Dealing with the Difficult Patient: When Bad Patients Happen to Good Doctors

Director, Laser & Cosmetic Dermatology, The Mount Sinai Hospital; Associate Clinical Professor, The Icahn School of Medicine of Mount Sinai; Private practice, Waldorf Dermatology & Laser Associates

At the American Society for Dermatology Surgery (ASDS) meeting, one of the more popular sessions year after year is a panel called “When bad things happen to good doctors.” Even the most highly skilled and vigilant among us will have a complication at some point during our career. But what about “When bad patients happen to good doctors”? Surely we've all encountered what we often diplomatically term the “difficult” patient. Every physician has recounted a tale of a patient encounter that went sour to a group of colleagues shaking their heads in understanding.

In a perfect world, we, and better yet our staff before we enter the exam room, will feel the tingle of our finely tuned “spidey senses” and find a politic way to avoid doing an aesthetic procedure on someone you suspect will be uncommonly “difficult.” Unfortunately, many do get through our early warning mechanisms. Once the physician-patient relationship is established, the physician has an ethical and legal obligation to take care of that patient for what is termed “a reasonable period of time,” often defined as 30 days, after giving written notice of dismissal.

Just as we prepare strategies to deal with procedural complications, it is wise to consider how you and your staff will deal with problematic patients. We can't control everything, but the less left to chance, the smoother our day.

Types of “Difficult” Patients

I divide difficult patients into four categories:

• The Overly Anxious Patient
• The Patient With Unrealistic Expectations
• The Patient On A Mission
• The Angry Patient

The Overly Anxious Patient is the most benign of this group but can sap a significant amount of your and your staff's time. This is the patient who asks the same questions again and again, before and after every appointment, by phone and when in the office. My favorite is the patient who goes through one or several thorough discussions about a procedure and plan with me and my staff, agrees to it, and then just as I am ready to start asks, “But is it dangerous?” Depending on how well you know that patient, this could be a sign to postpone the procedure. However, I find most of those patients just want reassurance. Many are long-time patients who have had numerous procedures and clearly trust me and my staff. However, if there is any concern that informed consent hasn't been obtained, including answering all the patient's questions, the procedure should stop and the concerns reviewed again. Warn your staff to be ready for hourly or daily calls after the procedure and to treat the patient kindly and seriously. It is often easier just to “prophylactically” set up extra follow up appointments

Watch Dr. Waldorf discuss strategies for dealing with difficult patients in the latest edition of Heideas for Aesthetic Practice, available on ModernAesthetics.tv

The Patient With Unrealistic Expectations is often difficult to detect before treatment. In the filler world, these are often the “10-01” folks—the ones who need 10 syringes of something to get to their goal but feel they should only have to pay for one syringe. They say they understand when you tell them what they will need and that starting with less will mean less meaningful results. But at follow-up they lament, “But I thought it would be better than this,” or, “I expected that line to be gone,” despite an excellent outcome. Document what you recommended and be sure that your staff echoes your words. If your message has been consistent and you have good before and after photos to review with the patient, it is possible to convert them to happy and satisfied either with what has been done or a realistic continuing treatment plan. If the patient is still unhappy, be sure that you understand what still bothers her–don't assume it is what you were treating last time. If what still bothers her is something that the first procedure didn't or can't address, then suggest what will. Unfortunately, there are patients who insist that neither they nor family nor friends can detect any improvement despite what you and your staff see as great visible and photographic results. This is the person you cannot help. Do not apologize for the results. Instead say something to the effect of, “I'm sorry that you aren't pleased with the results that we appreciate. Unfortunately if we aren't seeing the same thing, I don't think that I can provide what you are looking for.” At that point, you generally uncover if the patient truly does not appreciate the results or if he or she is actually a member of the next category.

The Patient On A Mission wants to pay as little as possible and get as much as possible. The patient who insists she sees no improvement may just be needling for free additional treatments. Unless the results have surprised you by being less than you anticipated, just say, “No.” Clearly review the original plan that was discussed with the patient before treatment, including the need for ongoing care. I will tell the patient that given what was done, she is right on target and the next step for additional improvement as we move toward the goal is more treatment, now or later. Someone in the office must politely remind the patient of the anticipated cost of any additional treatment. Other patients on a mission dismiss the value of what you've done, whether it is evaluating them and making a treatment plan (“But you didn't do anything!”), or those who say after a procedure, “But it only took five minutes—it shouldn't cost so much.” When I hear this, I quote one of my colleagues and say: “Five minutes and 20 years of training and experience.” Also in this category is “the haggler,” a patient who asks for a discount all the time, often with some sad story. One recent patient told me, “But I'm going through a divorce,” to which I responded that I understood but that most of my patients are going through something difficult. She responded, “Yeah, that's what my divorce lawyer said, too.”

The final patient category is the most difficult to manage: The Angry Patient. If the patient is angry but for a reasonable reason—like you are running late or someone did not give full instructions—it is important to listen, apologize, and assure the patient you will review what happened so that it doesn't recur. A small gift like a sunscreen or cosmeceutical product is often appreciated and goes a long way to show you are sincere. However, if the patient is excessively angry or even abusive toward you or your staff, there may be nothing you can do. The anger may stem from the patient being a member of one of the first three categories whose goals haven't been satisfied. It's also important to consider that it may have nothing to do with you at all. It is critical to get this patient out of the waiting room or away from the reception desk and into an exam or consultation room as quickly as possible. Time spent in a public area feeds the flames because there is an audience for the anger. Sit with the patient and a member of your staff calmly and listen. One of the hardest things to do is to sit quietly while someone else tells you how horrible you are, but it is necessary. Use a technique called “reflecting”: Paraphrase and restate the feelings and words of the speaker, as in “I'm hearing you say that…” Reflecting confirms you are indeed hearing the patient both for you to figure out the issue and for the patient to feel acknowledged. Document what was said and who was in the room with you. And make sure your staff takes post-treatment photos—even if it is done while steam is coming out of the patient's ears. If the patient is litigious, you want to have documentation of your results.

The Feeling Spectrum

No physician would go to work everyday if most patient interactions weren't positive. The satisfaction that comes from helping other people is still a major draw of medicine as a career. Patients are as diverse as the population—some have auras so happy you can feel them on the other side of the door; others, less so. And most, like us, are people who are reasonable and have good and bad days. So don't let the bad eggs spoil the dozen for you.