Becoming "Difficult"

At 6 a.m. on my third day at the hospital, I was frantically calling and e-mailing my friends who were physicians, hoping and praying that one of them would get me the medical care I desperately needed. I was in excruciating pain and terrified that I would miscarry the precious baby inside of me. I had been seen by multiple physicians in the previous week, but I still didn't have a diagnosis. Upon admission, I told the internist my strong suspicion that I had a serious infection. However, the specialists who had since evaluated me had written off my complaints as a "functional syndrome"—a diagnostic label used to describe symptoms that have no clear cause and for which there is often, as in my case, no treatment recommended. I had thus been dismissed as a hysterical pregnant woman whose problems were emotional, not medical. I felt abandoned by the medical system, and I was terrified that I or my baby would die.

Ironically, in my professional life, I am a psychiatrist who is consulted by other physicians to manage the patients they don't know how to help, many of whom would be described in the medical literature as "difficult." Although I am not typically a difficult person, mistreatment by an imperfect system forced me to become a difficult patient and to see things from the patient's perspective.

Physicians are held to a high standard of professionalism in their relationships with their patients. But when faced with difficult patients, many physicians react like anyone would, whether their behavior is professionally appropriate or not. These doctors may avoid interactions with patients whom they find unpleasant, pushing them off until late in the day, acting distant or abrupt to silence them, or even lashing out at them, driven by a sense of frustration and helplessness when treating this kind of patient. Physicians may then weigh the risks and benefits of potential interventions inaccurately because of the impaired relationship, and this can lead to either undertreatment of difficult patients (because the doctor dismisses their symptoms) or overtreatment (because the doctor wants to placate them). Physicians' time constraints, fatigue, burnout, and ineffective training in communication skills combine with a medical system overly focused on test results and imaging studies (which can be inaccurate or misleading) to further marginalize the difficult patient; most physicians just don't have the energy or expertise to work with them.

During the five days between my admission and the test result that confirmed I had a "real" medical problem, I was—like difficult patients often are—mistreated by the physicians from whom I needed help. The decision not to treat my symptoms—meant to minimize harm to me and my baby—actually resulted in worse pain, more anxiety, progression of my infection, and intense emotional and physical stress on my body. I would not have become such a difficult patient if the medical system had responded more appropriately to my complaints from the beginning.

As medicine becomes more technology-oriented, less time and emphasis are placed on learning and practicing the art of the doctor-patient relationship. Patients are viewed as the sum of their diseases, rather than as unique individuals with physical, emotional, and spiritual needs that impact their health. I now see that difficult patients are sometimes a byproduct of a system that disregards their individual needs. Once a patient is classed as difficult, a vicious cycle may ensue: the patient has bad interactions with her doctors, leading to inappropriate medical management, which further exacerbates the feelings or behaviors that made the patient difficult to begin with. The tension escalates as patient and physician behave in untoward ways, and the quality of both the relationship and the care deteriorates. Until the medical system encourages physicians to become competent healers and not just technicians, I worry that more and more people will become "difficult."

Although doctors will never be able to fix all that ails us, I hope that the doctor-patient relationship, professionalism, and good communication will take a more central role in the future of hospital-based medicine so that all of our patients—even the...