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I quite often receive invitations to attend workshops on ‘dealing with difficult patients.’ I am also asked to run them myself as an educator. I always say no. By inclination and training, I believe that if you assume certain people are ‘difficult’ by nature, rather than appearing so because of their context and circumstances, you have already lost half the battle. My own experience with patients who have seemed difficult at first is that many have turned out to be the most rewarding to work with. I prefer to understand dysfunctional communication in terms of interactions that are flexible, rather than personalities that are fixed. That is not to say that patients cannot behave in ways that are challenging, including being angry or rude. Rather, it is to accept that the real challenge is usually how to remedy the situation by the way you respond. This perspective is taken for granted in fields like counselling, mediation, social work or therapy. In those settings, ‘difficult’ behaviour is recognised as a being a common result of adverse experiences or former encounters with authority, and as a consequence of feeling powerless.1 At root, it signifies suffering and frustration with the failure to relieve it.
It was therefore refreshing to receive two invitations recently that turned the traditional approach on its head, by asking me to take part in events focussing on ‘difficult doctors.’ These invitations – and the conversations that followed – prompted me to consider how we might take a similar dispassionate perspective on ‘difficult doctors’ as well and try to understand what makes us difficult ourselves in the view of many people.
Ways of thinking
There may be specific reasons why doctors can be as difficult as anyone in other walks of life, or possibly more so. In order to become a doctor, you need to be more intelligent than average and more ambitious, competitive or even driven. This may incline you to be self-critical, but also critical of others.2 At medical school, you will be the recipient – some would say the victim – of a training that is gruelling, and which institutionalises you into ways of thinking and speaking that are significantly different from most people you will see as patients. This may well impair your ability to communicate with them, in a way that will make you seem difficult in their judgement, even if you are not aware of it. Although medical students now receive training in communication skills and on how to listen and receive feedback, the role models they see and the so-called ‘hidden’ curriculum are likely to counteract this with subliminal messages that reduce their empathy.3
Once qualified, doctors are likely to work in contexts that are pressurised, stressful, hierarchical, and with a shortfall between the health needs of the population and the services you are enabled to offer. None of these conditions are likely to incline you to saintliness. Indeed, it may be a miracle if they do not predispose you to impatience, irritability and even arrogance. This is perfectly obvious to almost anyone outside medicine. (You can check this out with non-medical friends.) A significant proportion of the narratives you will hear socially, or see on social media, will concern doctors who have been inattentive or dismissive, said offensive things, made mistakes, or behaved wrongly in other ways. Such stories often concern incidents where doctors have wielded arbitrary power but seemed oblivious of doing so. Or they relate to dysfunctional systems (for example, never seeing the same doctor twice, or poor communication between different departments) which many patients rightly find unacceptable but doctors largely tolerate.Many patients nowadays will expect healthcare providers to behave like a service industry, attending to them courteously, and responding positively to complaints. All of this is often ignored within the medical world itself, where accounts of medical heroism and troublesome patients are far commoner than confessions of miscommunication, moral failure or poor performance. It is not easy to persuade members of our profession that difficult doctors, or doctors behaving in difficult ways, may actually be a more endemic and intractable problem than difficult patients.
If we look at medical encounters in this light, the business of ‘dealing with difficult patients’ appears rather differently. I should emphasise that I am not talking here about flagrant misbehaviour on either side, where it may be necessary, for example, to sanction a patient for threatening staff or discipline a doctor for bullying. I am referring instead to the ordinary, everyday practice of medicine. What we observe here, day in and day out, are conversations between two imperfect individuals (one a patient and the other a doctor), each trying to overcome considerable personal or professional handicaps, in circumstances that are very often far from ideal. The pressure to succumb to exasperation on the patient’s part or to a lapse into incivility on the part of the doctor is great, and it is continuous.4
The crux of the matter, however, is this: doctors are paid to help patients, and not the reverse. Patients expect us to try and help with their own predicaments and are not necessarily sympathetic to ours. Naturally, some patients will be more kindly disposed towards us than others, and some will be more willing to make allowances over such things as waiting times or other problems that may be beyond our control. But such kindness on their part is discretionary. There is nothing in the implicit contract between patient and doctor that requires it. By and large, it remains our responsibility and not that of our patients to reflect on difficult encounters, apply curiosity into what it going on, and develop insight into the difficulties that we may have brought to the situation.
A wise teacher once told me: ‘the only person in the room you can ever change is yourself.’ Many patients stop appearing ‘difficult’ when doctors recognise they have legitimate reasons for feeling upset and critical, allow them to express their grievances without foreclosing the conversation, acknowledge individual and systems failings, and are willing to apologise for these. When people who come to us for help appear difficult, they are unlikely to change unless we first show our own ability to change.
Patient consent for publication
I want to thank Dr Muiris Houston for the invitation that prompted this article, and for his comments on an earlier draft.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; internally peer reviewed.