Whether it be a physician, nurse, physical therapist or social worker, health care providers of every kind will often have patients on their service with such serious quirks that the quality of their treatment and recovery may be at risk.

Practitioners will especially have their hands filled when caring for individuals suffering from axis II (personality) disorders who have little insight into their behavior. Other compounding factors such as drug addiction, medical phobias, and fixed alternative views of health care can add additional barriers to the treatment of these patients.

It is therefore essential for providers to have a few tools in their belts before stepping in to meet their next difficult patient. Below are some ideas to consider.

Being a patient is an emotional roller coaster.

It’s not easy being a patient. Trust me.

Although the pricey hospital rooms come with a full range of personal staff along with meals in bed, a prolonged stay at your nearest medical center is the furthest experience from that of a five-star hotel. Not only are you confronted with and constantly reminded of your serious illness, but you are also poked and prodded throughout the day and night by doctors, nurses, phlebotomists and anyone else remotely involved in your care. Often, your sleep-wake cycle is so disrupted due to this relentless attention that you may experience extreme fatigue, emotional lability, and depending on your age and condition, delirium.

Despite this, patients are still unfairly expected to be acquiescent if not grateful to the medical staff during their period of hospitalization.

It is therefore paramount as practitioners to step back and recognize the immense amount of emotional stress exacted on your patients throughout the course of their hospital stay. This is an especially important concept to recognize when caring for the patients on your service who truly test your nerves and ability to empathize.

It’s okay to say no.

When dealing with manipulative patients, you must remember that your job is to provide appropriate care (discussed later) rather than to be at their constant beck and call.

A patient has the right be involved in their medical decision-making, but by no means should they use that right for malicious gains or for unreasonable demands.

This is especially true if these requests can do harm. A classic case that illustrates this point is when a physician submits to a demanding patient by administering a much higher dose of opiate pain medication than recommended, ultimately causing the patient to go into respiratory depression (hypoventilation) and necessitating emergent assisted breathing and immediate transfer to the intensive care unit. Although easier said than done, saying no can avoid such needless travesties.

Some quick tips on saying no to a difficult patient: be direct, encourage open dialogue, explain the reasoning behind your decision, and make the rest of the patient’s health care team aware of this discussion in order to reduce any chance of miscommunication.

Each and every patient has the right to appropriate medical care.

Regardless how intrinsically selfless, accepting, kind, and tough-skinned of an individual you are (and as I picture you to be), there will be difficult patients down the road who will make every step of your treatment goals a marathon to accomplish. Some will try to negotiate real care for malingering gains while others will flat out become disrespectful to the medical staff. There will be times where patients will refuse certain treatments without explanation or demand to walk out against medical advice even in their most de-conditioned state.

Despite this, and as cliché as it sounds, you must have the intention of treating every one of your patients as you would treat your family members. Each patient on your service, regardless of his or her behavior, deserves appropriate medical care.

The distinction between appropriate care vs. ideal care in the setting of treating difficult patients is that their challenging behavior may not allow them to receive ideal care.

Consider the following: After much education, exploration, and gentle persuasion, a patient on your service continues to refuse a certain standard-of-care antibiotic for his or her pneumonia. It is appropriate in this scenario to treat this patient with an agreed-upon second line antibiotic that may be less effective. (Of note: It is important to document these management decisions in order to have it on record.) Although not ideal, this strategy far surpasses the deliverance of unwanted care or no care at all.


A friendly reminder to those just starting out in their respective health care positions: Your patient demographic will not be solely be made up of sweet old grandmothers telling you how lovely you look in scrubs or a white coat.

Throughout your (very successful) career, you will at times be confronted with bizarre patients, incorrigible patients, and yes, patients that you may not like (I said it!).

Do not go in blindly into these hospital rooms without a plan. It is these situations that become breeding grounds for inadequate care, medical errors, and subsequent malpractice suits.

Instead, remember to empathize, know when to say no, and treat these difficult patients with appropriate medical care.

And if after this successful care you still feel the need to shake your fists at the world, make sure to swing by sweet old Mrs. M’s room to receive a much-deserved pat on the shoulder.

Brian Secemsky, M.D.

Medical writing for patients, students
and practitioners.

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