American Farnily Physician

Practical Therapeutics

Managing the Difficult

Physician- Patient Relationship
n-!OMAS L. SCHWENK, M.O., and SAMUEL L ROMANO, PH.O.
Universily of Michigan Medical School. Ann Arbor, Michigan

:.:::!: yeor mcrrib crs
~,:::difjermt
I ,",<".::colflUulry
i ~ri':'arE' onieles
I 'e Pract ic a 1
:nerapcutiC5." ru.
I ~'!nc [ifth in a 51'n"e5
·;c", the Universuv
~J.'.1ichigan Medicol
I S:hool, Ann Arbor.
A dlHlcult physlclan-patlent relatlonshlp rather than just the patient. A high level
can have slgnlflcant consequences for both of awareness. or index of suspicion, that
the physíclan and tire patlen!. DIHlcult re la- such a relationship is developing is also
tlooshlps can le ad to frustratlng, dlssattsty-
important. This article discusses the na-
IIlg, adversarlaf and expe nslve medlcaf care ,
ture, causes and man.agement of the diffi-
The dlHicult relationship ls often a c onse-
cult physician-patient relationship,
quence 01 a breakdown Jn communfcation
between physlclan and patient. Speclllc
Freque ncy
causes kicluoe technlcal communlcatlon
barriers, diHlcufty in dlseussing certaln top- No study has directly examined the fre-
les, unmet or vlolated norms and expecta- quency of the difficu!t physician-patient
tlons (both the physlclan's arxí the patlent's) relationship in family practice, but indi-
and a mlsmatch b€tween the physlclan 's and red. rneasures suggest that physicians find
the patient's personallty styles. Manage- as many as 10 percent of all patient in ter-
ment gl).815for the diHlcult relaUonshlp In- actions to be highly frustrating .' Recent
cluóe malntalnlng professlonal self-esteem,
studies of physicians ' frustration with
matntalll<'1g physlclan-patlent continulty,
patients who are "high utilizers" of rnedi-
minlmlz:lng the "medlcallzation" 01 the prob-
cal care show that one-third of the top
le rn by IImlting the use 01 tests and proce-
dures, and mlnlmlzlng hospltallzatlon and
decile of su eh patients were rated as very
relerra!.lt 15also Important to remember that frustraring by physicians.? Sirnilarly. stud-
althoogh the relatlonshlp may continua lo be ies ha ve demonstrated that as many as
trustratiog or conllictual, It can be etíe ctlve- 30 tó40 percent of patients report signifi-
Iy managed with approprlate strategles. cant diss.atisfaction with any given medi-
cal interaction .'
The frustrating and dissatisfying physi-
Consequences
cian-patient relationship can ha ve signifi-
cant errotional. financial. legal and clinicaI Consequences of the difficuIt physi-
consequences. However. like any rnedi- cia n-pat ient relationship range from the
cal diagnosis, t he difficult physicia n-pa- annoying to the catastrophic. The diffi-
tient relationship hasspecificcauses, gen- cult physician-patient relationship can
eral management strategies and specific cause Ieelings of frustration, dysphoria,
interventions. The recognition of the po- anger and inadequacy, causing physi-
tential causes and the successful use of
management straiegies depend on the wil!-
cians to blame patients for the problern .'
A common manifesration of this blame is
ingness of the family physician to see the the labeling of patients with derogatory
difficult relat ionship as a problem created na mes. The difficult physician-patient

I
Gucst editors of the by both the physician and the patient, relationship has also been shown to be
:{'1rs are Barbara S
associated with two to three times higher
':>gor, M. D., and
~nornas L. 5ch1..lX'11k.
rates of radiographs, Jaboratory tests and
\!.D. See editorial on page 1389. physician referrals."

