Dynamic Chiropractic – July 30, 1993, Vol. 11, Issue 16

Coping with the Undesirable Patient

By Abne Eisenberg
Doctors reading this column should immediately be able to think of at least one or two patients whom they wish would simply disappear. The longer one is in practice, the better the chances of encountering such undesirable patients.
They are a serious fly in the ointment when it comes to the life of any serious member of the healing arts.

What exactly are the characteristics of an undesirable patient? Better still, is there such a thing as a universally undesirable patient -- someone who upsets every doctor they consult? While it may be imprudent to make such a sweeping generalization, this writer finds the temptation extremely inviting.

Thankfully, after 40 years of practice, I have encountered less than a dozen undesirable patients. I suspect that such a small number can be explained by the fact that, over the years, I have become more adept at spotting the trouble-makers very early.

May I posit this question to my readers? Do you think there is such a thing as a universally undesirable patient? By universal, I mean someone who consistently gives every doctor a hard time. Perhaps, if I described in greater detail the characteristics of such an individual, you will better understand what I mean.

These are patients who have made the rounds of an excessive number of doctors in their area; they also possess a profound fluency when it comes to describing their symptoms. These are two of the cardinal characteristics typifying universally undesirable patients.

Then, of course, there are the less notorious forms of the undesirable type. They can be identified by the following behaviors: (1) They are constant complainers -- no matter what you say or do, they find fault; (2) when it comes to keeping appointments, they are repeatedly late; (3) if they flatly miss an appointment, they give some lame or transparent excuse; and lastly (4) they often have a poor payment record. These are but a few of the pathognomonic symptoms of the undesirable patient.

An analogy could be drawn between the undesirable patient and the mischievous child. During infancy, the child is wholly dependent upon the mother for survival. If it is hungry, it cries; if it needs its diaper changed, it cries. Whatever its needs, the prelinguistic child cries. After the acquisition of speech, the child's needs are served by various symbols (words). If thirsty, it calls out the word "water"; if it wants to be held, it calls out the word "up." As further maturation occurs, it learns how to psychologically manipulate its words; that is, weave them into self-serving tools.

Putting aside whether or not this analogy is completely appropriate for undesirable patients, it does serve to illustrate a point: Undesirable patients definitely seek attention. They will go from doctor to doctor, do negative things that draw attention to themselves, and repeatedly incur rejection. In the moment they encounter a doctor who will not tolerate their misbehavior, they move on to the next doctor -- constantly in search of a doctor who will accommodate their psychologically felt needs.

A classic example of such negative patient behavior immediately comes to mind from my own practice. This particular 50-year-old female patient, while waiting for treatment, would brazenly go behind my desk without permission and use the phone. On another occasion, I came out of a treatment room to find her looking through my appointment book. Then came the coup de grace: She dared to contradict my interpretation of her x-rays. While directing her attention to an acute subluxation of L-5, she remarked, "It looks all right to me." This was the straw that broke the camel's back. I was totally offended by her audacity and, after one other similar performance, I decided to discharge her from my care. I simply told her that she was not responding to treatment and I thought she should consult a neurologist. At first she resisted being dismissed and tried to persuade me to reconsider. I was resolute in my decision and stuck to my guns. Finally, she failed to return.

When one first goes into practice, the prevailing tendency is to tolerate such patients; however, as the years go by and the practice becomes more securely established, this benevolent tendency begins to wear thin. Doctors become more selective regarding whom they will treat; they do not routinely accept any patient who calls or come through the door.

In time, all doctors discover that due to their individual personality and lifestyle, they have attracted a particular type of patient. For example, if you are inclined to be the intellectual type, you will attract patients with similar inclinations. Conversely, if you are less lofty in your thinking and more readily immersed in other pursuits, you will attract a different kind of patients. Please do not take this observation too seriously. I am merely suggesting that doctors appear to attract patients according to some unwritten interpersonal pattern of affinity.

Consider this hypothetical situation. One day, as if by magic, all of your current patients have been exchanged with those from another local chiropractor's office; in turn, the other chiropractor has acquired all of your patients. What consequences, if any, do you think would result from such a mysterious exchange? I submit that the consequences would be significant. Unless you are an emotionless automaton, imperviously going from room to room rendering silent therapy, you will be profoundly aware of the difference.

