II. Risk Factors
- Medical Provider factors
- Provider Burnout, exhaustion, Fatigue or sleep deprivation
- Time pressure
- Provider insecurity or sense of challenge to medical opinion
- Provider discomfort with diagnostic uncertainty
- Provider with limited training in psychiatric conditions
- Provider difficulty with communication (especially Expressing Empathy)
- Patient factors
- Patient angry, demanding or manipulative
- Noncompliance with recommended therapy
- Somatization
- Excessive Worry
- Drug-seeking behavior or Chemical Dependency
- Chronic Pain Syndrome
- Multiple presenting complaints at each visit
- Personality Disorder (e.g. Borderline Personality Disorder)
III. Management: General
- See CALMER Approach to Difficult Clinical Encounters
- Listen and allow patient to speak uninterrupted
- Name and validate the emotion you sense the patient is feeling
- Problem solve with the patient on preventing similar difficult encounters in the future
IV. Management: Dependent and insecure patient
- Signs
- Patient praises provider and requires increasing time and needs from the provider
- Provider Approach
- Establish and maintain professional boundaries
- Schedule regular appointments, and reassure patient of continued care
- Encourage patients active involvement in decision making and medical plan
V. Management: Entitled and demanding patient
- Signs
- Patient bypasses standard medical protocols, assumes special medical access and angry when not catered to
- Provider Approach
- Address specific emotions and their underlying causes (e.g. acute illness, serious comorbidity, pscyhosocial stressors)
- Assure the patient of sound medical care
- Discourage mis-directed anger
VI. Management: Manipulative patient who rejects help
- Signs
- Recurrent presentations for potentially serious symptoms, yet refuses or non-compliant with recommended approach
- Provider Approach
- Refocus attention
- Patient to provider connection
- Symptomatic relief over medical cure
- Set reasonable expectations that patient is willing to pursue
- Informed Consent when this is likely to result in worse outcomes
- Refocus attention
VII. Management: Self-destructive patient with sense of hopelessness
- Signs
- Despite maximal management, patient continues self-destructive behaviors, and health problems progress
- Provider Approach
- Manage underlying Mood Disorder (Major Depression or Anxiety Disorder)
- Address specific underlying causes (e.g. limited funds or medical system access)
- Establish reasonable goals and congratulate patients when progress is made