Dr. Tony Miksanek, a small town physician in Illinois, describes varieties of difficult patients in this week’s Health Affairs. He describes types that many physicians may recognize:
- the self-reliant “know-it-all” who renders his physician ineffectual by not following medical advice, showing up sporadically, and relegating the physician to functioning as “pen and prescription pad”;
- the “worried well” hypochondriac, who constantly pesters her physician with phantom and non-emergent problems, is convinced that there’s something wrong with her, and seeks medically unnecessary care (“testophilia,” i.e. a love of diagnostic tests); and
- the pain-in-the-neck patient, paranoid about insurance coverage, whose pessimism about his recovery prospects becomes contagious.
Dr. Miksanek offers suggestions on how to handle these “problem patient” archetypes.
Recommended Action: Providers who encounter these patient archetypes may find Dr. Miksanek’s perspective (below) helpful:
How not to care for difficult patients is pretty obvious: Don’t brush them off. Don’t use “stress” as a diagnosis for unexplained symptoms unless you’re 99 percent sure that anxiety is an accurate diagnosis and not just a cop-out. Don’t be angry. Don’t be punitive. Don’t propagate despair.
How to care for difficult patients? Inside my office, I know that it involves protocols and limits, truth (including knowing when to admit “I don’t know” to yourself and your patient), information and resources, and goals for reasonable results. In my heart, I know time is key. Time is a precious commodity subject to the laws of supply and demand. Difficult patients require more time. Busy doctors find that time is in short supply. Difficult patients are at risk of becoming casualties of the almighty schedule. A fifteen-minute time slot is hardly enough for complicated patients. No one would make a major decision—choose a spouse, buy a car or a house, select a college, pick a job—after only fifteen minutes of deliberation. Why then do we cram important decisions about personal health matters into fifteen-or twenty-minute appointments?
What exactly drives the office schedule of a doctor and dictates how much time is allotted each patient? Multiple considerations, but the big ones include patients’ needs, reimbursement, practice volume, hospital responsibilities, a doctor’s energy level, and the office staff’s desire to get a lunch break and still make it home by 6 p.m. When one is dealing with difficult patients, a good case can be made for longer but less frequent office visits.
Extended visits would likely improve patient and physician satisfaction, improve compliance, and upgrade the quality of care. Providing people with more face-to-face time with their doctors does more than merely help communication. Longer visits might actually be more cost-effective than brief ones by reducing the need for frequent follow-up appointments, curtailing the number of consultations and second opinions, decreasing excessive testing, cutting down on the cost of transportation and gas consumption necessitated by repeated short visits with the doctor, and minimizing the amount of missed work for numerous appointments. In this sense, lengthier visits are a bargain. Too bad insurance companies and other payers don’t see it that way.
As with all things, unfortunately, identifying the challenge — a broken compensation system that drives doctor-patient interactions into brief allotted visits without sufficient time to develop relationships, discuss issues, and reach considered decisions — is easier than getting to the solution.
Harry Nelson is a partner in Fenton & Nelson, LLP. Fenton & Nelson counsels physicians and other healthcare providers on regulatory compliance and business matters, including informed consent and practice management. For additional information, please contact him at harry@fentonnelson.com
©Harry Nelson 2008
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