Managing Difficult Patient Encounters

Justin Bailey, MD, University of Washington School of Medicine, Seattle, Washington;​

Full Circle Health, Family Medicine Residency of Idaho–Boise, Boise, Idaho
Susan A. Martin, PsyD, University of Washington School of Medicine, Seattle, Washington;​Family Medicine
Residency of Idaho–Caldwell, Caldwell, Idaho;​Idaho Psychology Internship Consortium, Nampa, Idaho
Angela Bangs, MD, MBA, Full Circle Health, Family Medicine Residency of Idaho–Boise, Boise, Idaho

Family physicians commonly find themselves in difficult patient encounters that can result in dissatisfaction for the patient
and physician. Successful navigation of these encounters includes recognizing common physician factors, such as systemic
pressures, interpersonal communication, and situational issues. The practice of labeling patient types can lead to disparities
in care and patient harm and should be avoided. When physicians recognize that they are in a difficult patient encounter,
simple mindfulness approaches, such as the Name It to Tame It and CALMER approaches, can improve outcomes. CALMER
approaches help physicians acknowledge which situations they can control, alter their thoughts about the situation, and tol-
erate uncertainty. Physicians working with patients to create a therapeutic bond can focus the encounter to understand the
situation that the patient is experiencing and work to recognize and acknowledge strong emotions that are nonproductive.
Negotiating an agenda can help manage expectations of what can reasonably be done during each visit. Supporting patients
by validating their symptoms and helping them embrace uncertainty can enable them to take control of their diagnosis and
focus on managing chronic conditions rather than curing them. Motivational interviewing is a useful tool to help patients
take ownership of their illnesses and therapeutic goals. Self-care through reflection groups or personal coaching or coun-
seling can help physicians feel supported and avoid burnout. (Am Fam Physician. 2023;​108(5):494-500. Copyright © 2023
American Academy of Family Physicians.)

Difficult patient encounters are common in SYSTEMIC PRESSURES

family medicine. Physicians who experience fre- Physicians face pressures from the medical system
quent difficult clinical encounters are more likely in which they work, including increasing corpo-
to experience low job satisfaction and burnout ratization of the health care system, shifts toward
than those who do not.1,2 productivity-based pay structures, increasing
Successfully navigating difficult patient encoun- documentation and regulatory burden, and loss
ters requires understanding and identifying phy- of autonomy.7,8 Time constraints and documen-
sician and patient factors and external conditions tation requirements can turn the focus away from
that may apply to any clinical situation.3 Physi- the needs of the patient.6 Lack of support staff
cians bring their own experiences, biases, values, can exacerbate the stresses on time-constrained
strengths, and weaknesses to all patient encoun- physicians.9
ters. Patients bring their own personalities, values, The concept of moral injury describes the harm to
complex medical needs, varying levels of health physicians who are prevented from providing appro-
literacy, and communication styles to their inter- priate care. Moral injury in medicine lacks a standard
actions with physicians.4,5 Both patients and phy- definition but has been described as the emotional
sicians are affected by conditions in the medical response that can occur after events that violate a
system that are beyond their control.6 person’s moral or ethical code and the challenge of
knowing what care patients need but being unable to
Identifying Physician Factors provide it due to constraints beyond the physician’s
Table 1 lists physician factors that can contribute control.10,11 The COVID-19 pandemic included many
to difficult patient encounters.6-13 elements of moral injury. A recent study showed
that 60% of physicians reported at least one charac-
CME This clinical content conforms to AAFP criteria for CME. teristic of moral injury in the first two years of the
See CME Quiz on page 447. pandemic.12 Increased misinformation and general
Author disclosure:​No relevant financial relationships. distrust of the medical establishment eroded founda-
tions of the patient-physician relationship. An article

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 DIFFICULT PATIENT ENCOUNTERS
SORT:​KEY RECOMMENDATIONS FOR PRACTICE

Evidence
Clinical recommendations rating Comments
Avoid labeling patients during difficult encounters and instead assess for con- C Expert opinion and systematic
tributing factors such as underlying substance use, trauma, chronic pain, and review
psychological conditions. 2,16,17,19,20,22,27

Consider using mindfulness techniques such as Name It to Tame It or the C Expert opinion in absence of
CALMER approach to improve communications. 33,34,39,40 clinical trials

