Ten challenging patients (and how to tackle them)

I had a first the other week; I shouted at a patient over the phone. I deal with angry patients on a daily basis but somehow, on this occasion, something snapped.

You may be aware of the acronym ‘HALT’ – hungry, angry, late, tired – which tend to be precursors to a dysfunctional consultation. And on this day, I had all four. I was hungry because I had not eaten lunch. I was angry because I was the duty doctor on our busiest day, and we were four GPs down. I was late because my morning surgery took longer than anticipated, and I was tired because I was up in the middle of the night with my five-year-old daughter who was sick.

Developing good consultation skills underpin everything we do, lead to increased doctor and patient satisfaction and result in fewer complaints. It is ultimately an art to actively listen to the patient, while also actively managing the consultation. It is as if GPs have to first split their brains into two parts which work concurrently, and then merge the two halves again at the end of a consultation. But as a GP, you are the master of this skill.

Here are some of the most common patients and challenges you may face in everyday clinical scenarios and how to address them.

1. Angry patient

There are many reasons why a patient may be angry. They may have had access issues, perhaps no one has got to the bottom of their illness or, more commonly, they may just have a life that causes them to feel that way.

Anger doesn’t erupt out of nowhere and the signs are usually there as the patient arrives. If you acknowledge some of these signs early on, patients feel they are being taking seriously and listened to.

And although anger can set off a reflex adrenaline response, it is unlikely that the anger is directed at us personally; we are normally just the outlet for the patient’s expression. It is therefore important to keep some of our own emotional reactions in check and control that ‘inner chimp’.¹

• Key strategy: Set boundaries
• What to say: Nothing – listen calmly, then acknowledge their anger
• If that doesn’t work: It is important to assert boundaries at this stage, ranging from advising the patient how their behaviour is making you feel, to stating the consequences of continuation of this behaviour.

2. Patient in pain

Pain has always held a fascination for me. There are so many facets to it, and none more fascinating than our psychological appraisal of it. But regardless of the underlying causes or maintaining factors for a patient’s pain, it feels very real for them. It is irrelevant how much of the pain is ‘organic’ and how much is ‘psychological’; it is important to acknowledge their suffering and negotiate a plan to manage it.

Doctors often have a mistaken belief that when patients complain of pain, all they want is stronger analgesia. Often, what they want is empathic listening.

• Key strategy: Show empathy
• What to say: ‘It sounds like this pain is having a profound impact on your life. What can we do to help?’
• If that doesn’t work: However challenging, try to maintain a positive regard for the patient and take the time to understand their life and what it must feel like to step into their shoes and walk around in them, as Atticus Finch said.²

3. Patient armed with a ‘shopping list’

I understand why patients do this; they’ve waited three weeks for an appointment and are unaware you have patients booked at 10-minute intervals. There is no point getting frustrated at them – they need an explanation and negotiation.

There are two types of ‘shopping list’ consultations: overt and covert. For the former, acknowledge the list, explain time constraints and ask the patient to prioritise one or two things, having advised what is achievable in a single appointment. 

The covert list is when a patient springs new problems on you after you have been consulting for 15 minutes. You can address all their problems and run late, you can advise them to rebook but risk missing a red flag or something that was important to them, or you can begin the consultation by asking if they have any other issues they want to discuss.

• Key strategy: Negotiate
• What to say: ‘I feel I will not be doing a thorough job if we try to deal with more than one issue today and I want to cover things properly’
• If that doesn’t work: You can book patients in for double appointments if they always have a lot of issues to get through

4. Complex comorbidity patient

I doubt comorbidity would have been much of an issue 20 years ago, when secondary care followed up all patients with long-term conditions. But these days, patients with complex comorbidities are like unwanted visitors, and hospital managers put enormous pressure on consultants to discharge them. But as patients live longer, and survive long-term conditions, we need strategies for managing complex patients in primary care.

The obvious solution is establishing continuity of care with a named GP. It is also imperative to prioritise clinical problems – you can’t deal with all of their problems at once.

Red flags obviously need to be addressed immediately, followed by what is most important for the patient. You may need to chip away slowly while you get to know the patient.

• Key strategy: Establish continuity of care
• What to say: ‘What is troubling you most at the moment?’
• If that doesn’t work: Accept that you will run late and buffer your surgery with breaks to allow you the slack to manage these longer consultations

5. The ‘gimme’ patient

When patients demand medications or investigations, it is often challenging for GPs to manage this in a patient-centred manner.

But it should be a true partnership approach. There must be a balance between the doctor’s and the patient’s agenda so that the pendulum doesn’t swing between being overly prescriptive and overly submissive. The only management options that should be shared with the patient are those that are also reasonable for the doctor.

It can be hard for patients to understand why their requests are being declined, so we need to emphasise that the reason is based on their best interests.