'iovember 1992 1503

 American Fam.ily Physician

TABLE 1

Cornmon Causes of the Difficult

Physician-Patient Re lat ionship

T echriica l or process problcrns. such as cornmunication barriers or

conver-sat ional sryk-s
Top ics or issues t hat rhe pat ient Iinds diíf icult or uncomfortable lo discuss tionship can cause a loss of continuity o
care. which can lead to expensive. episodi
Topics or issues i hat the physician (inds diHicul1 or urxornfortable to discuss
medical care in which tests are repeated,
Physici a n expe-ct at rons t hat are nOI mei by t he re lat ions hip. or norrns í hat
are cha ljenged by rhe pat ienl's b;'havior increased physician time is required an
Pat ient ex pec I al ion..s thal are not mei by the re lat ions hip (e.g .. unre alist ic
patient trust must be reestablished.
g oa ls of t re at rnent or t he st igrnat izat ion of c e rt a in diag noses) Another consequence of the difficul
Specif ic p.a.Jienl pcrsonalit y st yles or undiagno se d psychiatric diseases that physician-patient relatiovahip. of ten un-
innuencc be havior ~ recognized by the physicia n, is the "grief'
felt by the physician, who moums the lo
of a satisfyingrelationship (or an idealíz
Although quantitative research is lack- version of the relationship) in which th
ing. most malpractice defense attomeys physician performs a valued service an
and risk man.agement professionals be- [he pat ient is involved and appreciative.
lieve that difficult physician-patient rela-
tionships are responsible for a large nurn- Underlying Cau.s.es
ber of malpractice sui ts. e A patie:nt's anger Common causes of the difficult p~s¡_':
is thoug.ht to be as strorig a rnotivating fac- cian-patient relationship are listed in 'Ja-
tor as a physiciari's negligence in prompt- ble 1.1.8·9 Technical barriers to effective
ingpatients to sue. As few as 10 percent of communication include Jan.guage bar-
clearly neglige:n t acts result in a malprac- riers (e.g.. foreign language, cultural icif
tice suit. while more than 50 percent of oms), memory impairment or cognitiva
suits involve medica] acts that have trivial deficiencies in the patierit, inadequaís
or temporary results or involve no de- time, inadequate privacy (e.g., requests
rnonstrable harm. 7 An educ~tion.al ínter- for medica] consultation in the grocery
vent ion designed to improve physician store or at a cocktail party) and physician
interviewing and communication skills fatigue or distraction. Certain conversa-
•..•
"as shown to reduce the risk that a physi- tional styles+-for exarnple, patients who
cian will De sued in the subsequent year. 7 are reticent, rarnbling or vague-can be
The írustrat ing physician-patie:nt rela- irritating to physicians. Conversely. phy-
sicians who use medical jargon or unfa-
miliar medica] terminoJogy can be an-
noying to patients.
Th<> Authors
Patients may feel extremely uncom-
THOMAS L. SCH\-VENK. !vi D. fortabJe about raising o r discussin.g cer-
is associare prof essor and chairman ol rhe De- tain topics. such as sexual concems, abuse
oartrr-ent oí Familv Prac t ice al t he Univcrsit y of
(sexual, physical, substance), fa mily tse-
~1ichi¡;an Medicai School. Arvn Arbor, A grad-
u at e of t hc Univcrsit y of Michigan Medica l crets" (e.g.. psychiatric illness, marital
School. Dr. Schwenk c omplc- ed a rcsiderxy and infidelity, abortion) and terminal care
f ellowship al t h e Unive rs it y of Ulah Affiliated issues (such as resuscitation plans). Par-
Hospit als. Sall Laxe Cily. ticularly sensitive issues for rnost patients
S.A.MUEL E. RO~\'LAu'JO, PH.D. ir-elude disagreernent with [he physician's
is a clinical ps ychologist and director 01 the recommendations, a desire for another
Family Coun.sclirlg Scrvice al t he Universit y of opinion or negativc feedback about the
\lichigan Medica] Ccntcr. Ann Amor. Alter physician and his or her oHice.
rcccíving his deo orate dcgree irom the Sratc
Univcrsit y of N('w York, Buf Is lo, Dr. Romano
Physicians may also have topics that
cornplcicd a residcncy in t he Dcpart roent of they find uncomfortabJe and that they
Family Practice al iho St are Univcr s it y of Ncw may avoid or deal with in a cursory rnan-
York Medical5<:hool. BuHalo. ner, including abuse (particular!y sexual
1504 vol u rnc 46, nurnber 5
 American Farnily Physfcían

