October 2003 Bulletin

Difficult patients or relationships

Recognize sources of difficulty, repair or prevent them

By J. Gregory Carroll, PhD, and Michael G. Goldstein, MD

A 34-year-old man is referred to you as a new patient with persistent lower back pain. Early in your initial interview with the patient, he reports that the pain resulted from an injury he sustained at work a few weeks ago. He reports further that his pain medicine seems to help with the symptoms and that he does not want to have any extensive testing done at this time. He goes on to say, “I brought these papers for you to complete and sign. I think it is time to claim this injury as a work disability.”

For many orthopaedic surgeons, this scenario rapidly begins to take on the appearance of another “difficult patient,” one who may be expected to resist conventional diagnostic procedures, refuse or undermine therapeutic regimens, show little improvement in functional status and focus on the “extended” need for pain medicines.

For the clinician, this scenario is often associated with feelings of apprehension or dread that may be based on similar cases that were problematic in the past. All too often, it proves to be a self-fulfilling prophecy. The result is usually frustrating for clinician and patient alike.

Our teaching experience and educational materials at the Bayer Institute for Health Care Communication indicate that this is an important moment for the surgeon to make a critical distinction. Is this truly just a ‘difficult’ patient? Or, is there more to it than that?

How might the perspective of the orthopaedic surgeon and his or her response to a patient’s requests contribute to the difficulty? How do the surgeon’s own assumptions, perceptions, clinical experience and expectations influence the level of difficulty? Also, how do they affect the working relationship with this patient?

The purpose of this article is to review the major sources of difficulty that physicians report in their working relationships with patients. Then, we’ll discuss a conceptual model that helps prevent such difficulty from striking without warning and helps repair the relationship when it does.

Sources of communication difficulty

First, it is important to note that clinicians generally cannot agree very well on what they consider most difficult about their interactions with “problem patients.” In our half-day workshops on this topic, we present a series of 15 brief video excerpts of clearly frustrating moments in doctor-patient interactions. Each excerpt was developed from actual clinical cases and carefully re-enacted using professional actors.

Our experience with thousands of participants in hundreds of workshops is that clinicians differ markedly in terms of which cases they rate as the most difficult among any three choices.1

To paraphrase a little differently, it is clear that the difficulty is—to a large degree—in the eyes, the ears, the mind and the heart of the beholder. From our review of the literature and our experience teaching the workshop, three prevalent sources of difficulty have emerged: (a) limited clinical success to date or perceived low likelihood of success; (b) inflexibility of the patient, clinician or both; and (c) poorly aligned expectations between the patient and the clinician.2

Returning to the case example above—the patient with lower back pain—most orthopaedic surgeons are likely to experience some difficulty in this interaction because the patient does not appear to be interested in any diagnostic testing or therapeutic regimen. Thus, the likelihood of clinical success seems low.

Second, the patient appears to be inflexible, at least at the outset, and seems intent only on getting a surgeon’s signature for the disability papers and another prescription for pain medicine.

Third, the patient and surgeon are likely to have very different expectations for the visit, and this will present even more difficulty, especially if the particular misaligned expectations are not addressed.

Conceptual model

White and Keller developed a model for recognizing, repairing and preventing difficulties in the clinician-patient relationship such as those described in the preceding case.1 The first step is simply to observe and reflect upon the tension level in the relationship.

For the orthopaedic surgeon in our example, this means noticing one’s own level of tension or frustration, observing any frustration on the part of the patient and being curious about the origins or sources of this tension.

Part of this process is considering one’s own feelings or emotions as data. Another part is what White and Keller call, “Don’t just do something, stand there.” In other words, the surgeon should take a moment to think about what is going on, why he or she is reacting this way and which sources of difficulty may be at work.

The next stage involves the “ADOBE” model, a communication strategy with five components, each of which may be employed either to repair the communication difficulty or to prevent it from taking hold:


All clinicians will experience some interactions with patients as particularly difficult or challenging. They should expect much of the difficulty they encounter to depend upon their own experience, beliefs and perceptions about the interaction. It helps to recognize three general sources of difficulty in clinician-patient relationships: limited likelihood for clinical success, lack of flexibility and mismatched expectations. These are the predictors of more difficult interactions for most clinicians.

To repair or prevent these difficulties in the practice of orthopaedic surgery, we strongly recommend use of the communication skills identified in the ADOBE model.


1. White MK, Keller VF: Difficult clinician-patient relationships. Journal of Clinical Outcomes Management 1998; 5:32-36.
2. White MK, Keller VF, Gordon GH: Annotated bibliography on “difficult” clinician-patient relationships. West Haven (CT): Bayer Institute for Health Care Communication; 1998.

J. Gregory Carroll, PhD, is chief executive officer, Bayer Institute for Health Care Communication. He can be reached at (800) 800-5907 or gregory.carroll.b@bayer.com

Michael G. Goldstein, MD, is associate director of the Bayer Institute, Clinical Education and Research, and can be reached at the same phone number or michael.goldstein.b@bayer.com

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