Communicating With the Troubled Patient

Craig R. Hildreth, MD

Among other sundry duties in the course of the professional career, physicians are charged with making every attempt to gain the trust of their patients, with the goal of creating a bond that ameliorates the frustration and anxiety associated with the long march from illness to haleness. This consummation, no doubt the recipient of devout wishes, unfortunately can be a tough nut to crack. Some of the folks under our care have built-in resistances to our ministering. They are inherently skeptical of the devotion or even the motives of the person designated to give them satisfaction. They exhibit a disturbing lack of faith in the benefit of encouraging words, resulting in a posture that can try the equanimity of the doctor. I refer specifically to those patients who suffer from anxiety, hypochondria, or discontent. One can bend only so far under the strain of attempting to bring comfort to these restless souls before snapping like a rope bridge in chapter seven of a jungle thriller.

That’s the crux of the matter-when communicating with the difficult patient doctors are advised to avoid such approaches as snapping, bristling, or even a subtle curling of the lips. One simply has to learn, and often with haste, a skill set that rallies the crowd and keeps the play moving along to the next act with minimal discord. We should also resist the temptation to skip lightly over dicey topics such as side effects or prognosis. In accordance with Murphy’s Law such shortcuts double the odds of a calamity, which undoubtedly leads to the conclusion that the doctor is a double-talking warthog.

Take the example of the patient suffering from high anxiety. The first step to be taken in calming the waters is to refrain from creating a folie à deux of terror. I find that displaying tranquility and listening intently, with an occasional sympathetic nod, works well. It helps to identify the emotion with a gambit like “You seem scared,” which often releases the cathartic waterfall. It is also worthwhile to bring the patient’s loved ones into the conversation. Be honest when discussing side effects and outcomes, and although not all physicians would agree, never underestimate the return on investment of injecting some well-timed humor into the visit. Try to allay the patient’s fears by pledging the best and most diligent care. When all else fails, pass out T-shirts that say “KEEP CALM and [indelicate transitive verb] CANCER.”

The hypochondriac is, in my opinion, a lost cause. One might as well search for the missing nose of the Sphinx as try to satisfy patients afflicted with a superhuman awareness of their inner workings and a firm conviction that they are cursed with the “death of a thousand complaints.” Nevertheless, one should attempt to attend to them, asking the clever questions one learned in school and poking around the corpus for clues. Be patient and have faith-before indigestion sets in the visit will be over, at which time it would be pretentious for the doctor to expect tears of gratitude for diligently chronicling the hypochondriac’s woes. No, just expect the diary to be stowed away until the next visit. One is allowed to enjoy a discreet smile, especially after the patient has been convinced, however reluctantly, that Death is not lurking nearby with an upgrade to first class on the flight to infinity.

The secret to helping these patients, if there is one, is to never allow the patient to interpret one’s words and body language as judgmental. The oncologist who appears unsympathetic or irritable takes the risk of unleashing what the psychologists call “displaced aggression,” which has the same effect on the master plan as lighting a match in a shed full of dynamite. No matter how convinced the patient is that a tumor grows behind the left ear, one must suppress the urge to react as if the family dog just recited a limerick. As if this isn’t hard enough, self-control will really be put to the test when we meet our greatest challenge, viz, the disgruntled patient.

Discontent and displeasure usually infects people long before they find themselves in the oncologist’s office. Consider it a pre-existing condition, born of an unknown date, nurtured by experience, wielded with resolve and building enough tension to make the doctor have second thoughts about not putting windows in the exam room. These patients are masters of the silent stare, possessing the uncanny ability to make one feel guilty of some unnamed crime against humanity. Subject-verb disagreement and tics often appear when an oncologist has to counsel one of these stone faces.

Yes, despite best efforts sometimes one fails to swing the attitude around to sunshine and flowers. The patient is certainly allowed to be unhappy about the diagnosis (perfectly understandable), to be unhappy about taking chemotherapy (an honest emotion), but is it productive to register disgust with everything the oncologist has to say? Is it customary to greet a bit of good news the same way one reacts to the discovery that one’s connecting flight is rolling along on the tarmac, sans oneself?

The disgruntled patient is frustrating by all means, but short of a breach of one’s probity it is better to shelve any thoughts of confrontation. When sketching out the essentials my advice is: stick to the facts. Iterate and reiterate the unassailable truths about their situation; show them the evidence behind each decision; explain with clarity the reasons why this and not that was ordered. Be stout. Don’t give them any grounds to think that they have hired a milksop or a dullard.

This piece of advice was given to me early in my career: “Always give out a big smile just before you walk into a patient’s room, and just after you walk into a patient’s room.” After years of laboring in the clinic I understand why: it means you, not the troubled patient, have just set the tone for the visit.