TABLE2

Patient Personality Styles that May Contribute

10rhe DifficuJt Phys ician-Patie nt Relationship

The pa ssive. dependent. ovcrdernanding pat icnt whosc cxpectations for

physician lime and e xpcrt ise exceed t he physicians capabilit ies
The dra rnatic. errotionally involved. scductive. affe<tion.ate patient who se Iy likely to lead to difficult interactions"
IX"Cdfor auention exceeds t he physician's time and energy are listed in Table 2.
The long-suf le r ing. masochistic. dcnying patient who has a need ro It is important to recogniz e that many
maintain his or her "sickr-ess" patients Jabeled by physicians as diffícult
He sornatiz.ing pat ient who challengcs I he physician wilh a se-emingly or frustrat ing have uridiagnosed psychi-
endkss varíe: y of hypocbondriaca l and somato(orm compJaints atric illnesses. such as major depressive
Thc a ngry. derna nding. compJa ini ng pat ient whose expecrat ions and disorder, dysthymia, generalized a nx iet y
me!hod of express ing t hern can offend the sensibiJities aOO threaren the disorder, panicdisorder and substance or
dutonomyoE the physician
alcohol abuse." These illnesses can dra-
matically affect the patient's ability to
communicate. AJso, they may underlie a
abuse), sexual paraphilias (or any devia- wide variety of potentially signihcant
tion from the physician's sexual norms) symptoms, such as fatigue, chest pain and
and disagreement with a previous physi- neurologic complaints. Such symptoms
cian's recommendations. may be difficult to relieve until an accu-
Physicians bring significant needs and rate diagnosis is made. In addition, at
expectations to the physician-patient in- least one study has shown that physicians
teraction, including a desire to be needed are less aware of symptoms of depression
by the patient and to gain satisfaction and an.xiety in frustrating patients than in
from providing ca re, an enthusiasm for other patients, suggesting that the accu-
dealing with irnportant biomedical prob- rate diagnosis of such psychiatric disease
lems and challenges, a sense of closure requires particular physician effort .:'
and satisfaction with their recommenda-
t ioris and interventions, anda patient who General 1vtan.agement Strategies
is cooperative and appreciative.l Patient V/hile a difficult relationship mal' con-
behavior may conflict with these needs tinue to have frustrating Ieatures. it can be
and expectations. Exarnples of patient rnanaged to the satisfaction of both the
behaviors that may frustrare physicians physician and the patient. Appropriate
include detailed questioning of recorn- .nagement goals are described in Ta-
rnendat ions, making specific suggestions C,2 3. These goals suggest general rnan-
about tests or treatments, and quoting agernent strategies.
specific medical recomrnendat iors from Four general strategies for the difficuJt
lay publications. physician-patient relat ionship are dis-
Physicians also bring familia], cultural. cussed below."
religious, social, ethnic and racial norms Strategy I : Clanfy proiessionat [eel-
and values to the relat ionship. Patients ings about the patient . Even with sat isfy-
may unintentionally chaJlenge these norms ing patient relat ionships. the physician
and values (e.g .. belief in "horne reme- must be absolutely clear about his or her
d ies." fa il ure to ta ke fu l! cou rse of medica- basic goodwill and benevolent intento
tion or reliance on religious faith for cure). This is even more important for the diffi-
A varíety of patient personality t ypes cult physician-patient relationship. These
have been described as "diíf icult ." How- relationships require absolutely clear. hon-
e ver. whether a personality type contrib- est and well-intentioned cornrnunicat ions.
utes to a difficult physician-patient rela- Al! patients deserve what Carl Rogers. a
t ioriship is dependent on the interaction noted psychologist and advocate for pa-
of the pat ients and the physicians per- tient-centered medica] ca re, called "un-
sonalit y, experience, values and expecta- conditional positive regard." This rneans
Tións , Patient personality types particular- treatment with respect. dignit y and ki¡,¿-

\ovem ber 1092 1505

 American Farr.ily Physician
::1
I:i'ii
n
-~
TABLE3 e
Management Goals for the Difficult ReLationship "
.1')