Incorporate motivational interviewing as a tool when working with patients. B Limited-quality, patient-
Motivational interviewing improves the therapeutic alliance with patients and oriented evidence and expert
can effectively influence behavioral change.41-45 opinion

Use communication strategies of active listening, validating emotions, explor- C Expert opinion in absence of
ing alternative solutions, and providing closure when in emotionally charged clinical trials
encounters. 21,47-52

A = consistent, good-quality patient-oriented evidence;​B = inconsistent or limited-quality patient-oriented evidence;​C = consensus, disease-
oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://​w ww.
aafp.org/afpsort.

in American Family Physician focused on countering medi-

TABLE 1 cal misinformation.14

Physician Factors That Contribute INTERPERSONAL

to Difficult Patient Encounters Communication with patients is key to accurate diagnosis
and patient satisfaction. Physicians who are unable to com-
Interpersonal
municate with patients due to language and cultural barriers,
Bias toward specific medical conditions or populations
have knowledge deficits and biases toward specific condi-
Communication barriers (e.g., language, literacy, poor
tions or populations, or who lack trust can struggle to obtain
rapport)
the information necessary for an accurate diagnosis.15-17
Differing expectations from patients (e.g., goals of visit,
expected results)
SITUATIONAL
Lack of trust
Lack of quality sleep or other personal issues can affect
Situational thinking, limit physical stamina, accelerate burnout, and
Inadequate training reduce empathy.6 Medical knowledge deficits can lead to
Lack of resiliency frustration with patients.18
Personal health issues (e.g., mental health condition)
Identifying Patient Factors
Physician insecurity about their medical knowledge
Sleep deprivation
Most physicians identified a patient’s ability to frustrate or
trigger an emotional response as the most common patient
Systemic factor encountered.1,4,14 Table 2 lists other patient factors that
Corporatization of medicine (i.e., inadequate time for can lead to difficult clinical encounters.2,19-21
patient care) Previous models for difficult encounters involved label-
Increased documentation requirements ing different patient archetypes, but evidence suggests that
Lack of staff support and resources labeling a patient as difficult can cause serious harm.16,17,22
Moral injury (the challenge of simultaneously knowing Labeling patients in the medical record, such as noncompli-
what care patients need but being unable to provide it ant, or using race identifiers and quotation marks can lead to
due to constraints that are beyond our control) disparities in care and worse health outcomes.16,17,22
Social determinants of health (health-related social Physicians are more likely to perceive patients with mul-
needs, including housing instability and nutritional
tiple complex diagnoses and vague medical problems as dif-
insecurity)
ficult in the context of time pressures.23,24 Physicians often
Systemic racism (systemic unfairness that leads to socio-
economic and health disparities for patients)
perceive patients who request unnecessary imaging, labora-
tory tests, or procedures as difficult.25
Information from references 6-13. Anger, agitation, or demanding and manipulative behav-
iors can elicit strong defensive responses from physicians and

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 DIFFICULT PATIENT ENCOUNTERS

