II. Risk Factors

  1. Medical Provider factors
    1. Provider Burnout, exhaustion, Fatigue or sleep deprivation
    2. Time pressure
    3. Provider insecurity or sense of challenge to medical opinion
    4. Provider discomfort with diagnostic uncertainty
    5. Provider with limited training in psychiatric conditions
    6. Provider difficulty with communication (especially expressing empathy)
  2. Patient factors
    1. Patient angry, demanding or manipulative
    2. Noncompliance with recommended therapy
    3. Somatization
    4. Excessive Worry
    5. Drug-seeking behavior or Chemical Dependency
    6. Chronic Pain Syndrome
    7. Multiple presenting complaints at each visit
    8. Personality Disorder (e.g. Borderline Personality disorder)

III. Management: General

  1. See CALMER Approach to Difficult Clinical Encounters
  2. Listen and allow patient to speak uninterrupted
  3. Name and validate the emotion you sense the patient is feeling
  4. Problem solve with the patient on preventing similar difficult encounters in the future

IV. Management: Dependent and insecure patient

  1. Signs
    1. Patient praises provider and requires increasing time and needs from the provider
  2. Provider Approach
    1. Establish and maintain professional boundaries
    2. Schedule regular appointments, and reassure patient of continued care
    3. Encourage patients active involvement in decision making and medical plan

V. Management: Entitled and demanding patient

  1. Signs
    1. Patient bypasses standard medical protocols, assumes special medical access and angry when not catered to
  2. Provider Approach
    1. Address specific emotions and their underlying causes (e.g. acute illness, serious comorbidity, pscyhosocial stressors)
    2. Assure the patient of sound medical care
    3. Discourage mis-directed anger

VI. Management: Manipulative patient who rejects help

  1. Signs
    1. Recurrent presentations for potentially serious symptoms, yet refuses or non-compliant with recommended approach
  2. Provider Approach
    1. Refocus attention
      1. Patient to provider connection
      2. Symptomatic relief over medical cure
    2. Set reasonable expectations that patient is willing to pursue
      1. Informed Consent when this is likely to result in worse outcomes

VII. Management: Self-destructive patient with sense of hopelessness

  1. Signs
    1. Despite maximal management, patient continues self-destructive behaviors, and health problems progress
  2. Provider Approach
    1. Manage underlying Mood Disorder (Major Depression or Anxiety Disorder)
    2. Address specific underlying causes (e.g. limited funds or medical system access)
    3. Establish reasonable goals and congratulate patients when progress is made

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