-,
1.' Minimize

2. M.aintain
"medica lizat iori." rhrough judicious use of
inappropriare
diagnostic tests. thcrape utir prcc edure-s. hcspita lization and reíerral,
with correspondingly greater eíícr: to uncover dep ression and ocher
psyehiatric illrcsses.
physician-patient continuit y to t he gre at est ext ent possib]e .
of pat ients. ~.II Effective strategies incluci
request ing feedback from patients
1
an
3. Ma int ain profess ional selí-cstcern rhrough t he maximal use of product ive colleagues about ways to improve coa
a nd constructive physician bchaviors and support systerns. munication skills. rernoving barriers t
4. Focu.s on t he more sat isf yi!'lg a nd product ive aspecis of I he pal ients communication by understanding an
pe rsorialit y and behavior. adapt ing to the pat ierit's communicabo
5. Re-c'Yr'-iJize t ha: r he re latiorehip will probably a lways be less sat isfying style. using an interpreter, involving farr
t ha n desired.
ily members, and providing for a long(
initial visit to allow patients with a les
direct conversational style or cognitiv
ness. although not necessarily with love. irnpa irment to tell their story.
of every patient for whorn the physician The physician should also use effectiv
provides services. \f\.'hen a physician is rechniques of reassurance therapy for th
unable to do this because of physician- many patients who somatize or requ~
pat ient corúlicts in sryle. behavior orvalue help for otherwise trivial physical com
.._ systems, the physician should consider plaints. Effective reassurance therapj .
, transferring care of the pat ient to another involves six steps (TabIe 4).12 .-:
physician. U ihese occasions are frequent, Step 1, obtaining a det ailed descriptiJ;
it is necessary to examine the causes for of the pat ients symptoms, often requires
this excer.s: .c stress and the physiciari's more than one appointment. The phyJ..
apparent i.nability to cope effectively. cian can ask the patient to bring Jists to
Being honest about one's feelin.gs to- t.he appointment and can deal wit.h ~
•.••
--arothe patient is critica!. The physician "three most important syrnptoms" at ea<1
who feels depressed, arixious. frustrated visito Step 2 involves eliciting the crnO-
or angry should ask hirnself or herself tional rneaning of symptoms, such as ri-
sorne important quest ions: \Yhat does the alistic Fears. irrational phobias, COnDeO-
pat ient do to elicit these feelings7 What tions to illnesses in friends or relativei,
needs dces the patient nave to behave this fear created in the patient by the absenct
\\--a1'7\f\.'hat is there about the physician's of complete explanations, and "ariniver.
motivations. value systern. stresses or sary" reactions.
behaviors that may be causing this un- Step 3 is the physical exarnination. Itr
productive interaction7 selectively repeating only lirnited por-
Acceptance and uriderstanding of such tions of the examination as necessary dur-
Ieelings can provide relief but may also ing future visits, the remaining time in
cause a feeling of "grief" over the loss of a each visit can be LL<;ee1 for discussion about
satisfying relationship. Because most phy- the patient's concems and underlying fed..
sicians have a slrong desire to be needed ings about being il!.
by their patients, the loss of a previously Steps 4 and 5 involve making a specific
sat isf ying relationship may be "mourned" diagnosis, which may include nonbio-
by the physician, although the physician medica] pathophysiologic explanations
rnay not recognize that his or her response Diagnoses for which the physician needs
eman.ates from this process. to provide extra rcassurance and cornmu-
Strategy 2: Use precise and cffec1ive com- nication include those with strong stress
.. munication and interuieunng t ech niq ues . or ernotional componcnts (strcss-rclated
Srudies have demonst rated lhat bctter phy- diagnoses such as fibromyalgia, chronic
sician t ra inirig in thepsychosocial dimcn- fatigue, tension headache o r irritabk boweJ
S.;\~¡JI~ ,J P?~~c:--:~ c:!:.\? can JCJd to clinical syndrome) and more specific psychiatric
irnprovement in the functional outcomes diagnoses (major depression. genera 1ízed .
1506 volume 46, nurnber 5
 Arnc r ic an Fa mily Physicían

