Working With Challenging Patients

The patients we see can be quite challenging. Most practices do not have psychological support on site. The following, along with our section on Patient Agreements, will help you optimize interactions with difficult patient and difficult situations.

Identify Patient’s Agenda

This is crucial foundation from the onset of your doctor-patient relationship. If the healthcare provider and patient are not on the same page, the relationship is likely not going to succeed. Why are they here? Why now? What are they looking for? Is what they desire a treatment you feel is medical sound? Are there contributing psychological issues? Are you the appropriate healthcare provider to treat this patient?

Identify Control Issues

Do you feel like you are going into battle when you’re working with certain patients? Do you cringe when you see certain names on your patient list for the day?  Are you drained following appointments?  Is your patient consistently bargaining with you and making excuses for failing to follow recommendations?

Identify Barriers

Does the patient have a support system? Is family or a significant other involved? If so, are they a support or a barrier to optimizing treatment? Do any family members have a chronic illness or an addiction?  Has the patient ever taken or bought illicit or prescription drugs?  Do you have concerns that the patient may divert medications?  Are they asking for early refills?  Is the patient employed?  If so, are there disability issues?  Does the patient have past or current psychological issues?  What type of psychological treatment have they tried and for how long?  If indicated, are they open to working with a therapist?  Are they open to use of medication to treat mood issues?

Identify Boundary Issues

Is the patient respectful to you, your staff, and your colleagues? Do they make their scheduled appointments? Are they focused on medications you don’t think are appropriate for their symptoms?  If you refuse requests, how do they respond? Have they ever acted inappropriately? Have they threatened self-harm, harm to you, or harm to your staff if they do not get what they are requesting? Do they respond to consistent boundaries and expectations you set?  Have a zero tolerance policy for inappropriate behavior toward your staff, and toward yourself.

Think About Responsibility

Does your patient take responsibility for their medical care?  Do they blame others for their lack of progress?  Are you working harder than your patient?  

Think About What Your Patient Hears

Stress and mood issues can contribute to your patient’s difficulty listening to and/or recalling information explained and goals established in an office visit.  Have your patient verbalize, in their own words, information and recommendations you presented in the appointment.  If they are not focused or not understanding, you will know immediately, which will save time and optimize treatment. Take the opportunity pause, and reset.  Explain your analysis of their condition and your treatment recommendations again, and have them repeat those back again. It can be helpful to have a pen and paper ready for your patient, and encourage them to take notes during the appointment.

Our patients can be demanding and complex.  Caring for them can also be incredibly rewarding. But if things aren’t going well, it can be tremendously helpful to have a good working relationship with an interdisciplinary group of health care providers to whom you can refer your patient:  Psychologists, psychiatrists, social workers, palliative care specialists, etc.

However, if they do not respond, termination and referral to another practice may be necessary. It is not a sign of failure. If they are not there for the right reasons they can be time consuming, drain emotional energy and use a disproportionate use of resources. It’s not unusual to begin to use avoidance strategies, which can compromise patient care.


Remember—Set your patients up for success. Similar to an Opioid Contract, it may be beneficial to have guidelines written out in the form of an agreement for your patient to sign at their first appointment.  That will also provide a great jumping off point for an open discussion, as well as an impetus for patients who might otherwise be reluctant to ask questions.