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The Difficult Patient Solution

Mar 21, 2022

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Every physician has had a difficult or challenging patient at some point. And, let’s be real, anyone can be difficult for another person, given the right circumstance. But for doctors, especially, demanding patients can be a source of immense stress. The encouraging truth, however, is that it doesn’t have to be, even when the experience is quite negative. There is a solution to handling a frustrating patient, without the extreme solution of dismissing the person from your practice.

Coaching and mindset work are amazing tools that offer a solution. This doesn’t mean that the pain disappears completely or that, when it comes, it’s less legitimate. It simply means that there is hope that interactions will become less personally distressing. That you’ll bring fewer and fewer irritations home. And maybe even come to the place where you can reduce the urge to convince patients of your viewpoint or replay the interaction over and over in your mind. Speaking of which, your mind is where you can make it happen. Let’s talk about how.

“What makes someone challenging or a problem or difficult is our judgment about them, is our thinking about them… other people can’t make us feel anything without our permission.”  – Dr. Sara Dill

What You’ll Learn 

  • Redefining the difficult patient 
  • Separating fact from feelings
    • An exercise in thought examination
  • Emotional Adulthood versus Emotional Childhood
  • Where your power lies: responding rather than reacting
    • The slow motion replay
  • Recognizing that they have freedom but so do you

Contact Info and Recommended Resources

Connect with Sara Dill, MD, The Doctor’s Coach

Want to know more about me and how I learned to stress less? I recorded a trailer for my podcast that includes some of these details. I’ve also included a short bio below. 

Meet Dr. Sara Dill

Welcome to my podcast, Stress-Less Physician. I’m Sara Dill, MD, board-certified dermatologist and pediatric dermatologist. Like nearly all physicians, I used to believe the way to be a good and successful doctor was to work hard, always say yes, and put patients (and everyone else) first. I was successful following that pattern but (as is typically the case) I felt perpetually stressed out, overworked and unhappy. 

Compelled by the truth that I’d worked too long and hard to simply accept stress as inevitable, I was determined to find the answer. In order to fully devote myself to discovering a solution, I took a sabbatical from my practice and studied life coaching. I completed two life coach training programs, numerous other courses, read 100s of books, and used coaching to transform my own relationship to work.

What I learned was that stress is a symptom. It all has less to do with the actual hours you work than with your thoughts about your work.

With this knowledge, I took control of my life. So can you! But you don't have to take years or go on sabbatical. I did it so you don't have to. And I’m here to help.

Transcript

I’m Dr. Sara Dill, and this is the Stress-Less Physician Podcast, episode number six. Welcome to the Stress-Less Physician podcast. I’m your host, Dr. Sara Dill, MD. Using my unique combination of coaching and mindfulness tools, I will teach you practical ways to reduce your stress level, feel happier at work, and create a better balance between your medical career and personal life. If you are a busy practicing physician who wants to design a life and medical career that feels good to you, you are in the right place.

Hey, everyone, how are you? I am doing great. Except I have to confess, I’m a little cold today. I live in Santa Barbara, and I know I shouldn’t be complaining about the weather, especially because I lived in New England for about, I think, 11 years for school, for training, and for work. And I want to say I love New England; I miss it a lot. But Santa Barbara gets this cold, chilly, damp fog, and it just feels extra cold. And today there’s this cold wind as well. So, it’s embarrassing, but sometimes I even wear my New England clothes out here. It feels that cold to me. It’s embarrassing. I think we just acclimate to where we are, probably.

So, I’m a little cold, but otherwise doing great hope you are too. So, today I want to talk about difficult patients, and I want to talk about the solution to them. And look, if anyone listening is not a physician, this is not personal. Every one of us, including and especially maybe as physicians, we all have the potential to be a difficult patient for someone. And in fact, I think doctors frequently make for difficult patients, for other physicians as well.

So, I think coaching and mindset work and thought work are great tools for solving this difficult patient problem. I am in many physician Facebook groups and the frustration and the stress so many doctors experience around difficult or challenging or demanding or entitled patients is immense. It’s real.

I want to emphasize too here, that although I talk a lot about how in some way, we are the cause of our own experience of the world and that we’re the cause of our own emotions, that doesn’t mean that the negative emotions and the emotional suffering we feel is less legitimate or that it hurts less. I like the idea that pain is pain, even if our unsupervised thinking is the cause of a lot of it. In a future podcast, I think we’ll talk about this idea of clean pain versus dirty pain.

