Managing Difficult Patients in an Era of Interprofessionalism

“Managing Difficult Patients in an Era of Interprofessionalism” was presented at the Minnesota Psychological Association First Friday Forum series on June 5, 2015, by William Robiner, Ph.D., A.B.P.P., L.P.

Who are difficult patients and why should health professionals be concerned about managing them?  Like beauty, difficulty lies in the eye of the beholder.  Patients might be labeled “difficult” when health professionalshave difficulty working with them (Wessler, Hankin & Stern, 2001).  In health care, patients may be considered challenging if they are “interpersonally ‘difficult,’ psychiatrically ill, chronically medically ill, or lacking in social support (Adams & Murray, 1998).”  Difficult patients are those with whom health professionals feel frustrated, uncomfortable, ineffective, or threatened (Duxbury, 2000) or whose disorders do not respond to treatment (Pollack, Otto, & Rosenblum, 1996). Because health professionals invariably will encounter difficult patients they need to be prepared to manage them so as to provide quality health care and to cushion their impact on individual clinicians and the system.

Behavioral aspects that lead a patient to be seen as difficult include being demanding, blaming, unappreciative, defensive or angry.  Other factors are perceived risk of abuse, violence, suicide, litigiousness, or making reports to regulatory boards. Various pejorative terms have been used with reference to difficult patients, including “train wreck,” “crock,” “frequent flyer,” and “heart sink” (i.e., patients who cause clinicians’ hearts to sink when they encounter them).

Mental health professionals may consider patients with personality disorders, poor impulse control, substance abuse and somatoform disorders, or self-destructive tendencies to be difficult.  Other health professionals may find patients with multiple symptoms, poor responses to treatment, resistance to health professionals’ recommendations, specific medication conditions (e.g., chronic pain), or terminal illnesses to be difficult.  Somewhere between 15% (Hahn, et al, 1996) and 30% (Havens, 1978) of primary care providers’ encounters with patients are estimated to be troubling to physicians.  Difficult patients are nearly twice as likely to have a mental disorder than non-difficult patients (Hahn et al., 1996).

The emotional impact of difficult patients on professionals can be powerful, triggering anxiety, sadness, anger, guilt, shame, burnout, powerlessness, exhaustion, or a sense of being manipulated (Bernhardt, Silver, Rushton, Micco, & Geller, 2010).  Difficult patients introduce stress not only to clinicians, but also to clinics, hospitals, and health systems. In 2009, 5% of patients accounted for nearly half of all health care spending. Among the non-elderly “high spenders,” mood disorders accounted for the second largest patient group (National Institute for Health Care Management, 2012).  As the health care system is being transformed from payment for services to payment for outcomes or value, high utilizers of health care become a particularly important subtype of difficult patients to manage effectively.

Cases in point are patients who do not adhere to treatment recommendations.  As former Surgeon General C. E. Koop quipped, “Drugs don’t work if you don’t take them.” The World Health Organization (Sabate, 2003) estimated mean adherence to long-term medication regimens as just over 50% in affluent countries, and lower in poorer countries.  Dolder et al. (2003) estimated 50% nonadherence for antipsychotics, and Avorn et al. estimated 48% nonadherence to statins.  DiMatteo (2004) estimated mean adherence across 17 conditions with a mean nonadherence rate of about 25%, with higher rates in sleep disorders, diabetes, pulmonary disease, end stage renal disease (ESRD), and other conditions. Dew et al. (2007) estimated that even in transplant patients, for whom non-adherence can lead to acute rejection, graft loss or fatality, 36% are non-adherent to medication.

Patients may fail to follow health professionals’ directions for many reasons: motivation, personality, defiance, denial, fear of adverse effects, forgetfulness, anxiety and depression, misunderstanding, lack of support, or cost.  Depressed patients across chronic physical illnesses are three times more likely to be non-adherent than are non-depressed patients (DiMatteo et al., 2000).  Medically ill people with behavioral comorbidities can rack up medical costs two to three times as high as those without them (Milliman, 2013).  Seven out of 10 of the top factors leading to deaths in the United States include behavioral or emotional components (e.g., diet, tobacco use; Mokdad et al., 2004), underscoring the necessity of addressing behavioral and emotional issues in health care.

Various approaches for addressing difficult patients have focused on enhanced communication techniques.  For example, these approaches have included the NYU Macy Initiative on Health Communication (Kalet et al., 2004), and incorporating other strategies, such as caregivers’ self-regulation and support in the CALMER approach (Roberts & Dyer, 2004; Pomm, Shahady, & Pomm, 2004).  Improved tracking patient behavior (e.g., Goetz, 1010; Robiner et al., in press) can create feedback loops by which patients and providers develop more precise ways of measuring, and thereby changing, behavior patterns to increase adherence.