y,,\BLE4

Six 5tep-s of R.eassurance Therapy

I Oblain;; dctailed description of lhe paí ien ts syrnptorns ,

. Elicit t h e ernot iona l rne a ning or conrent of the s y rnptorns .
I - ['('r[orm an apprcpr iare ly thorough physical ex a minat iori.
¡ " M.3k..ea specif« diagnosis, which will oíren includc nonbiomedical Strtnegy «: Set appropriaie /imils ard mo-
I . p.l!hophysiologic e xplanat ions .
bilize useiul support syslems. Physicians
¡ S bplain t he signi[icafl(e 01 the symploms to t he pat ient .
o Conclude with expressions of re assura nce a rid support. may sometimes nave difficulry ack.nowledg-
ing their personal and professional lim i ts .
Wíth the difficult physician-patient rela-
p,r¡,>ed [rom 5apira. JI
tionship. sett ing limits is cr itical The phy-
a nxiet y disorder or cornrnon sornatoforrn sician must know how much he or she can
disorder). It is important to corinect the give. how much time and energy can be
symptoms to the diagnosis and to ínter- devoted to a particular patient and how
pret the specific meaning that the symp- much control the physician is comfort-
toms may have to the patient , able relínquishíng. Reality testing with
Step 6, reassurance. may be the short- colleagues is also useful, including the
est step if the pat ient has been well-pre- ability to present and discuss patients the
pared. Physicians often move too soon to physician finds frustrating lt is also im-
re assurance and consequently are inef- portant to recognize that it is cx:casionally
fect ive , This leads to a need to backtrack necessary to termínate a relat ionship.
in an inefficient, time-consuming way.
Strategy 3: Heme a high index of suspi- Strategies for Specific Personality Styles
cien far undiagnosed psychiatn'c illness, When planninga man.agement strategy
A large number of patients have undiag- for a patient whose personality style is
nosed psychiatric illness. and the lack of contributing to a difficult physician-pa-
an accurate diagnosis frequently contrib- tient relationship, it can be helpful to con-
utes to the development of a difficult phy- sult with a colleague in behavioral me-di-
sician-patient relationship.!' Some meas- cine or a mental health therapist. This
ures that increase diagnostic accuracy are consultation can enable the physicia.n to
given in Table 5. accurately identify the personality style,
to separare the physician's issues from
those generated by the patient, to clarify
f_.l,BLE 5 his or her own feelings toward the patient,
and to develop and practice the appropri-
Methods to Incre ase Accuracy in Diagnosis ate interventions. Strategies for the Iol-
o{Psychiatric Illness lowing personality types are intended to
lessen the incídence of difficult physi-
.Ask specilic questions about diagnosuc criteria lor suspecred dise a se (e.g., cian-patient relationships as well as to
C.;CE questions to de.ect alcoholism; quest ions about fatigue. sleep
improve the quality of interactions when
o:;t urbance. low rncoc a;od motivation to derect dcpression).
such a relationship exists.
Use screening quest ionnairrs (e.8., M ichigan Alcohol Screening T est Ior
The passioe, dependent , ouetdemand-
alcoholism, Beck or Cente r Ior Epidemiologic Srudics-Depression Ior
dcpression. Ha rnihon-A Ior a nxict y l. ing pat ient . In dealing with a patient who
"Hedge ones bets" in discussion "'ith pat icnt rcgarding the likelihood oí
is passive-dependent and demanding of the
biornedical versus ps ychiat ric diagnosis to avoid a prcrn at ure physicians time and at tent ion. jt is criti-
cornmitment [02 pr olongcd biomedical eva luat ion. cal to see the dependen! behavior as a syrr-p-
I'ur sue Iurt her diagnosric inforrnat ion Irorn [ami!y mernbcr s. tom of the patient's ncediness. arising from
Se awa re of the paticnts aHe,t and nonvcrba l bchavior. lack of self-esteem. mistrust of others and
:\clnowledge that [;12n" SOm2! ic complaints cannot be cx pla incd necd for help in decision rnaking.
biorncdicail y, especia"!' when rhcy involve rnuh iplc organ systcrns. The physician should develop a toler-
Se J!l'ft for leeling, of dvsphor ia - your ícc ling s mal' rnir ror t he crnot ional ance for the dependen! behavior without
S:Jtr oí rhe pat icnt , feeling he or she must always respond to
it. This is best accomplished when the