But for now, I want to make it clear that I hope that when I talk a lot about causing our own emotional response, that if you’re in pain, or you’re suffering or you’re struggling or feeling stressed out, your emotional experience, whatever it is, is true for you. And that feeling stressed out by difficult patients is hard and valid. And yet, I want to offer that it’s also optional. You really can solve the difficult patient problem, and not by dismissing them from your practice – although of course, that’s always an option. But you really can stop having difficult patients, maybe not 100%, but pretty darn close.

So, what or who is a difficult patient? I talk about this a lot in coaching. I coach clients on this frequently. And again, I get it. I think one reason I ended up taking a sabbatical from practice a decade ago—although I’m now back in practice and enjoying it—was because I didn’t really know how to deal with patients that I personally found difficult, and how not to take our interactions personally, and how not to take home my frustration and irritation, how not to continue to review it over and over again and how to not need patients to see my perspective. Or try to convince them that I was right. All of that really made for a lot more emotionally draining practice experience for me.

So, the first place to start is to notice that each of us probably has a different definition of what makes a patient or colleague or a family member. If you’re not a physician and you’re listening, this can be any person, this applies to all other people, is to notice that we all have a different definition of what makes someone “difficult” or “challenging.”

Who are the people, or the patients that you find difficult? How would you describe them to me? What do they say? Or what do they do? Often, we describe them as disrespectful or uncooperative or demanding, entitled, unappreciative, maybe unkind or rude, what else? But there’s not a universally difficult patient, I would argue at least. There are absolutely patients, however, that are difficult for you and for me, and for other physicians. The interesting thing is to notice that these might be different, they probably are different.

So, for me, a sort of classic, difficult patient, one that I’ve coached myself on many a time might be someone who shows up late, who demands a full skin check when they aren’t scheduled for one, or typically, it’s that late person who shows up late and also wants to be added on for a full skin check. Maybe a patient who has multiple different questions brings in a list. You know, we have thoughts about the list. Maybe a patient who brings in a map of all their skin complaints, and there are literally hundreds on there, usually not very well drawn picture. Those are some of my difficult patients.

So, I would like to just challenge you here to consider the idea that in some sense, there’s no such thing as a “difficult” patient, no such thing as an inherently difficult patient. So, stay with me here. What makes someone difficult or challenging? Now, if you’ve coached with me, you know the answer to this question. What makes something or someone a problem, for us, what makes someone challenging or a problem or difficult is our judgment about them, is our thinking about them.

So, you could have the exact same patient with the exact same dynamics, the exact same situation. And I can think they’re a problem and that they’re difficult or challenging. And you could think that they were great, or pleasant or funny, or normal, or whatever. So, many different options. So, the only difference here is how you or I are deciding to think about someone.

So, if I was coaching you on this, I would have you pick a recent difficult patient encounter, or again, just a difficult person, for anyone listening, and then just tell me all about it. You would probably think you were just telling me the way they were, just telling me the way it was. Notice what you think about when you think about that patient, what thoughts come out for you? Are they mostly negative? And I want you just to notice here and be a little careful here, because typically, you are likely going to think that you’re just describing them factually, just telling me how they are, that this is just how the person was or is.

And this is the hardest thing to see when you’re doing it yourself, when you’re coaching yourself, when you’re trying to look at your own mind, when you’re examining your mind with your own mind. This is why it’s helpful to do this on paper. I always have people write it all down. Or it’s helpful to do it with a coach or with someone else who can see when you think a thought is a fact but it’s not, it’s just a thought that you’re having, and point it out to you, which sometimes isn’t really something that you want to hear, but it’s where we start to do this work.

So, it’s hard to see that what you’re thinking is really just a thought or thoughts. It’s not factual—or at least some of it isn’t. So, factual here, the facts means that every single person, including the patient or person you’re labeling as difficult would agree in detail. So, look at your thinking about this challenging person and notice what you’re thinking, would they agree too? If they wouldn’t agree, then that’s probably a thought and not a fact. And if you notice a lot of negative thoughts, you probably feel pretty negatively about this person. If you have a lot of positive thoughts, it’s probably not a problem person for you, it’s probably not a difficult patient, you probably feel positive about them.

