Treating pain in a difficult patient may raise the challenge
and lower the expectations from any analgesic intervention. In this
section, the term difficult is applied to patients with behaviors, rather
than symptoms, that are beyond the norm and that undermine treatment.
Discussion of other difficult symptom presentations is beyond the
scope of this chapter. Difficult patients who are in pain often
are in conflict about whether or not they want care, want the care
they are offered, or want pain. Groves has said, “Such
patients simultaneously demand and reject care.” These
patients may also simultaneously obtain and undermine treatment
or flatter and frustrate their clinicians. In mild cases, they may
strike a cord of uneasiness in their caregivers. In severe cases,
caregivers may experience strong emotions such as fear and hate.
Some clinicians find it difficult to acknowledge or discuss patients
who strike a negative chord in them. Often, this is because of the
intrinsic conflict such patients raise with caregivers. Many clinicians
would simply rather not dislike any patients. Disliking a patient
is counter to what caregivers consciously strive to achieve—helping
in every way. So, even discussing a difficult patient can make some
clinicians feel uncomfortable, as if the patient is either being
mistreated or ridiculed. Certainly, this may occur with certain
individual clinicians in some situations. On the other hand, some
patients clearly are difficult, have long histories of inciting
strong negative reactions and difficult interactions with many health
care providers, and place clinicians in untenable situations in
which they ultimately feel bad. Not recognizing this phenomenon
is a disservice to the patient. But it is also of paramount importance
to recognize that most patients who make you suffer as a clinician
are probably suffering much more. Patients with dysfunctional patterns
of interactions with physicians usually have similar, if not worse,
problems throughout the rest of their lives. Thus, the clinician’s
discomfort is often just a small reflection of the patient’s
much greater torment.
Although there is no easy formula for what to do in these difficult
interactions, the common mistake is to miss opportunities in which
commonsense adjustments can ameliorate problems and prevent escalation.
Unfortunately, such difficult cases bring with them frustration
and, often, even more severe emotional responses, which taken together
diminish the clinician’s ability to bring common sense
to bear. In such situations, it is critical to recognize dysfunctional
patterns of patient and staff interactions as well as monitor one’s
own internal reactions. By doing so, one can then apply greater
awareness, deliberation, planning, patience, and caution to a difficult
situation rather than acting from impulse or instinct. This perspective
may make the clinician the only member of the treatment team able
to change the tide of acrimony and reestablish effective treatment.
What follows here is not new and is extensively taken from the work
of James E. Groves, as well as Adler, Buie, and Maltsberger, who
have published the seminal writings on this subject ...