing psychological problems which make them harder to manage alongside their serious physical problems.These patients require a multidisciplinary approach in their management as the family doctor will be unable to bear the entire burden alone.The majority of doctors agreed that patients with unrealistic expectations were difficult which was in accordance with other reports (23).This was highly significant in those with 10 or more years experience in the practice.
Our explanation is with experience, practitioners tend to identify the patient's needs rather than his desires, therefore in many occasions they find it hard to respond to unnecessary demands and consider such situations difficult to manage.
Patients who were unable to communicate their needs were deemed difficult by a large number of participating physicians.These patients usually need a practitioner with good communication skills, especially in observing and analyzing patient's non verbal actions.Patients with bad experience with health providers were difficult patients to most participants.This is expected, as these patients will be distrustful and hardly ever satisfied with the health care given.This will affect the doctor patient interaction, and many consultations with these patients will end ineffectively.Doctors need to regard this issue and be understanding of this background factor.
Participating doctors believed that the greater the work load and lack of job satisfaction, the more heart sink patients he or she is likely to report which was consistent with other studies (8).Being involved in various practice activities such as audits, researches, and journal clubs can improve doctors' morale, in Participants agreed that lack of training in counseling and communication skills can make them perceive some patients as difficult in concordance with other reports (24).This raises the importance of redirecting some of their continuous professional programs to fulfill these gaps.These are not exclusive skills acquired in undergraduate or postgraduate vocational programs but they are continuously needed skills especially for family doctors.
Almost half of them agreed that stresses in doctor's social life as well as having any psychological illness made them vulnerable to viewing their patients as difficult ones which was reported in other studies (8).This is a natural reaction as these factors hinder the doctor's intellectual function and mental wellbeing which are essential during a consultation.Doctors in these situations should delegate some of their workload if possible.Availability of counseling services for health care givers can help physicians in such circumstances (24).
Participants agreed that practitioners who dislike dealing with certain medical problems perceive patients as difficult.Doctors always prefer to deal with certain favorable health problems and feel confident in managing them as well as instinctively attending meetings and updating their information on subjects that they like and are familiar with.The relatively new concept of continuous professional development depends on a learner's personal experience and is self directed towards satisfying a doctor's educational needs.This concept can help to resolve this predicament.Consequently, dislikable medical conditions could become more intriguing for doctors.
Many of the factors related to the system, which most doctors agreed about, were also related to patient and doctor factors.Unavailability of direct social services in the clinic can increase the burden of patients with psychological and social problems.
Improper appointment system and non registration to a single family doctor encourages doctor-shopping behavior and increases the workload on the physician.This will contribute to the doctor viewing patients as difficult and complicated medical problems will be hard to manage in a short consultation time.
Absence of a strategy or a legal policy directed towards difficult patients in the clinic makes dealing with such patients difficult.Creating a protocol for identifying and managing difficult patients should be part of the team activity.This should include all reasons whether related to patients, doctors or the system and should be relevant to the clinic, as there is some variation between different practices.
Untrained and amateur reception staff poses a problem especially in the national health services as doctors have no role in their recruitment.They may not handle the patients wisely, and may affect the morale, attitudes and temperament of the patients (25).This will possibly negatively affect the doctor patient interaction.The size of the problem is ambiguous but the recommendation is that they have to be involved in continuous professional educational programs appropriate to their needs and to satisfy the requirements of the practice.
Free health service is a political issue which is very difficult to solve.On one hand charging patients may reduce the frequency of consultations, but on the other hand it will not solve their underlying problems.
In conclusion there is a triad of factors affecting the doctor-patient interaction, the patient, the doctor, and the system.Doctors' analysis of every difficult patient encounter and attempting to identify the causes behind it, may bring some understanding and help them overcome and accept their feelings towards these patients.Physicians need to enhance their skills in managing different psychiatric problems.It is necessary to allocate some of their continuous professional development to develop their communication, counseling competency and consultation skills.There must be more support from social and counseling services in primary care.These solutions will not solve the problems of difficult patients entirely, as it is unlikely that they will ever be cured.
Limitations of the study included reflection of only the physicians' point of view of difficult doctor patient encounters.Additional studies are needed to explore the views of patients, receptionists, other paramedical staff and those involved in the management of the system.This will refine and sum up all aspects of this dilemma, and undoubtedly will help the implementation of the suggested solutions.

Table 4
demonstrates factors related to the system that leads to perceiving patients as difficult from a doctors' point of view.The majority agreed that

Table 2 .
Number of doctors who agreed about the patients' factors that can make them difficult.

Table 3 .
Doctors who agreed about physician reasons that can make patient perceived as difficult.

Table 4 .
Number of doctors who agreed about system factors that can make patients difficult.