need for specific treatments or ability to pay for care can lead
TABLE 2 to feelings of helplessness for patients and physicians.28
Some patients with personality disorders do better with
Patient Factors That Can Lead to Difficult collaborative primary care and a behavioral health team
Clinical Encounters approach.29,30 Physicians should avoid labeling patients
Behavioral issues as dependent, entitled, manipulative, or self-destructive
Agitated, angry, defensive, frightened, or resistant because these labels inhibit collaboration and empathy.31,32
Demanding or entitled
Medical Setting
Drug-seeking behaviors
The practice setting can influence a patient’s experience. In
High utilization of health care
all medical settings, time delays are common. Practice-level
Lack of trust approaches, such as providing inviting waiting rooms, com-
Manipulation fortable seating and temperatures, calming music, and an
Manner in which patients seek medical care easy check-in process, can improve the physician-patient
Nonadherence to treatment experience.20
Not in control of negative emotions/grieving
Poor ownership of their health Therapeutic Approaches
Refusing to consider therapeutic avenues based on value FOCUS ON THE ENCOUNTER
conflicts The most important element in managing a difficult encoun-
Self-sabotage or powerlessness ter is to focus on the situation instead of the person.16,17,22
Suicidal and self-injurious behaviors Acknowledging emotions that are negative, nonproductive,
Unmotivated or cause distress can help reduce physician anxiety.33,34 Being
Vague or exaggerated body symptom complaints comfortable with discomfort and understanding that con-
trol is a myth can help physicians work collaboratively to
Medical, social, and socioeconomic conditions find common ground and focus on shared concerns.35,36
Medical:​chronic pain syndromes;​functional somatic
disorders;​history of physical, emotional, or sexual UNDERSTAND THE PATIENT’S SITUATION
trauma;​substance use disorder
As Dr. Francis Peabody stated nearly a century ago, “…the
Social:​belief systems unfamiliar to physician’s frame of
secret of the care of the patient is in caring for the patient.”37
reference;​conflict between patient’s and physician’s
goals for the visit A determined curiosity can uncover psychiatric conditions,
Socioeconomic:​financial limits causing difficulty with past trauma, substance use, and family or social dysfunction.
therapy adherence;​limited access to care, resulting in Understanding the patient’s situation can increase empathy
a need to cover more than four medical issues per visit;​ toward patient challenges and provide treatment direction.38
low health literacy/education;​systemic racism (systemic
unfairness that leads to socioeconomic and health dis- INTERPRET STRONG EMOTIONS
parities for patients)
Recognizing the strong emotions that are often triggered
Psychiatric diagnoses in the difficult patient encounter is an important skill. It
Bipolar disorders requires cultivating an ability to mentally step back from a
Borderline personality disorder strong feeling and simply observe it. Physicians should focus
Dependent personality disorder on interpreting the situation and determining an appropri-
Other personality disorders ate action rather than reacting to the strong emotion. This
dispassionate recognition of emotions is a type of mindful-
Adapted with permission from Cannarella Lorenzetti R, et al. Man-
ness.33 One way to do this is with the Name It to Tame It tool
aging difficult encounters:​understanding physician, patient, and
situational factors. Am Fam Physician. 2013;​87(6):​421, with addi- (Table 3).33,34,39 Another tool that can be used in cultivating
tional information from references 2, 19, and 20. empathy is the CALMER approach (Table 4).40

NEGOTIATE THE AGENDA

reduce collaborative care.26 Conditions that are traditionally Setting an agenda at the beginning of the encounter allows
difficult to treat, such as substance use, trauma, chronic pain, for shared decision-making on priorities. Agenda setting
and psychological conditions, can elicit frustrations before also enables the physician to agree that the patient is in dis-
the visit starts.27 A lack of shared understanding about the tress and accept responsibility for providing care.1

496 American Family Physician www.aafp.org/afp Volume 108, Number 5 ◆ November 2023
 DIFFICULT PATIENT ENCOUNTERS

VALIDATE SYMPTOMS AND UNCERTAINTY struggling. The physician may also consider rephrasing “this
A diagnosis is often viewed by patients as proof and vali- is going to be terrible” as “I feel worried, and I can build
dation of symptoms.38 Acknowledging a patient’s symptoms empathy.” It is also important to build awareness of what
and experiences results in a patient seeing a physician’s will- the strong emotions are saying. Patient context matters in
ingness to work with them and does not take away from an addressing each difficult encounter. The focus should be on
effective health care relationship.1,38 commonality with the patient rather than differences.
Clarification between illness, symptoms, or personal
experience vs. disease and abnormality in structure and ESTABLISH THE AGENDA
function of organs or tissue can help reframe the discussion Asking “what are we working on today?” lets the patient tell
with patients.38 Many illnesses are not structural, and exten- you their most pressing concerns and allows physicians to
sive workup to find a structural reason to validate symptoms negotiate what is doable in this visit. Discussing the expecta-
can cause increased harm.1,38 Finding a nonstructural diag- tions of the patient for management of their anxiety provides
nosis that justifies their illness can improve sense of self, pro- an opportunity for physicians to commit themselves to the
vide a common language for discussing treatment, and can patient and their self-management. Empowering patients to
help the patient move from a focus of curing the illness to make their own health care decisions and own their choices
coping with it.38 results in improved health outcomes.3,46
Examples of questions that empower patients are, “I
MOTIVATIONAL INTERVIEWING remember you telling me that a different medication was
Motivational interviewing is a counseling tool that can be helpful in the past. Can you tell me about that?” “I want
useful in helping patients feel understood and enable shared to help but I can’t prescribe the same medication because
treatment plans. It involves four main steps:​(1) asking the risk of dependence, withdrawal, and side effects from
open-ended questions to ensure a shared understanding;​
(2) affirming the patient’s priorities and efforts so far;​(3)
restating opposing priorities or values to allow the patient to TABLE 3
determine what treatment they can commit to (i.e., reflective
listening);​and (4) summarizing the decision and confirm- Name It to Tame It Mindfulness Tool
ing the treatment plan. Motivational interviewing allows Example
patients to express themselves while allowing physicians to A patient you struggle to work with has an appointment
affirm patient efforts, offer empathy, and develop a shared in your clinic. As soon as you see their name, your chest
tightens, and you snap at your front desk staff for sched-
understanding and course of action. Motivational inter-
uling them so soon after the last visit.
viewing improves the therapeutic alliance with patients and
can effectively influence behavioral change.41-45 Steps
Notice Notice the strong emotions that are
A Case Study occurring and name them (e.g., anger,
fear, unease). Choose a word to describe
A 72-year-old married woman with opioid dependence is in
the emotional reaction.
remission and struggling with mild cognitive impairment. She
arrives late to her appointment. At every visit, she describes Acknowledge Acknowledge this emotion and calmly
overwhelming anxiety and often requests a prescription of ben- hover over it to allow your executive
brain to filter and organize it.
zodiazepines. Five months ago, she was prescribed five tablets of
lorazepam by a colleague. A review of the prescription monitor- Make room Make room for the emotion. Be with
ing program shows that she is not taking other controlled pre- the anger, fear, and unease without
scriptions. You have recommended counseling, social support, explaining it.
behavioral health interventions, and family involvement, but she Expand Expand awareness and monitor strong
has consistently refused these suggestions. You feel frustrated awareness emotions so that the emotions do not
at every visit and note that you dread her appointments. take over when they return.

