Difficult patients, let’s just put it out there. You have them, I have them, we have all had them but I feel like no one really wants to talk about it. As physical therapists, we love our patients, we love our jobs, we love getting to know people, and we genuinely love helping others… But it isn’t always rainbows and sunshine and every so often, we get a reality check with a not so pleasant patient that is hard to deal with.

Who are these patients?

They might be aggressive, angry, or even down right demanding. On the other hand, they can be manipulative, inappropriate, or disrespectful. Are they this way because they are in pain, entitled, or are they just this way by nature? It’s probably a combination of many things but who is to know. I tend to think of these people as the bullies from high school that just needed a warm home environment and a list of rules to follow.

Now, how do we deal with them? Boundaries! Jessie Podolak wrote a fantastic article a few years ago “Boundaries Required: Empathy’s Not Empathy Without ‘Em” where she really dove into the why of setting boundaries. We know we need to set boundaries because they are good for the patient and good for us as the healthcare professional but it is still a very difficult thing to do!

So how do we go about doing it?

It starts with a team approach and keeping our patient interactions as standard as possible. In Tips for Dealing with the Difficult Patient written by Robert H. Blotter, MD he says,

“Standardized approaches can help lessen the emotions involved in dealing with difficult patients. Reasoned, consistent processes that provide clear boundaries from the start can not only avoid problems down the road, but also help defuse situations before they escalate.”

This is not to say that we have to treat our patients like we are robots but we definitely need to have a plan in place that starts with our front desk and transitions smoothly to the therapist and all other staff members they might encounter.

Then comes patient expectations. Barron, Moffett and Potter said in a 2007 article,

“Expectations are an integral part of the psychosocial makeup of each individual patient.”

We should be asking patients what they expect during their care so that we can meet these expectations and/or reroute them to be more realistic. We can set goals around meeting their expectations and include them in the process to give them ownership.

We not only need to learn patient’s expectations of us, but we also need to make our expectations of them very clear. A lot of the time this comes into play with setting boundaries on timeliness. I explain to my patients that their time with me is a reservation, not an appointment. I expect them to be on time just like they would be for a reservation at their favorite restaurant. This same thought process can be used with expectations of appropriate behavior in the clinic, willingness to try new things, or compliance with home exercises.

Sometimes things go a little too far and we just have to lay down the law to stop them from progressing. Sometimes we cannot easily get to the point with patients and we have to go to a more blunt communication. From time to time I have to politely say to a patient, “that is not an appropriate thing to say here” or “you cannot speak to me that way.” This is not an easy conversation to have but when it gets started, it usually resolves quickly.

Did some of you just shudder at the thought of being that upfront with a patient?

Good! That is where self-awareness comes in. Hopefully if you are not in a one person clinic or office, you have a melting pot of personality types. Find a coworker who can either troubleshoot with you or even take the patient onto their schedule.

I know there are many things to consider when setting boundaries with patients but in my experience, this is a good place to start! What strategies do you think you will implement in your clinic for handling difficult patients? Do you have any success (or even disaster) stories of setting boundaries with patients?

-Brooke