less likely to have medical problems, are more likely to seek medical help, and are more likely to comply with medical interventions (IOM, 2003c).

Management of Difficult or Problematic Physician–Patient Interactions

Physicians consider about one in six patients in the outpatient care setting to be “difficult” (Hahn et al., 1996; Jackson and Kroenke, 1999). Such patients are not necessarily those with complex medical problems; rather, they are patients whom physicians perceive as being demanding and aggressive, seeking secondary gains, and/or having a variety of nonspecific complaints that persist despite the physician’s best treatment efforts (Drossman, 1978; Novack and Landau, 1985; Steinmetz and Tabenkin, 2001). Difficult patients often have mental, mood, or personality disorders with or without comorbid alcohol abuse or dependence (Hahn et al., 1996; Jackson and Kroenke, 1999; Novack and Landau, 1985); display greater somatization (Jackson and Kroenke, 1999; Lin et al., 1991; Walker et al., 1997); and exhibit higher rates of health care utilization (Jackson and Kroenke, 1999; John et al., 1987; Lin et al., 1991). Problematic physician–patient interactions can result when patients with unmet expectations become dissatisfied with their care, and physicians become frustrated by patients who continue to complain despite the physician’s therapeutic attempts (Jackson and Kroenke, 1999).

A number of investigators have recommended general treatment approaches for difficult patients that include treating the underlying issue, such as depression or somatization, and improving specific communication skills (Block and Coulehan, 1987; Drossman, 1978, 1997; Epstein et al., 1999; Katon et al., 1990; Kroenke and Swindle, 2000; Lidbeck, 2003; McLeod et al., 1997; Novack, 1993; Okugawa et al., 2002; Platt and Gordon, 1999; Quill, 1985, 1989; Schwenk and Romano, 1992; Smith, 1992). Students should be aware of these approaches. Additionally, educating students in how to work with difficult patients enhances their understanding of why the behavioral and social sciences are critical to their training. For example, physicians with positive attitudes toward psychosocial aspects of care may better recognize and empathize with the suffering of such patients (Cassell, 1999). Physicians with optimal communication skills that incorporate a biopsychosocial perspective may be less likely to label certain patients as difficult (Jackson and Kroenke, 1999; Levinson and Roter, 1995; Williamson et al., 1981), more likely to learn about and help alleviate such patients’ emotional distress, and thereby engender greater patient satisfaction (Roter et al., 1995). Additionally, physicians with greater knowledge of the diagnosis of mental disorders are more likely to recognize and appropriately treat the mental health problems associated with difficult patients (Roter et al., 1997).

Medical students’ success in working with difficult patients is related to the effectiveness of their instruction in the social and behavioral sciences. Students must have positive attitudes toward working with psychosocial aspects of care. They must also acquire effective interviewing skills that enable them to elicit and



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