Outcome
PRACTICE EMPATHY
Naming the emotion and making room for these strong
The mindfulness approach of Name It to Tame It can feelings can lead to feeling more calm and balanced.
build awareness of your feelings and understanding of
the situation. The physician should acknowledge that see- Information from references 33, 34, and 39.

ing the patient is a problem and reframe it as the patient is

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 DIFFICULT PATIENT ENCOUNTERS

long-term use is too high. Are you willing to try one of these Physician Self-Care
other options?” The pressures of being a physician can lead to increased
isolation.53 Self-care is a process that lets physicians present
VALIDATE THE PATIENT’S SYMPTOMS the best versions of themselves with the needed reserve to
Instead of saying “There is nothing on your imaging that cope with difficult encounters.54,55 Resources on self-care can
would explain your symptoms,” try saying, “I understand include support groups, reflection groups, such as Balint,
that you’re hurt and that must be frustrating.” Acknowl- and professional coaching and counseling. References and
edging her anxiety and validating her
situation can improve the therapeutic
relationship and future symptoms. TABLE 4
Physicians who validate also encourage
a patient’s self-efficacy. How to Be a CALMER Physician
Element Approach
TOLERATE UNCERTAINTY
Catalyst for Remind yourself that you cannot control the situation.
Lack of a clear structural diagnosis can change Patients must own the responsibility for change.
worsen anxiety. Collaborating with
Physicians cannot control the patient’s behavior, but they can
the patient can create acceptance of
control their own reaction.
the diagnostic uncertainty and shift
Identify the stage of change and work toward moving patients
the focus to managing symptoms and to the next stage.
improve coping.
Alter Recognize that the only way physicians can control their reac-
EXPLORE RESISTANCE TO thoughts tions is to alter their thoughts about the situation.
to change Identify negative feelings the patient is eliciting.
RECOMMENDED THERAPIES
feelings
Motivational interviewing identifies How are these feelings affecting the doctor-patient
ambivalence toward change, hesitance relationship?
with suggested therapies, and barri- Do not take it personally. This is how the patient reacts in many
areas of their life, not just in the doctor’s office.
ers to changing behaviors. This helps
with “I don’t know” answers from the Consider why the patient may act this way (e.g., history of
abuse, loneliness).
patient. For example, “On one hand,
What can physicians tell themselves about the situation that
you are bored with your day-to-day
might make them feel less angry? (e.g., “I would be frustrated if
tasks and on the other, you are really I was in pain as well,” “If I felt lonely, I would worry that no one
anxious about trying out the senior cares about my opinion”).
center. I wonder what would have to
Listen and Negative responses to a patient’s behavior can limit how phy-
change for you to feel comfortable
then make a sicians perceive a situation and how willing they are to engage.
enough to give it a try?” “Are you will- diagnosis This can lead to errors in diagnosis. The ability to navigate
ing to work with me on this problem so negative feelings will improve the chances of making a correct
that we can find a solution together?” diagnosis.

