Difficult demanding and angry patients

There are patients in every practice who give the doctor and staff a feeling of 'heartsink' every time they consult.

Thomas O'Dowd 1988

Weston defines a 'difficult patient' as one with whom the physician has trouble forming an effective working relationship. 1 However it is more appropriate to refer to difficult problems rather than difficult patients—it is the patients who have the problems while doctors have the difficulties. Some characteristics of problematic patients, from the doctor's perspective, include:

• frequent attenders with trivial illness

• multiple symptomatology

• undifferentiated illness

• chronic tiredness

• negative investigations

• dissatisfaction with treatment, especially procedures

• non-compliant

• hostile or angry

• attending multiple therapists

• demanding on staff

• inconsiderate of the doctor's time

• taking multiple drugs

• seductive, then demanding

• manipulative

• taciturn and uncommunicative

Such patients are often referred to as the 'heartsink' patients, 2 referring to that certain sinking feeling on seeing them in the waiting room or their name on the booking list. They can provoke negative feelings in us and we have to discipline ourselves to be patient, responsible and professional. An inevitably poor consultation will follow if we allow feelings of hostility to affect our communication with the difficult patient, especially the demanding, angry or 'compo' patient.

However it is important not to misdiagnose organic disease and also to consider the possibilities of the following disorders, which may be masked:

• depression

• obsessive compulsive disorder

• bipolar disorder (manic depression)

• drug dependency

• alcohol abuse

• schizophrenia

It is therefore appropriate to maintain traditional standards by continually updating the data-base, integrating psychosocial aspects, carefully evaluating new symptoms, conducting an appropriate physical examination and being discriminating with investigations.

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