Chapter 6

### Introduction

There are patients in every practice who give the doctor and staff a feeling of ‘heartsink’ every time they consult.

Thomas O'Dowd 19881

Weston defines a ‘difficult patient’ as one with whom the physician has trouble forming an effective working relationship.2 However, it is more appropriate to refer to difficult problems rather than difficult patients—it is the patients who have the problems while doctors have the difficulties.

The proportion of consultations that are taken up by difficult patients (also called heartsink or hateful patients) has been measured as being 15%.2 While in the minority, by their nature they can often take up a disproportionate amount of the doctor's time, energy and emotional reserves. One difficult patient may disrupt an entire consulting session. The concept of the difficult patient was first popularised by the landmark paper by Groves in 19783, and many difficult patient types have since been described. Four of the more common and better-known types4 are as follows:

1. The dependent clinger

Dependent clingers require constant reassurance, and have an unquenchable need for explanation, affection and attention. They may break social or professional barriers to meet this need, such as calling the doctor at home or continually making unplanned presentations at the surgery. The doctor can feel threatened by such patients, and if pushed away, dependent clingers can feel rejected, which may exacerbate their behaviour. They respond well to an empathic approach that needs to be delivered within clearly defined and enforced boundaries.

2. The entitled demander

Entitled demanders attempt to control the doctor through intimidation and by inducing guilt or fear in the doctor. They project an air of superiority and entitlement, and may demand tests or consultation prioritisation, withhold payment and are often litigious. The doctor may understandably feel afraid and despairing in such situations, but this type of difficult patient is often driven by an underlying insecurity and is attempting to obtain control through bluster. The appropriate use of power is clearly required for such patients, but it is important (and often difficult) to stay in control and interact in a respectful and non-confrontational manner. This may include pointing out calmly but clearly when boundaries are being crossed.

3. The manipulative help rejecter

Manipulative help rejecters are patients who are on a self-destructive path but refuse to take important medical advice. They crave the relationship with the doctor and solving or improving the medical situation may threaten that relationship. Substance abuse is a common manifestation of how manipulative help rejecters present and manipulate the relationship, as are non-compliance and chronic pain issues. The doctor can feel frustrated and even demoralised, and it is important to reflect on our own feelings and expectations with such patients.

4. The self-destructive denier

Rather than wanting to cling to the doctor (like the manipulative help rejecter), self-destructive deniers appear to want to damage themselves, their motivation driven by self-loathing. ...

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