Patients with Challenging Behaviors: Internet Expertise

By Isabel N. Schuermeyer, MD, Tatiana Falcone, MD, and Kathleen Franco, MD

From time to time, all physicians encounter patients whose behavior evokes negative emotions. In 1978, in an article titled “Taking care of the hateful patient,” Groves detailed four types of patients — “dependent clingers, entitled demanders, manipulative help-rejecters, and self-destructive deniers” — that even the most seasoned physicians dread, and provided suggestions for managing interactions with them. The topic was revisited and updated in 2006 by Strous et al.

Now, more than 10 years later, the challenge of how to interact with difficult patients is more relevant than ever. A cultural environment in which every patient can become an “expert” via the internet has added new challenges.

This article further updates the topic of managing challenging patients to reflect the current practice climate. We provide a more modern view of challenging patients and provide guidance on handling them.

A medical degree from Google

A 45-year-old man carries in an overstuffed briefcase for his first primary care visit. He is a medical editor and recently worked on a case study involving a rare cancer. As he edited, he recognized that he had the same symptoms and diagnosed himself with the same disease. He has brought with him a sheaf of articles he found on the Internet detailing clinical trials for experimental treatments. When the doctor begins to ask questions, he says the answers are irrelevant: he explains that he would have gone straight to an oncologist, but his insurance policy requires that he also have a primary care physician. He now expects the doctor to order magnetic resonance imaging, refer him to an oncologist and support his request for the treatment he has identified as best.

The Internet: A blessing and a curse

Patients now have access to enormous amounts of information of variable accuracy. As in this case, patients may come to an appointment carrying early research studies that the physician has not yet reviewed. Others get their information from patient blogs that frequently offer opinions without evidence. Often, based on an advertisement or Internet reading, a patient requests a particular medication or test that may not be cost-effective or medically justified.

In a survey more than 10 years ago, more than 75 percent of physicians reported that they had patients who brought in information from online sources. This practice is only growing, including in older patients.

Physicians may feel confused and frustrated by patients who come armed with information. They may infer that patients do not trust them to diagnose correctly or treat optimally. In addition, discussing such information takes time, causing others on the schedule to wait, adding to the stress of coping with over-booked appointments.

Why so overprepared?

Internet-seeking, intensely questioning patients clearly want more information about the treatments they are receiving, alternative medical or procedural options, and complementary therapies. The response to their desire for more information affects their impression of physician empathy.

Adapting to a more informed patient

Approaching these patients as an opportunity to educate may result in a more trusting patient and one more likely to be open to physician guidance and more likely to adhere to an advised treatment plan.

In a review of the impact of internet use on healthcare and the physician-patient relationship, Wald et al urged physicians to:

• Adopt a positive attitude toward discussing Internet contributions
• Encourage patients to take an active role in maintaining health
• Acknowledge patient concerns and fears
• Avoid becoming defensive
• Recommend credible Internet sources.

Laing et al urged physicians to recognize rather than deny the effects of patients’ online searching for information and support, and not to ignore the potential impact on treatment.

One approach to our patient is to say, “I can see how worried you are about having the same type of cancer you read about, and I want to help you. It is clear to me that you know a lot about healthcare, and I appreciate your engagement in your health. How about starting over? Let me ask a few questions so I can get a better perspective on your symptoms?” Many times, this strategy can help patients reframe their view and accept help.

Patients with challenging behaviors will always be part of medical practice. Physicians should be aware of their reactions and feelings towards a patient (known in psychiatry as countertransference), as they can increase physician stress and interfere with providing optimal care. Finding effective ways to work with difficult patients will avoid these outcomes.

Dr. Schuermeyer is Director of Psycho-Oncology, Department of Psychiatry and Psychology. Dr. Falcone is staff in the Epilepsy Center, Department of Psychiatry and Psychology. Dr. Franco is staff in the Department of Psychiatry and Psychology.

This abridged article originally appeared in Cleveland Clinic Journal of Medicine and can be read in full here.