• Key strategy: Have a discussion about their best interests
• What to say: ‘I’m sorry but I don’t think it is in your best interests for me to be prescribing you more sleeping tablets’
• If that doesn’t work: Take a minute to explain the consequences of repeated benzodiazepines or unnecessary scans

6. Self-destructive patient

Human beings self-destruct in all sorts of ways; the person with COPD who continues to smoke and the woman who overeats in spite of being too overweight for the fertility clinic.

What all these patients are likely to have in common is the inability to deal with emotional pain in a healthy and constructive way. Sadly, this cannot be taught in a 10-minute consultation.

It is easy for a GP to become subconsciously paternalistic under these circumstances, which can lead to dysfunctional consultations. Consider using motivational interviewing. It is not just a buzzword, the technique enables a doctor to remain detached while sowing seeds of reflection in the patient’s mind.³

Motivational interviewing has the added benefit that we will not see it as a personal failure if we are not successful.

• Key strategy: Use motivational interviewing
• What to say: ‘You mentioned earlier that you would do anything to see your kids again but you haven’t contacted the alcohol service. What do you think would help you right now?’
• If that doesn’t work: Accept you are a facilitator, not a fixer – if emotional baggage is placed on your lap, politely place it back on theirs

7. Patient with medically unexplained symptoms

When I first qualified as a GP, patients who had multiple somatic symptoms were called somatisers. This was a little unfair as we couldn’t be 100% certain that their physical symptoms were not indicative of an illness that was yet to be diagnosed.

Medically unexplained symptoms is a better term because it is not labelling the patient as ‘having it all in the mind’ and opens up the possibility of underlying illness. It is also a term that can be openly shared with the patient in order to decide on a management plan.

I am usually very honest about my appraisal of unexplained symptoms, advising that I cannot fit their symptoms into any kind of disease category that requires investigation. But l also explain that I will remain open minded about exploring new symptoms that arise.

• Key strategy: Be honest
• What to say: ‘At the moment, I can’t explain all your symptoms, but there is nothing that alarms me about them either. We need to keep you under review and have an open mind about doing more tests if anything changes’
• If that doesn’t work: Use the ‘best interests’ discussion (point 5)

8. The patient with unrealistic expectations

I usually find these patients the most frustrating, probably because their behaviour comes across as irrational at times.

It may be a patient demanding treatment that is not available on the NHS and saying you are doing nothing to help them. Or it could be a patient requesting an urgent appointment for their own convenience rather than an urgent clinical need.

I find it is useful to encourage the patient to draw up their own list of management options for their problems, which I will write down and perhaps add to. Once a list has been drawn up, we assess which options are achievable and the patient is empowered to choose one of those.

This approach takes time but it is worth it if you want to continue having a good long-term relationship with the patient.

• Key strategy: Let them create their own management options.
• What to say: ‘You have mentioned you want to be referred for laser hair removal on the NHS. What other things do you think will help you for this?’
• If that doesn’t work: Remain empathic while asserting the boundaries in which you work.

9. A new complex patient

These patients may be either new to the practice or new to you. Either way, when they present with a long history of a complicated neurological condition, for example, and want ‘something’ to be done about it, you may find it difficult to keep your cool.

If the patient is new to the practice, take a step-wise approach to information gathering and use the first consultation purely to listen to the patient’s concerns.

It is then important to book a follow-up appointment after reviewing the patient’s medical records in order to complete the assessment and consider the management option. In total, this may take three to four appointments.

If the patient is known to another GP, simply address any priority issues during the appointment and then direct the patient back to their usual GP (see also point 4).

• Key strategy: Use a step-wise approach
• What to say: ‘I don’t think I’m going to get to the bottom of this today. Do you mind if we book a follow up appointment as it will give me a chance to have good look at your notes and what’s been going on?’
• If that doesn’t work: If the patient has a potentially urgent issue which needs to be managed today, then arrange to call them back at the end of your surgery, when you have more time to look at the notes.

10. A non-English-speaking patient

Your first decision is whether to call an interpreter. This is not as easy as it sounds as the patient may speak some English and not feel an interpreter is required, or they may attend with English-speaking relatives.

But it is vital not to compromise the quality of your consultation. If you feel the patient’s English is not adequate or the family are not translating verbatim what you are saying, you need to either terminate the consultation or insist on an interpreter.

However, even with professional interpretation services, you cannot always be certain of their quality assurance.

Cultural differences within a consultation are equally important. Patients from many cultures often expect a far more paternalistic approach from their doctors than they get with British GPs. That is not to say a variety of management options shouldn’t be offered, but you must also respect a patient’s wishes for you to become prescriptive if that is expressed.

• Key strategy: Use an interpreter if necessary
• What to say: ‘You speak English well but we are having some problems with medical words. Is it ok for me to call an interpreter?’
• If that doesn’t work: Terminate the consultation. Do not compromise your consulting skills if you feel that you cannot assess a patient properly.

Dr Shaba Nabi is a GP trainer in Bristol