Another development increasingly recognized as essential to the delivery of quality health care is the role of health care teams (Mosser & Begun 2014), which may be particularly useful in the management of difficult patients.  Interprofessional collaboration involves providers from different disciplines communicating effectively, making decisions interactively, and providing care in a coordinated fashion that facilitates optimal patient outcomes. Effective interprofessional collaboration has been shown to lead to improvements in: patient outcomes, use of clinical resources, health professional satisfaction, access to health care, exchange of knowledge, and increased respect among colleagues (Institute of Medicine, 2013).

The Institute of Medicine (1972) first called for interprofessional education over 40 years ago to enhance the ways by which health professionals interact with each other in delivering care.  The focus on interprofessional care gained momentum with the Interprofessional Education Collaborative Expert Panel (2011) publication of the Core Competencies for Interprofessional Collaborative Practice, which delineated 38 competencies across four domains: Values/ethics, roles/responsibilities, interprofessional communication, teams and teamwork. The University of Minnesota Academic Health Center is at the forefront of this work with its establishment of the National Center for Interprofessional Practice and Education in 2011.

These advances reflect acceptance of the biopsychosocial model (Engel, 1977), which contends that health is affected by biological, social, and psychological factors. Increasingly, patients in primary care and medical specialty clinics are screened for risk factors that are amenable to psychological interventions (e.g., depression, insomnia).  In light of the contributions of these factors, psychologists are poised to play increasingly valued roles within interprofessional, collaborative practice models.  Psychologists can deliver a variety of approaches such as motivational interviewing (e.g., for substance abuse, medication non-adherence), preventative and management health strategies (e.g. for managing diabetes, obesity, and cardiovascular risk), and non-pharmacological treatments (e.g., for depression and insomnia), as well as behavioral and cognitive behavioral approaches to promote a range of health behavior changes (Belar & Deardorff, 2009).  Such efforts are essential as it is recognized that mental health comorbidities such as depression increase the annual costs of care for health conditions, hypertension, asthma, and diabetes (Petterson et al., 2008) and that treating them can reduce costs (Katon et al., 2006).

This push for interprofessional practice is consistent with the Triple Aim – the Institute for Healthcare Improvement’s (Berwick, Nolan, & Whittington, 2008) agenda to simultaneously improve patients’ experience of medical care, population-based health outcomes, and per capita cost.  Bodenheimer and Sinsky (2014) proposed expanding it to the Quadruple Aim to include improving the work lives of health care providers (e.g., decreasing burnout), which yields yet additional opportunities for psychologists to have an impact on enhancing health care.

Not only do psychologists possess many of the skills and competencies that benefit diverse patients and interprofessional teams, but participation in such teams is beneficial for psychologists and for the field as well.  Consequently, the newly introduced APA Standards of Accreditation for Health Service Psychology require accredited psychology graduate programs, ‘internships,’ and ‘postdoctoral residencies’ learners to demonstrate competency in “consultation and interprofessional /interdisciplinary skills” as part of accreditation. The Patient Protection Affordable Care Act (2010) recognized the connection between behavioral and physical health and relatedly created Accountable Care Organizations and Patient-Centered Medical Homes to facilitate interprofessional practice. Despite the structures created for and benefits of interprofessional collaboration, a recent World Health Organization (2010) study revealed that just 5.9% of psychologists in training had received education on interprofessional practice.

Studies have repeatedly shown that when behavioral health is incorporated into medical treatment, patients demonstrate improved outcomes related to their medical condition, physical health, and quality of life (Katon et al. 2010, Woltmann, et al., 2012). Although addressing behavioral health factors is fundamental to realizing optimal health care outcomes, psychologists have yet to play the fuller roles in the health care system that would serve patients and the profession well.  We are now in a time that patients and increasingly the organizational structures and payers within health care value psychologists’ competencies for enhancing patient communications, addressing behavioral and psychosocial issues, and interacting in clinical and research endeavors.  It behooves psychologists to “lean in” further to the health care system to become more integrated with overall health care delivery, so as to better address the needs and circumstances of all patients, especially those who pose the greatest challenges to clinicians and the health care system.  For the discipline to thrive, it is essential that psychologists expand their purview, move beyond their silos and comfort zones, and actively stake out broader and more engaged roles throughout the evolving health care system.

Dr. Robiner is the Director of Health Psychology at the University of Minnesota Medical School, where he also is the Director of the psychology internship.  He maintains a busy clinical health psychology practice and is involved in diverse research projects involving adherence, the mental health workforce, and a range of professional issues. He currently is the psychologist consultant to the PERL study which is funded by NIH to prevent early renal loss in people living with Type I diabetes. He formerly was Vice President of MPA.

Dr. Zagoloff is a licensed child and adolescent psychologist who focuses on the treatment of youths and families impacted by anxiety and mood disorders. In addition to clinical work, she is heavily involved in the education of psychology and psychiatry learners and is especially interested in facilitating shared learning experiences between these two groups. 


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