So, I would start by having you describe this difficult patient. And often, we just say things like, “They’re so demanding” Or “She was really unpleasant.” Or “He was really disrespectful.” We have these labels that we put on patients, demanding, unpleasant, disrespectful, rude, annoying, entitled. You can just see, it’s like little sticky notes that we put on people. And then it makes it difficult for us to see them more clearly. So, these sticky notes, these labels, these judgments, these thoughts, these are all our opinion, right? Our judgment, our perspective. And I mean judgment here, not necessarily in a negative way, it’s our assessment, our perspective.

And so, then I would ask you to tell me what did the patient actually say or do? What are those facts that has you think or interpret them as being disrespectful? What did they say or do that you thought was demanding, or unpleasant, or rude, or entitled? And this is where the power of coaching lies, looking at the actual facts, what someone said or did, the events that unfolded. And then why those facts like being 10 minutes late, asking for a full skin check, maybe calling you by your first name instead of Doctor whatever. Why are those a problem for you?

Sometimes I ask, “So what?” in a very kind way. So what? Why is that a problem for you? Why is that disrespectful? Is it possible that someone else could even think about it in another way? Starting to really examine your automatic thinking or interpretation of that as being, of course, disrespectful, everyone would agree with me. But would everyone agree with you? Would the patient agree with you? So, then you can ask yourself this question, why am I choosing to think this way about this patient? Why am I making x mean y? Now, you probably ought to tell me that the reason you think this way, is that they really are disrespectful, or a jerk, or annoying, or whatever.

Because we are very convinced often that this is just right and true, and that our experience is valid. And again, I would say it is valid, but what if it’s optional? Do you want to keep thinking and feeling this way about patients or about other people in your life? Couldn’t it be more enjoyable, more empowering, to start to understand that I could actually decide to think and feel differently, not for the patient or the other person, but for me.

So, I know this is a stretch, because usually, we really don’t see it as a choice, we see this person, this patient as inherently difficult. This person is challenging, and therefore, that’s why my thoughts are the way they are. But thoughts aren’t just set in stone. We really do have the ability to choose what we want to think, at least in the future we do after we become aware of our ability to do so. We can’t go back and tell ourselves that we could have thought differently. Yesterday, or a year ago, right? Because we didn’t, we didn’t know. Now we do. And what we decide to think will determine how we feel.

And most of us, what we do with things like this is we have our thoughts on autopilot. And then we blame the other person for how we are feeling. We say no, the reason I’m stressed, the reason I’m upset, the reason I’m frustrated, is because of how this other person was, what they said, what they did. So, this is the opposite of what I discussed in my first podcast episode, which was emotional adulthood.

So, emotional adulthood is this idea that we are responsible for what we feel 100% of the time, that other people can’t make us feel anything without our permission. So, the good news is, is that no one else, especially not a patient, that you find difficult, can control how you feel, can make you feel things. Other people don’t make us feel anything until we have thoughts and opinions about them.

So, when we blame how we feel on other people, again, this is very common, this is something called being an emotional childhood. Again, not something to judge yourself about or anything, especially if this is new to you, just noticing when you’re responding versus reacting. That’s how I like to think about it. Is it like just pushing a button and then I just react? Or am I actually choosing my response? That’s really what responsibility means. So, in emotional adulthood, we’re taking responsibility for what we feel 100% of the time, for creating our own emotions, when we understand this pattern. So, responsibility means we have the ability to choose our response, our thoughts and our feelings.

But it can be difficult to decide to take full responsibility for how you think and feel about this person, especially if everyone else agrees with you that they really are frustrating or annoying, or demanding or difficult. That’s sometimes the problem with being around people who are supportive or venting or complaining, it can be a way to bond and to feel connected. But sometimes it doesn’t really help you shift things, it doesn’t help you start to change how you are thinking and feeling. So, I would just notice, how do you feel when you think all these negative thoughts or these challenging and difficult thoughts about this person?

So, what matters is how you feel when you think X, Y or Z. You have a choice on how you want to think and feel. This shift will take you out of feeling like a victim, takes you out of that victim role, and puts you back in charge of you. And so ask yourself the question, do I want to keep choosing to think this way about this person? Especially if you don’t feel good. Basically, you can ask, “Do I want to keep feeling frustrated, or angry or upset, or disrespected, whatever it is, when I’m confronted with this person, or patient or this kind of situation?” So, this awareness alone can start to shift a lot for you.

