Introduction
Difficult patients are the bane of many
physicians' professional existence, trying their patience, testing their
limits, and challenging their ability to provide care.
Some people restrict their understanding of
"difficult patients" to those who are noncompliant with their
physicians' orders or advice. This is a surprisingly sizable group.
According to one study, only one-third of patients are compliant with a
prescribed treatment regimen.1 That is, they keep scheduled
appointments with their physician, they have diagnostic tests performed,
they seek out suggested referrals, they follow instructions for
post-procedure care, and they take prescribed medications as
directed.
Fully two-thirds of patients are noncompliant.
Communication issues may be responsible for the behaviors of half that
group, or one-third of all patients. They simply may not understand what
to do, how to do it, or the importance of doing it. Those in the other
half of the noncompliant group are noncompliant by choice.
Who are these patients and why do they persist
in misusing or even abusing the physician-patient relationship? They may
be dealing with job loss, economic crisis, or crushing family
responsibilities that make compliance with a treatment regimen only one
more burden. Perhaps they are so in need of attention that even the
anger or frustration of the physician fills their emotional vacuum.
Perhaps they doubt the efficacy of the treatment regimen because of
stories they have been told by friends or relatives. Perhaps they have
ethnic practices that conflict with the prescribed regimen. Perhaps they
fear "bothering the doctor" with questions they need to ask and concerns
they deem unimportant. Perhaps they are simply willful, demanding, and
defiant. Or perhaps not.
Perhaps, instead, the problem is not the
patient's but the label attached to him/her. In the medical arena,
compliance has traditionally indicated the extent to which a patient has
cooperated with the physician's treatment plan. But what if the
treatment plan reflects only the physician's goals and omits the
patient's? And what if the patient is compliant with another, unspoken
treatment plan about which the physician has asked no questions and has
no knowledge?
This course looks at difficult patients, not
only those deemed "noncompliant" but also those who make unrealistic
demands, those who exhibit abusive behaviors, and those who fail to pay
bills. It examines some of the reasons that may underlie the behaviors
of these patients. And it proposes some risk management strategies to
help physicians better work with those patients who seem, but do not
choose to be, difficult while at the same time minimizing the risk of
liability represented by those who persist in the behavior that earns
them the label "difficult."
1 Stein, R. Noncompliance in the Treatment of
Chronic Disease. LeNurse, Inc. Available at
www.lenurse.com/articles/article6/. Accessed 30 Sept. 2003.
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