No\'embcr 1992 1507

 h~rlcan ra m u y i lly~lLlajl

Difficult Paticnt-Physicia n Rebtionship

physician avoids the lendency to see the seductive behavior mal' necessitate ter-
behavior as a personal threat. Modest mination of the relationship.
gratification for a short time is reasonable The long-slJffering, m asoch ist ic, deriy-
(e.g.. a slightly longer office visit initially), ing paiient . The patient who exhibits these
but il is necessary to set limits when the behaviors has a nce d lo ma inta in his oro
pat tem is recogn iz cd. her "sick ness" and constan: nced of careo
-Setting limils iliCJudes conlrolling the Rather t han being over tly demanding,
length and frequency of office visits and these patients seern to have resigr-ed them-
t elephone calls, and expressing the expec- selves to their fate. Such resignation can
tation that the patient wil] transfer sorne be frustrating for the physician who is
of his or her support needs to other indi- trying to help.
viduals or groups. The paticnt must be The physician should recognize tha!
given an explanation of the decision to set this behavior may be the pat ierit's best (or
limits and the need and importance of only) way of coping with despair, anxiety
doing so. Setting limits requires negotia- or stress. Rather than confront the patienj
tion a nd compromise between widely dis- directly or attempt repeated reassuranc~
crepant views regarding how rT:Lich time the physician can acknowledge the pal .
and attention are necessary. At all times, rient's courage and self-sacrifice in th¿
the physician should use empathy lO focus face of illness or debilitat ion. The ernpha]
on the emational needs that are behind the sis is more on empat hy than on medica1
pat ients seerningly excessive requests. data. The physiciari's frustration can ?1
The dramatic,
involved. affectionate
behaviors
seductive. emotiorwlly
patient. Seductive
should not elicit a similar re-
used as a reflection of the frustration
patient must feel at the lack of control
his or her J ife.
01 thi

sponse Irorn the phys ic ian. but rather TIJe sornat izing, hypochoru:in'iUal pa.
should be seen as a symptom-the patient tient. \t\'hen a patient repeatedly preserif
is needy and asking Ior support and a pos- with a range and intensity of symptoml
it ive response, albeit in a n inappropriate that resist biomedical explanation. the ph~
íashion. Confidentia] consultation with a sician must acknowledge that the syrnp
trusted colleague can help clarify and sep- toms are legitimate and make a commi~
arate the physicians feelings and needs ment to work on the pat ients behalf fo!
Irorn those of the patient. symptom control (as opposed to diseas!
Once this behavior is iderit ified, the cure). The somatizing pat ient frequenth
phvsician should set limits in a n explicit benefits from his or her behavior throug.]
and noripunit ive way. For e xarnple. a spe- seconda ry gain (t he phys icians at tent ioi
cific staternent about [he necessity to stay and the closeness of the medical relation
focused on the pat ients s ymptorns and ship). A high index of suspicion and th
medical needs may be neccssary. \Vhen a prov ision of continued medical careis im
pal ient makes ina ppropr iately fa mil iar or port a nt ("hypochondriacs get sick too")
personal comments about lhe physician but diagnostic proccdures and rcferral
(e .g.. "you seern so much more under- must be select ive and lirnited. for reason
standing about my problems t ha n my ofboth cosl and qua lit y of careo
husband/wiíe"). rhc pat ient should be Somatizing pat ient s necd support arv
lold ihat such comments are unhelpful or reassurarxe rather than symptornat ic trea!
cven that they rnake the physician Ieel rnent or biomedical cure. They may bm
uncomfortable. An irnrnediatc st aí ernent fil [rorn an explanation t hat their syrnp
redirecí ing the discussion to the pertincnt toms may be a way of dealing with strd
medical issue is thcn advisable Persistent Occasionally, the secondary gain that t1í
]508
J
volurne 46, numberi
 .J ~ •••
_.~__ =..
_~
.

