Voices From the Field: How We Deal With Difficult Patients

In order to help you to both enhance your practice and increase your bottom line, Dynamic Chiropractic PracticeINSIGHTS asks practicing chiropractors, like you, for ideas and solutions that have been tested in real-world environments. In this issue, we asked: "Which kinds of patients are the most difficult to work with? How do you deal with them?"

The Know-It-All

According to doctors, the most commonly reported type of person who is difficult to work thinks they are better than the doctor, and therefore are uninterested in most, if not all, of the doctor's recommendations. Dr. Stephen Savoie of Clermont, Fla., characterizes this type of difficult patient as the one "who wants to be the doctor."

"They don't want to follow treatment recommendations and want to set their own schedule," Savoie said. "Typically they do not improve and of course, it is the doctor's fault. When I get one of these patients, I sit them down and have a frank discussion about the need to follow 'my' recommendations if they truly want to improve their health.

"If they absolutely refuse to be compliant, I tell them that to continue (patient visits) would be a waste of my time and their money, and they should seek care from another provider."

Much like the patient who wants to be the doctor, the problem patient for Dr. Brian Blower of Freeport, Bahamas, knows best - at least in their own mind.

"Perhaps the most difficult patients are those that are looking for relief of their painful symptoms, but are locked onto the pain and uninterested in what you may have to say or do about its cause," Blower said. "This type of non-compliant patient does what he always does, but expects something different (to happen). If he doesn't get it, he degrades you and your care as being worthless. We call this type of person a 'Bayard', which means one that goes confidently along convinced by his own ignorance."

Dr. Eugen Roth of Benalmadena, Spain, also has coined a name for the difficult patient: the "bully" patient. Roth characterizes the types of demands that you can expect from a bully: "'Crack my neck on this side, now that side. The other chiropractor did this, so do it too. Now crack my lower back, now the other side. Do that standing one.' "

Roth's simple solution: "Refer them to the physio!"

While many respondents stated it was best to end the relationship with the difficult patient, Dr. Richard Hargreaves of Bellingham, Wash., chooses to win over his "know-it-all" patient.

One of the more difficult types is "the person who perceives they are 'fit' simply because they go to the gym on a 'regular' basis and now see their body to be requiring only a 'couple of treatments' to be 'fixed.' However, this person usually has overestimated their physical condition and capabilities," Hargreaves said.

"This is highlighted during the initial examination and strength testing, which shows a history of unbalanced and misdirected training which is the result of reading a book, going online, or being trained by a 'trainer', who knows zero about the spine, posture, and carriage.

"How do you deal with them? Repeatedly, but gently and clearly, give them doses of reality regarding the true physical condition of their joints and connective tissues. Some of my best patients are these people who [eventually] come around to do honor to their health."

The Non-Committer

Much like the patient who thinks they know best, the patient who is not committed to their health will not follow the doctor's plan of care. Dr. Ron Waxman of Illinois feels that the best solution when dealing with patients who won't commit to his care recommendations is to let them go.

"The patient who is not committed to getting well (is) therefore not going to comply with your care program," Waxman said. "I look them in the eyes and let them know that they will not get well and they should stop coming into the office. I am willing to let them go without hesitation."

But while some doctors have little to no tolerance for troublesome patients, Dr. Jared Van Anne of St. Louis gives more allowance for potential improvement.

[pb]He describes his typical difficult patient as: "too busy for the necessary frequency of visits and/or at-home exercises." In response, Van Anne said he uses "tactful confrontation and (a call for) accountability that addresses the reality of the situation.

"In other words, telling the patient that if they do not make their appointments as recommended or complete their at-home exercises, they can expect to fail.

"This serves two purposes: It shows the patient that you care about their best interest and it will either motivate the patient to participate in the healing process or free up time for you to help patients who 'want' to get better."

Gender and Emotions

Most of the responses received discussed specific types of patients; however, others based their responses on more generalized concepts. For example, Dr. Ron Tripp of Norman, Okla., felt that men, in general, were more inclined to be difficult.

"Men are mentally 'fixers': fix the immediate problem and everything is fine. It is a study-proven male trait," he said. "Unless male patients are at an injury state that may end their careers, they do not accept or comply with treatment plans for restoration of a healthy spine.

"Women are 'pro-active' and are interested in preserving health and taking measures to maintain a health level that is not burdened with 'emergency' conditions if they can avoid it. They comply with check-up recommendations and react to early warnings of problems and address them immediately.

"In the case of men being 'fixers', I stress the importance of prevention versus intervention on health issues," Tripp said.

Some doctors blamed emotions as the primary factor contributing to a difficult patient. In such cases, Dr. George Burdi of Lake Forest, Calif., chooses to take more of a counselor role: "Unhappy patients are very difficult because they seem to have a chip on their shoulder, so anything done is not enough," Burdi asserted.

"One solution is to find something they like to do or talk about and bring conversations around to that topic. Then work in or relate how chiropractic helps in doing that particular thing," he said.

Doctor, Look at Thyself

While most responses we received specified various types of difficult patients, others cautioned their fellow doctors to look at themselves as the potential cause of a problem patient.

"The most difficult patient is created out of our own discomfort," explained Dr. Jim Roth of Milwaukee, Wisc. "We tend to project a difficulty [on] a patient before they actually present it (i.e., report of findings).

"I have a tendency to judge beforehand how much the patient is going to listen to what I have to say, and how much they will actually follow through. Consequently, I have a self-fulfilling prophesy happening.

"After 20 years in practice it is easy to become disillusioned. Insurance companies, politics, patient's preoccupations, etc., chip away at our philosophy of what chiropractic means to us."

Along the same lines of a self-fulfilling prophesy, Dr. Lawton Howell of Las Vegas believes the best way to avoid difficult patients is to attract the ones that you want.

"The attitude and behavioral traits of any patient are often based on your marketing efforts and type of patients you serve," he said. "To avoid patients who are difficult to serve (i.e., late for appointments, no shows, lack of commitment and financial issues), be sure your marketing messages, both internal and external, are targeted to your desired perfect patient."

"Generally, when you attract a patient based on free services, you attract the wrong patient profile. Your marketing efforts always contain a STATED and UNSTATED message. It is the unstated message that has the greatest impact on the success of attracting and retaining the preferred patient."