On a conscious level, most of us are sensitive to the kinds of patients we treat. The simple act of looking at your appointment book at the start of a routine practice day could easily send a mini-shock through your brain. Why? Because you see the name of a certain patient -- one who spells aggravation -- a downright nuisance. Such disquieting feelings are also experienced on a subconscious level. While we might conveniently rationalize the existence of an occasional "bad apple," they surreptitiously take their emotional toll.

The practice of chiropractic should be a joy. Making people feel better and alleviating their suffering should deliver one of mankind's highest rewards. While most patients seem to appreciate our efforts and a few consider us gifted with supernatural powers, there are those whom we can never please, i.e., the undesirable patient. Why then should we tolerate them? Unless you have a rescue mission, a compulsive need to save the world, one must develop the ability to quickly identify and successfully cope with undesirable patients.

Another characteristic of the undesirable patient deserves special mention. It has to do with psychological payoff. Put simply, they have made sickness their life's work. No matter what is done for them, failure is inevitable. To be healthy would impose certain responsibilities with which they would prefer not to deal. The first and most conspicuous clue you will get comes during the case history. They vigorously complain that no doctor has ever been able to help them.

Notice should be taken of something called "spill-over." Any encounter you may have with the undesirable patient at the office does not stop there. The emotional reverberations may well accompany you home and spill over to your family and close friends. Unless you are able to distance yourself from these negative emotions, they can often contaminate your thinking and infiltrate your personal life.

Consciously or unconsciously, some form of rapport occurs between every doctor and patient. Treatment does not occur in a vacuum. Both patient and doctor alike develop a unique attitude toward one another. This is especially true in chiropractic where we lay on hands in a very unique manner -- a way not shared by any other branch of the healing arts.

Once the undesirable patient has been identified, the doctor must then decide what to do about it. There are two readily available options: (1) discharge the patient by using some form of pretense, or (2) continue treatment by not emotionally processing the unnerving stimuli the patient emits. If discharging the patient presents a communication problem for the doctor, some discrete subterfuge might be in order: Keep the patient waiting longer than usual, cut back on the amount of treatment usually given, or suggest that they do not appear to be responding appropriately to the treatment being given. Naturally, if the aforementioned ploys are incompatible with the doctor's attitudes, values, or beliefs, the problem will go unchanged.

Tolerance levels among doctors differ. Some have an uncanny gift enabling them to remain detached -- to emotionally distance themselves from their patients. Other more empathic doctors take everything their patients say and do to heart.

Because we live in an extremely litigious society, where the threat of malpractice is a constant source of concern, managing the undesirable patient is especially precarious. Although every patient, under certain circumstances, is a potential malpractice suit, the undesirable one represents double jeopardy. Not only are they inclined to have an adversarial attitude, but also a presumptuous disposition toward the doctor.

A saving grace in dealing with the undesirable patient is the group practice. The offending patient can discretely be reassigned to another doctor. While this may or may not work, it provides a viable alternative to arbitrarily discharging the patient. If, however, you are dealing with the universally undesirable patient, every doctor in the group will probably refuse to treat this person.

Almost inevitably, treating undesirable patients becomes a self-defeating process. The more you do for them, the less they appreciate it. Hence, the conscientious doctor who continues to treat them will ultimately succumb to frustration. Moreover, such frustration will, if allowed to continue, affect your treatment of other patients.

In the final analysis, each of us must ask ourselves whether the end justifies the means. Does the income derived from treating an obnoxious or otherwise undesirable patient justify the emotional pain and suffering they so often cause? Can you afford to have your peace of mind needlessly compromised by a patient whose paramount purposed is to get attention by rubbing you the wrong way? Probably not.

Lastly, lest the intent of this column be misconstrued, the reader should not take its meaning to suggest that the undesirable patient be denied chiropractic treatment. The recommendation being made here is that such treatment be provided by doctors who are emotionally better equipped to cope with such individuals.

Abne M. Eisenberg, DC, PhD
Croton-on-Hudson, New York

Editor's Note:

As a professor of communication, Dr. Eisenberg is frequently asked to speak at conventions and regional meetings. For further information regarding speaking engagements, you may call (914) 271-4441, or write to Two Wells Avenue, Croton-on-Hudson, New York 10520.


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