Being Difficult

Nor is there a consensus about what "difficult" means. Some doctors regard patients with substance-abuse problems or those who don't take their advice as difficult, while others are bothered by patients who exude a sense of entitlement or who repeatedly complain about symptoms for which no physical cause can be found.

"Difficult patients are in the eye of the beholder," said Arthur A. Levin, director of the Center for Medical Consumers, a New York-based patient advocacy group, who considers the term an artifact of a time when doctors were regarded as omniscient and patients were expected to unquestioningly do what they were told.

"My worry is that it locates all the problem with the patient, when the question for doctors is why the relationship is not going well," said Robert Arnold, a professor of medicine at the University of Pittsburgh who studies doctor-patient communication. "I think sometimes doctors find patients difficult because they push our buttons. A lot of doctors, including me, have a problem with control."

In some cases, said Children's National Medical Center physician Nathaniel Beers, president of the D.C. chapter of the American Academy of Pediatrics, patients who seem difficult may "just really be advocating for high-quality care" for themselves or a relative.

In Beers's view, difficult behavior typically has a cause, although it may be rooted in an earlier encounter with another doctor. "There's often some provocation that has occurred," he said.

One 52-year-old Washington policy analyst said her oncologist recently implied that she was difficult because she asked questions about his recommendations for treating her breast cancer.

"Are there difficult doctors who don't like to be questioned?" asked the woman, who requested anonymity to avoid alienating the oncologist, on whom she is dependent.

"It takes a huge amount of fortitude to do this when you're alone in a doctor's office" and are ill, she said. "His attitude is that I should just leave it to him."

Miksanek said he would not consider such a patient difficult. His own list includes those who blow off his recommendations; those who demand every new test, whether they need it or not; and patients who make "reverse house calls" and show up at his home unannounced at night or on weekends. Then there are those who complain that they are not getting better. "They say, 'I've been coming here for three visits and my knee still hurts, but I don't want to lose 50 pounds.' "

Regardless of the difficulties treating such patients, Miksanek said that the worst thing a doctor can do is to terminate the relationship by saying "there's nothing more I can do for you."

"That's like a nuclear bomb," he said, adding that in some cases patients may have nowhere else to turn. "My antidote to a lot of these difficult patients is simply time."

Other doctors practice preemption.