and assure him or her that successful treatment of the
condition will not result in loss of the patient-physician relationship. The self-destructive deniers evoke
all of the feelings of the other subtypes in addition to
malice. These patients require decreasing expectations
that perfect care will be delivered and may require a
psychiatric consultation. In the end, how the physician
feels about the patient is of little importance; what
matters is how he or she behaves toward the patient.
The physician plays a role of equal importance
to the patient in difficult encounters. The physician
may have a negative bias toward a specific disease,
have poor communication skills, lack experience, feel
overworked, or suffer from personal health issues.
Although most literature on the difficult encounter
focuses on the difficult patient, one study attempted
to characterize the difficult physician. A total of 1,391
family medicine, internal medicine, and internal medicine subspecialists completed the Physician Worklife
Survey regarding personal and practice characteristics
and work satisfaction. On multivariable analysis, high
work frustration was independently associated with
age younger than 40 years old, higher stress levels,
subspecialty practice, and higher number of patients
with psychosocial or substance abuse disorders. The
number of hours worked greater than 55 hours per
week had borderline significance. 22 Another study
showed female physicians who had lower scores on the
physician satisfaction scale and were less satisfied after
difficult encounters than their male counterparts. 25 To
better navigate difficult encounters, physicians must
practice self-reflection and recognize bias and should
seek support from trusted colleagues or Balint groups,
which focus on the clinician-patient relationship.
Situational factors also must be considered. Time is
a precious resource in all aspects of medicine, and time
limits can compromise the ability to communicate
effectively. The physician should acknowledge time
delays and plan for additional counseling time with difficult patients. The physician also should maximize the
time available by sitting at the patient’s level, maintaining eye contact, and conducting the encounter with a
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The patient encounter is shaped by the behavior of
the patient, the response of the physician, and the
situational factors. Each of these must be recognized
and addressed in order to optimize communication.
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