We all have patients who are more challenging than others. You see their names on your schedule, and you moan quietly while taking a deep breath. Sometimes the stress starts before the first visit. Then you read their chief complaint — and it’s something like “need early refill on my Xanax and Adderall.” The heartburn starts.
Every specialty has its fair share of challenging patients. If you aren’t mindful of how you approach these encounters, they can lead to excess worry, burnout, and the perpetual landmine of fiery google reviews. Over the years, I’ve developed a few go-to techniques for handling these interactions.
1) Listen more, talk less.
There’s an old proverb that goes, “You have two ears and one mouth — use them in those proportions.” With taxing patient interactions, it helps to follow this advice. Everyone loves to talk about themselves. Just the simple act of active listening with thoughtful follow-up questions will help you get off on the right foot with most folks. Even if you don’t agree with the patient’s perspective or request, active listening can accomplish the strikingly effective Jedi mind trick of you coming out of the encounter unexpectedly liking the patient. I once saw an 85-year-old new intake with a chief complaint of “I need more Xanax and a higher dose.” Just reading the age and the request, I could feel myself getting tachycardic. With her advanced age, increasing the dose of a highly addictive and sedating narcotic would be dangerous. (In the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults, Xanax comes up at the top of the list.)
During the course of my one-hour intake with this patient I learned she was an active ballroom dancer (at 85!), a part-time stand-up comedian, and an expert quilter. Even though I did not acquiesce to her Xanax request, we had a surprisingly pleasant appointment. I learned about the person and the story behind the request. She would continue to ask me for Xanax every three months for the next five years. Although my answer on the Xanax never changed, I always enjoyed our appointments as I learned more about the sprightly 85-year-old.
2) Be curious.
As an addiction psychiatrist, I frequently see patients whose first words are “I’m not stopping the heroin.” When I hear unsafe and contraindicated patient requests like that, I have to fight against the urge to stand up and show the patient the door. To handle these patient requests effectively, then, I try to approach the interaction from a genuinely curious perspective. I’ll say things like: “Tell me more about your relationship with heroin? What are your biggest fears about heroin? What do you want to change (if anything) about your relationship with heroin? What brings you to this appointment?” Coming from a place of curiosity instead of judgment puts rocket boosters on the otherwise slow process of enabling psychological safety. It shows patients you care about them, and that you’re a helper, not a harmer. Additionally, it gives patients the green light to be honest. Depending on the appointment content, honesty might be a desperately needed feeling and skill they have not practiced in a very long time.
3) Find something you like about the patient.
Even if you curiously listen more and talk less, there are inevitably patients you just plain don’t like. This feeling sometimes originates not so much from the content of the request but the way in which the request is delivered. They are rude. They are loud. They interrupt. They are late to the appointment (my ultimate pet peeve). Your dislike could also have more subtle and unconscious origins.
Countertransference occurs when you project positive or negative feelings onto a patient based on traits or characteristics that remind you of someone in your own personal life. For example, I really looked forward to appointments with one of my patients because she looked so much like my mother and played the piano like her. Conversely, I dreaded appointments with another patient because she had the same nasally voice of a mean math teacher I had in high school. When you find yourself disliking a patient despite active listening and curiosity, it sometimes helps to consciously look for something about the patient that you do like, identify with, or respect. People are complex. Rarely is someone all good or all bad. If you look hard enough, there is always something you can find to like about someone. I once had a patient who asked me for very early refills on her stimulant medication every time I saw her. I loathed these interactions. I desperately looked for something likable about her to dilute my perpetual frustration with the same tiring conversations about early refills. Over time, I learned that she was a single mother of four working three jobs and living in a dilapidated trailer in the Shenandoah mountains. Although I never relished the conversations about controlled substances, I admired her work ethic and could relate to her rural upbringing. Keeping this in mind, I did not completely dread my interactions with her.
4) Practice proactive self-awareness, and “widen the gap.”
We cannot control the thoughts or feelings that pop into our mind (sometimes appropriately called “automatic thoughts”). We can control how we respond to them. Sometimes the most powerful way to control our thoughts and feelings about challenging patients is simply to be aware of them in the first place. In the minutes before I see a challenging patient, I close my eyes, take a deep breath, and tell myself “Watch for clouds. The storm is coming. You got this.” This is a ritual that helps me consciously remember that I might get frustrated, but that I also know how to control my emotions versus letting negative emotions control me. Some folks call this “widening the gap.” By simply being aware of your emotions, you lengthen the amount of time or “gap” between automatic negative emotion and your potential to act from a place of unbridled feeling versus neutral, calm logic.
5) Plainly state that you disagree.
At the end of the day, even if you regularly practice all four of the techniques above, there will still be times you have to decline a vehement patient request or demand. This is inevitable in medicine. I used to oversee callback requests to unhappy patients with complaints about their recent health care experience. Sometimes, the patient would demand things I simply could not agree to. “I need a six-month supply of my Adderall.” “I am not going to complete those urine drug screens but I want my Suboxone prescription.” In situations like this, it helps to say, “We will need to agree to disagree on this.” It is the most polite, professional way of saying “No.” In a gentle but unambiguous way, it communicates that you understand your position differs from theirs, and yet you cannot accommodate what they want. When we communicate clearly and specifically, we give our patients the gift of professional honesty and integrity.
Albert Einstein famously said, “In the middle of difficulty lies opportunity.” Try to view each challenging patient as an opportunity to grow your listening and communication skills, master emotion, and learn more about different perspectives. The storm will come. Some days it will rain much harder than others. But you have all the rain gear you need to sail through to sunny days.
What techniques do you deploy when dealing with difficult patients? Share in the comments.
Lauren Grawert, MD is a double board-certified addiction psychiatrist. She received her medical degree from Medical University of South Carolina College of Medicine and has been in practice 15 years. She speaks multiple languages, including Spanish. She was chief of psychiatry at Kaiser Permanente of the Mid-Atlantic from 2018-2022. She is currently the CMO at Aware Recovery Care. She enjoys working with the media in her spare time to reduce stigma around mental illness and addiction. She has been interviewed by SAMHSA on co-occurring disorders and most recently published articles in Capital Psychiatry and Northern Virginia Magazine.
Patient details have been changed to protect privacy.
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