Make an Restate the plan of care made with the patient to get a confir-
Further Communications
agreement mation of their agreement.
Solutions
This will help patients increase the awareness that they are
For all communication, especially emo- making a conscious choice to continue working with the phy-
tionally charged discussions, physicians sician. Additionally, it helps both the physician and patient see
should use active listening skills, vali- increased control in managing the issue.
date patient emotions, explore alterna- Educate and Help patients set realistic, achievable goals on which the physi-
tive solutions to problems, and provide follow up cian and patient can agree.
options for the patient (Table 5).21,47-52 An
approach that identifies and addresses Reach out Acknowledge that difficult patient encounters can take a toll on
and discuss physicians. Find appropriate avenues to ensure self-care.
physician and patient contributions to feelings
the difficult encounter can result in more
effective care, less burnout, and improved Information from reference 40.

physician and patient satisfaction.1,47

498 American Family Physician www.aafp.org/afp Volume 108, Number 5 ◆ November 2023
 DIFFICULT PATIENT ENCOUNTERS
TABLE 5

Communication Strategies to Redirect an Emotionally Charged Clinical Encounter

Strategy Physician actions Examples

Use active listening Understand the patient’s priorities, “Please explain to me the issues that are important to
let the patient talk without inter- you right now.”
ruption, and recognize that anger is
usually secondary to another emo- “Help me to understand why this upsets you so much.”
tion (e.g., abandonment, disrespect)

Validate the emotion and Name the emotion;​if you are “I can see that you are angry.”
empathize with the patient wrong, the patient will correct you;​
(understanding, not disarm the intense emotion by “You are right—it’s annoying to sit and wait in a cold
necessarily sharing, the agreement, if appropriate room.”
emotion with the patient)
“It sounds like you are telling me that you are scared.”

Explore alternative Engage the patient to find specific “If we had told you that appointments were running late,
solutions ways to handle the situation differ- would you have liked a choice to wait or reschedule?”
ently in the future
“What else can I do to help meet your expectations for
this visit?”

“Is there something else you need to tell me so that I

can help you?”

Provide closure Mutually agree on a plan for “I prefer to give significant news in person. Would you
subsequent visits to avoid future like early morning appointments so you can be the first
difficulties patient of the day?”

“Would you prefer to be referred to a specialist, or to

follow up with me to continue to work on this problem?”

Information from references 21 and 47-52.

tools for physician well-being can be found at https://​w ww. the Procedures Institute at Full Circle Health’s Family Medi-
aafp.org/family-physician/practice-and-career/managing- cine Residency of Idaho–Boise.
your-career/physician-well-being/practicing-self-care.html.
SUSAN A. MARTIN, PsyD, is an assistant clinical professor
This article updates previous articles on this topic by Cannarella in the Department of Family Medicine at the University of
Lorenzetti, et al., 21 and Hass, et al.56 Washington, Seattle;​the director of behavioral sciences
Data Sources:​We searched the Cochrane Database of System- for the Family Medicine Residency of Idaho–Caldwell;​
atic Reviews, CINAHL, PubMed, EBSCO Host, and Essential and program director and site supervisor for the Idaho
Evidence Plus. Search terms were difficult patient encounters, Psychology Internship Consortium, Nampa.
challenging patients, anger, noncompliance, physician-patient
relations, physician-patient communications, heartsink ANGELA BANGS, MD, MBA, is a third-year resident
patients, demanding patients, patient satisfaction, motiva- at Full Circle Health’s Family Medicine Residency of
tional interviewing, literacy, abuse, somatoform disorders, and Idaho–Boise.
chronic pain. We also searched the bibliographies of previously
identified studies and reviews, the ClinicalTrials.gov registry, Address correspondence to Justin Bailey, MD, FAAFP,​Family
the U.S. Preventive Services Task Force, and UpToDate. We Medicine Residency of Idaho, 777 N. Raymond St., Boise, ID
included only English-language publications. Whenever possi- 83704 (justinbailey@​fullcircleidaho.org). Reprints are not avail-
ble, if studies used race and/or gender as patient categories but able from the authors.
did not define how these categories were assigned, they were
not included in our final review. If studies that used these cate-
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500 American Family Physician www.aafp.org/afp Volume 108, Number 5 ◆ November 2023