Managing the Difficult Patient Interaction

By Michael T. Puerini, MD, CCHP-A

Posted on September 2, 2008 – While the term “difficult patient” defies a specific definition, every medical provider has dealt with difficult patients. Approximately 15% of primary care patients outside the correctional setting are thought to fall into the category; therefore, in a correctional health care setting, the percentage can be expected to be at least this high. Several factors unique to our practice environment contribute to this. Our patients are incarcerated and frequently suffer from serious grief and loss issues, fear and drug addiction or withdrawal. In recent years, the percentage of our patients who are diagnosed with serious mental illness has skyrocketed. They have personality disorders, impulsivity control issues and have suffered physical abuse and violence in much higher percentages than the general population. Additionally, our patients have a greater potential for medical diseases than the general population. For example, at least 30% of incarcerated individuals are thought to be chronically infected with Hepatitis C compared to 1.2 % in United States population. Medical providers in correctional settings are faced with these realities as well as other factors more or less unique to this environment. We have been well trained in the treatment of diseases such as diabetes, heart disease and cancer. We were not trained in requests for shoes, mattresses, low bunks and stair restrictions, yet we are frequently called upon to perform evaluations foreign to the usual practice of medicine. There is also a widely accepted dichotomy between our security function and our caring vocation. Importantly, the therapeutic relationship is marked by the potential for mutual mistrust. Not unexpectedly and consistent with human nature, our patients manipulate their environment to try to make it suit them. As the people in the building who are given some power and license to “stretch the rules,” our patients naturally turn to Health Services. Many of our patients, by virtue of a longstanding problem with drug addition, will seek and even demand controlled substances from us. Frequently, use of these substances is not in their best medical interest. Because of the circumstances described above and other factors, the therapeutic relationship, in many cases, can become problematic. For some patient encounters, patient care can seem onerous. We might consider different terminology, recasting the patient as challenging, malingering, or problematic; however, labels are more or less useless, can be dangerous and ultimately interfere with patient care. We can better describe the overall interaction of medical provider, patient, and the correctional health care setting as simply difficult. This might lead us to a more satisfactory solution. One solution in a correctional health care setting is the formulation and consistent implementation of a team-based patient management plan. Input of a variety of team members including the patient into the plan, and clear communication of the plan among team members are key factors for success. Regularly scheduled provider/patient visits with a single provider eventually results in more consistency, less redundancy of care and a less crisis based approach. Additional goals are patient accountability and education. Most of our patients will leave the correctional setting and one of our roles is to help them learn how to appropriately seek medical attention and communicate their needs. Some providers believe that regularly scheduling a patient on a weekly or bi-weekly basis is overly time consuming and impractical in a correctional health care setting. The fact is that most primary care providers accept that this approach is useful and proven. It is more effective for both quality medical care and time management of providers and nursing staff. In a future article, specific recommendations will be discussed regarding these regularly scheduled patient care visits. Ultimately, the short term time investment in a patient care management plan is a useful solution to the problem of the difficult patient, resulting in improved health status for the patient and less frustration for medical and custody staff. It can transform the difficult patient encounter into a win-win situation. Dr. Puerini is a member of the SCP board of directors and is Chief Medical Officer, Oregon State Correctional Institution. Readers may contact him at mike.t.puerini@doc.state.or.us.