.
Arncr ica n Family Physiclan

patient has from the persistence of syrnp- difficult patient-physician re!ationship

toms may be made explicit to the patient. are enormous. Effective management in-
The pat ients overus e of services can be eludes general stralegies appropriate for
managed with firm adherence to regular all physician-patient relationships. ',vhcth-
but time-limited office visits. Above all er they are difficull or not, arid strarcgies
else. the physician should attempt to int e- for specific situations. The physician who
grate the psychosocia] and biomedical approaches each patient with a high level
qua!ities of the pat ierits distress. of personal awareness, professional m a-
The angry, demanding, complaining turity, commilmenl to high-quality rned-
pat ient . The behavior of these patients ical care and communicalion expertise
arises from an unreasonab!e and exag- will be rewarded with an enhanced leve]
gerated fear that they will not get what of professiona I and personal sat isfact ion.
they Fp.:! they need=-whether it is the phy-
siciari's time, staff courtesy, convenient R EFER El'JCES
appointments or guaranteed results . The
1. Schh'e1k Tl., 1vf..arquez [T. Lcfever RO, Cohen
angry patient often fears rejection and has
M. Physieian and pat ient determinants of dií-
high control needs. This type of pat ierit Iirult physician-parient relation.ships. j Fam
can be provided with the opportunity to Pract 1989;28:59-63.
ventilare. and the anger can be respected 2. Lin EH, Katon W, Von Korff M, et al. Frustrar-
without the physician having to take it ing patients: physician and patient perspec-
tives arrong distressed high users of ll'l€"C.Íieal
personally. Un til the pat ien t's anger is d is-
services. J Cen lntem Med 1991;6:241-6.
pelled. confrontation or interpretat ion will 3. Cousins N. How patients apprajse p hysici ans .
be unsuccessful. Premature atternpts to N Engl j Med 1985;313:14.12-4.
intervene may result in def ensiveness and 4. Sarsky A]. Wyshalc: C, Latham KS, Klerman
esca!ation. The physician can retain con- CL. Hypochondriacal patients, thcir physi-
cians, and rheir medical careo j Cen Int ern
trol of the situation by !etting the patient
Med 1991;6:41J-9.
k now what will and wil] not be to!erated. 5. jchn C. Schwenk ri. Roi LO, Cohen M.
Once it is recognized that the pat ients \ledical eare and demogra phie eharaeterist ics
behavior derives from afear of losi.n.g con- of 'diíficult' patients. j Fam Pract 1987;24:
troj, the physician can provide oppo r- 607-10.
6. Bart~t EE. \.y'h.at's up doc? The patient and
tunities for the patient to rnaint a in sorne
the maipraetice sud. Risk Managc 1987;34:
control. For example. the physician can 26-.31.
offerchoices in diagnostic or therapeutic 7. RartleU EE. Crcat expect at ions: a t a le of mal-
options or give the patient responsibi!ity practiee. Risk Ma nage 1988;35:20-1,24.26-7.
8. Ncsheim R. Caring for pat ient s who are not
to monitor symptoms or disease pararn-
cas y to lile. Postgrad Mcd 1982;72:255-66
eters(e.g., a symptom log). The physician
9. Zinn \\';',.1. Doctors have Eceling$ too. JAMA
can also be particular!y at tentive to kcep- : 9SS; 259:3206-8.
ing the patient informed about dctai!s of lO. Croves [E. Ta k ing e are of t hc hat efu] patient.
the patients care. providing access to the ~ En¡;1 j Med 1978;2°3:883-7.
11. Smith CR lr. Monson RA. Ray OC Psychi-
patients medical record and offering reg-
atric consultation in somatization disorder. A
ular, [requent contacto \Vhen dea!ing with
randornized controlled studv. N Engl j Med
patients wilh this personality st vle. con- ]°86;314:1407-13.
sultation and re alitv tesring wit h a col- 12. Se pira JO. Reassurance the rap y. V\'hat to S.1y
league is hclpful. lo svrnptornat ic pat icnt s wit h b enign dis ca ses.
Ann Intcm Mcd 1972;77:60.3-4.
Final Comrncnt 1.3. Katon VV.Von Korff M, Lin E, el al. Dist rcsscd
h:gh utilizcrs of medical careo DSM-I!l-R
The crrotional.Iegal. financia! and rned- diagnoses and t rcct rncn: '1'..:L'd5. Ce~: Hose
ical bcnefits of dealing effeclively .•.vith [he Ps ychiatry 1990; 12:355-62.

;o\'cmber 1992 1509