From the Editors Desk: the Quandary of Difficult Patients
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Zablocki VAMC, Milwaukee, WI, USA; 2Medical College of Wisconsin, Milwaukee, WI, USA.
J Gen Intern Med DOI: 10.1007/s11606-020-05816-z © Society of General Internal Medicine 2020
15% of patients in primary care are perceived by U ptheirto provider as “difficult.” Dr. Groves’ sentinel 1978 1, 2
article on the “hateful” patient was initially controversial because it brought to light this unspoken, but universal experience.3 British GPs term such patients “heart sink,” because their hearts sink when they see the patient’s name on that day’s roster. Yet, it is not medically complex or patients with untreatable or terminal diseases that providers find troublesome. Patients experienced as “difficult” by their providers usually have underlying somatization or personality disorders or undiagnosed mental illness.2 Physical symptoms are the most common reason patients seek medical help, and our focus on differential diagnosis trains us to seek biological causes.4 Despite our best efforts, up to a third of symptoms remain unexplained, even after extensive evaluation; fortunately the majority self-resolve.5 Somatization disorders are the persistence of medically unexplained symptoms. Historically, the Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria were not representative of what providers experienced in primary care. Recognition of these patients as a specific group came with DSM-5’s inclusion of somatic symptom disorder. This diagnosis requires that patients have one or more distressing, persistent symptoms that result in a disruption in daily life and is accompanied by excessive thoughts, feelings, or behaviors around their symptom. There are a number of suggested management approaches for this group of primary care patients, such as CARE-MD or BATHE. The approach with the best evidence is ECGN (Educate the patient, Commitment, set Goals, Negotiate outcomes).6 All of these approaches share certain characteristics: frequent visits, listening attentively to and validating the patient’s concerns, expressing empathy, and minimizing referrals and testing. Providers who have received training in patient-centered communication approaches find fewer encounters to be difficult and have better patient outcomes.7 The second group of patients sometimes experienced by providers as “difficult,” and also common in primary care, are those with an underlying mental disorder. Unfortunately, less than half of mental disorders are recognized, largely because
patients with depression and anxiety present with somatic rather than psychiatric symptoms. Clinical clues that a patient with physical symptoms has underlying depression or anxiety include a greater number of symptoms, more stress and severity of symptoms and greater functional impairment than would be expected.8 A reasonable clinical approach to such patients is to take a careful history, do a thorough physical exam, and then tailor testing to explore alternative causes for the symptoms, while retaining a strong suspicion that depression or anxiety may be contrib
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