And then I would have you notice, how do you show up when you’re thinking and feeling this way, the original way? Are you showing up as the physician you want to be when you are feeling frustrated or angry or disrespected? Or maybe at home, are you showing up as the partner or spouse or parent when you are feeling frustrated or angry or disrespected or whatever? Are you behaving in the way you want to behave? We know you want the other person to change their behavior, but are you behaving in a way that you like? Do you want to show up differently? Are you feeling the way you want to feel, or being the way you want to be?

Typically, what’s really interesting is that we often end up behaving the way we are accusing the difficult patient or the difficult person of being. So, if I feel frustrated by a patient, not respecting me, you can notice, am I showing up respectful of them? Am I showing up respectful of me? When I’m feeling frustrated, how do I act? How do I show up? And then you get to decide who you want to be, how you want to think and feel and act in this situation, with this patient, or this kind of interaction or circumstance. And there’s something really powerful when you decide that you want to show up, or act or be a certain way, no matter how someone else is acting, no matter how someone else is showing up.

When you know that there’s nothing that anyone else can say or do that can make you think and feel a certain way, that you always have the ability, once you have this awareness to respond rather than react. You at least have the possibility. I’m not suggesting that we’re suddenly all going to become these perfect examples of people who never get upset or never lose their cool. I certainly am not that way. If you know me in real life, you know, I am still human. And I’m still doing this work myself.

But this is really the meaning of the saying that I love so much. I think it’s often attributed to Viktor Frankl. I don’t know if it really came from him. But this idea that between stimulus and response, there is a space right between something that happens and then our response, there is a space. In that space is our power to choose our response, in our response, lies our growth and our freedom. And I would say, in our response, in that space, and in our response, I would say this is where our power lies, this is where all our power lies. How do you want to be? How do you want to behave? How do you want to feel? What do you want to think when it comes to this person or patient? How will that make you feel? And then how do you want to act?

I usually want to act kind or calm or peaceful, or confident or amused. I often go for amused a little bit rather than upset. Because sometimes I think we humans are amusing, we’re funny, we’re interesting. We aren’t very rational, we’re very quirky. But you’re not always going to be able to get there yet, especially in the moment. So, it’s really helpful to do this practice over and over, of going back and replaying difficult patient encounters, or difficult person encounters, to look at times when you were upset by someone, although now you know that you weren’t really upset by them, but you were upset by your interpretation of them. And then do this work to change how you show up in the future. It’s like I describe it as a slow motion sports replay. You go back and you replay it and you pause, you notice, when did I start feeling irritated or upset? What was I thinking? What was I making their behavior or their words or their questions mean to me?

You might be thinking that it would just be easier if this difficult person just changed or disappeared. Sometimes we just want to delete people. Or if they just behave differently or just was a different person. And yet generally, sadly, we can’t make someone another adult do what we want. We can ask, we can request, we can explain, we can set boundaries, we can have office policies. And I would say, it also helps to recognize that other adults have the freedom, they don’t need our permission to be who they are and do what they want to do. They’re going to do it anyway. We can’t control other people. You can try, but whether they decide to comply or not, is up to them. That’s their choice, that’s the choice of other people. Just like we get to choose for ourselves. And I think there’s a lot of freedom in knowing that we can’t control other people, because it’s very difficult and exhausting to try.

It doesn’t mean that in this case, in a work situation, that you can’t have rules in your office, like a late policy or a mask policy or anything. Of course, you can. But what I’m saying is you can’t control whether someone is going to try to show up late, and then demand to be seen, or want to not wear a mask, or ask you to do whatever it is that they want you to do. Maybe write a prescription that you don’t want to write, they get to be them. And then you get to respond. And you get to say yes or no, or you get to decide for yourself. But I would just suggest what if it came from a feeling of calm, or again, maybe amusement rather than frustration or guilt.

So, again, let’s identify a difficult patient for you. Let all your thoughts out, be super judgmental, don’t rein yourself in, put it all on paper. Identify the actual facts, they said this, they did this. And then you’re going to ask yourself, “So what?” You’re going to ask yourself, “Why is this a problem for me?” You’re going to ask yourself, “What am I making it mean about them, about me?” You’re going to piece it all out. That’s one of my favorite questions. What are you making it mean? Why is this a problem for me? And then you can notice how you feel in that moment, and how you act? And then you can ask yourself, if you want to keep feeling this way? How would you prefer to feel and act?

If you had a choice of any feeling—if I came by, at a cocktail party with a big tray of drinks, instead of drinks, it was just different emotions. Would you choose frustrated? Would you choose angry? Would you choose disrespected? Or would you choose a different feeling? What would you have to believe to feel that way, in that moment or in the future and then show up the way you want to? Typically, what we need to let go of is worrying about what the other person thinks and feels about us. A lot of the time, that’s what you’ll discover, when you ask, “Why is this a problem for me?”

And we often need to give up taking it personally. Think about it. So, the patient shows up late in my practice, and then is very demanding about being seen – actually, I guess is requesting, demanding is again, my opinion – request to be seen. And then I think they don’t respect my time, and I feel angry. But then perhaps I add them on because I also feel guilty about not seeing them. I’m the one not respecting my time. And then I’m the one who’s angry and frustrated with them, which is really on me. So, you can see again, that this thought I have about them often then boomerangs back, and I become that person.

Versus if a patient shows up late and then wants to be seen, I can understand that they want to be seen. Maybe they didn’t understand how our scheduling works. Or maybe they ran into traffic. There are lots of reasons. Maybe they don’t understand—they probably don’t understand the impact that adding on everyone is late will have on my schedule and my other patients and I don’t see late patients, generally. And I allow for the possibility that they might feel angry and frustrated with me. And yet, I can feel understanding and compassion and still say no, or I can decide to say yes—not from guilt, but from deciding how I want to respond, maybe evaluating my schedule, understanding their preference, but also giving my preferences equal weight. That would look like me not disrespecting myself and not disrespecting them.

I honestly find the more that I do this work, the more clearly I can see people as they are and the more clearly I can hear their questions as questions and not taking things personally. And this, I think, is really a superpower. And so I would encourage you to just explore this, what if you do this work, and then you can just start to see people more clearly. It’s like taking off those sticky notes that we put all over people. Coaching is like cleaning your windshield or your glasses. We just keep taking off all those smudges, which are our sort of automatic thoughts, maybe our patterns of thinking. So, you start to see the world more clearly and with less emotional upset and drama for you.

So, if a patient tells me, that they think sunscreen is toxic – I’m a dermatologist – or asked me how I can recommend Vaseline Petroleum Jelly, which is one of my favorite things to recommend. But a lot of people are like, “Well, you know, it’s from petroleum and oil, and hence toxic”. I can just hear that now as their thoughts. And then I can decide how to respond. I honestly used to get so riled up about it and now I don’t. If someone thinks sunscreen is toxic, I’m just going to talk about clothing. I can tell them, “Well, I love Vaseline jelly, I use it all the time. I don’t think it’s toxic. But if you do, we can talk about other alternatives”. It doesn’t mean that I have to agree with them, but I also don’t have to take it personally or make it mean that they’re disrespecting me or anything like that. It just is so much easier.

I am also far from done with this. I don’t want to pretend like I’ve got this all figured out. I still coach myself on patient encounters that I find difficult. I just have way, way fewer and I enjoy my day and seeing patients, way, way more. That is how I know it’s working, that is how I know this works. Really, it really works. So, I think I’m going to do another episode on this, on how not to take things personally, how not to be bothered by what others say and do. I do think that this is really a part of it. And again, if you aren’t a physician, or even if you aren’t a physician, you can apply all of this to dealing with anyone you find difficult. So, I think it’s really amazing work to do. And I would love to hear how it’s going for you. So, for now, let’s just start with that difficult patient. I would say let’s drop the word difficult and go from there.

Thanks so much for listening. I love sharing all of this with you. And again, if you have any questions, feel free to give me an email, or let me know what you think. And I will talk to you next week.

If you are a busy practicing physician ready to start feeling less stressed, enjoy work more and learn how to create a more balanced and sustainable medical practice and life, sign up for a consult call with me at Saradill.com. That’s S-A-R-A-D-I-L-L.com. It would be my privilege and pleasure to work with you.

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