Disruptive Behavior by Patients Raises Ethical Concerns for Otolaryngologists

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Clinical Scenario

You are asked to consult on a 55-year-old male referred by his primary care physician for a greater than six-month history of bilateral tinnitus. The primary care physician requested this consultation by personal phone call, indicating to you that the patient has become increasingly anxious about the tinnitus and has been pressuring the physician for a prompt resolution. You feel comfortable evaluating patients with tinnitus and accept the request for consultation.

On the day of his appointment, the patient presents himself to your office two hours before his appointment time and informs the front desk that he would like to be seen as soon as possible. Your staff reassure him that he will be seen as close to his appointed time as possible but that other patients have earlier scheduled appointments. He returns to the front desk several times with the same request. Finally, he is brought back to the intermediate waiting room for the initial screening and to have his vital signs checked. He complains about having his blood pressure and weight taken, because, he tells the staff, his trouble is with his ears, not his blood pressure or weight. The staff member is courteous and patient, reassuring him that this is important information for you to consider.

When you enter the examining room to introduce yourself and greet the patient, he jumps up from his seat, shakes your hand, and tells you, “You have to stop this ringing in my ears!” You realize that this will not be an easy consultation, so you take a seat and begin to elicit a pertinent history and review of systems from the patient. The patient indicates that the onset of the tinnitus occurred gradually months ago but without any known inciting event. You learn that the patient is an automobile insurance salesman, which he claims is a very stressful job, subject to onerous oversight and unrealistic sales target expectations. He has been divorced for three years and has no children. The patient also relates a long history of insomnia, vague muscle aches, and a neurodermatitis being treated by a dermatologist with a topical preparation. He takes only a multiple vitamin and the occasional medication for sleep. He denies any head trauma, recurrent ear infections, exposure to loud noises, or Eustachian tube blockage. His last physical examination, according to the primary physician’s medical records, was essentially normal.

The Examination

You perform a complete head and neck examination, including nasopharyngeal endoscopy and a basic neurological examination. You find no evidence of any contributing pathology in your examination. Having re-reviewed the American Academy of Otolaryngology-Head and Neck Surgery’s clinical practice guidelines for tinnitus the day before seeing the patient, you begin to formulate a diagnostic plan (Otolaryngol Head Neck Surg. 2014;151(2 suppl):S1-S40). You tell the patient that the next step should be a prompt audiologic examination, conducted right away in your office. He agrees to this, and your audiologist personally escorts him to the sound booth.

Thirty minutes later, the audiologist steps into your office, closes the door, and tells you that there were no pathologies found on the complete audiologic examination, including special studies. But, as an experienced audiologist, she found the patient’s demeanor and behavior unusual. You discuss this with her for a short time, then return to the examination room to review the negative findings with the patient. You explain to the patient that at this point in time you would characterize his tinnitus as primary (idiopathic and not apparently associated with a sensorineural hearing loss), persistent (because it has lasted longer than six months), and bothersome (because it distresses the patient).

The patient requests a magnetic resonance (MR) imaging study, which he says was recommended for tinnitus by “experts” on the Internet. You try to explain to him that in the absence of any localizing neurological signs or symptoms, pulsatile tinnitus, or asymmetric hearing loss, an MR scan is not recommended by clinical guidelines. He further requests that “some medication be placed in my inner ear through the eardrum,” which he also gleaned from Internet searches. Again, you cite the recommendation of the guidelines against intra-tympanic medications in patients with persistent, bothersome tinnitus. The patient, obviously distressed and anxious, accuses you of “writing him off.”

Realizing that this patient’s reaction to his tinnitus is more exaggerated than the primary care physician presented to you, you begin to educate him, in a calm and empathetic manner, on the latest information regarding persistent, bothersome tinnitus and some management strategies that you would like to suggest to him. You also inform him about cognitive behavioral therapy for tinnitus and a possible trial of sound therapy. This extended discussion seems to calm him, and you send him home with some pamphlets regarding these potential therapies, asking him to return in one week for a second discussion. As he is making the return appointment, your billing clerk requests his insurance co-payment, and he refuses, stating, “He did nothing for me, so I am not going to pay until he does.”

The Return Appointment

The patient calls the office the very next morning, urgently requesting an appointment. You happen to be in the operating room that day, not in the office, and your receptionist offers him a 1:00 p.m. appointment for the next day you are seeing patients in the office; however, the patient presents himself to your office at 8:00 a.m. on your surgical day and demands that you see him in between surgical procedures. When the staff inform him that will not be possible, he becomes belligerent and verbally abuses the staff, who politely attempt to help him. He remains in the office waiting room for an additional two hours, grousing about your office to the other patients and repeatedly bothering the staff. Finally, he leaves.

He does show up for the next day’s appointment, but he is late and states he needs to be seen immediately. Before accommodating his request, the staff again ask him to provide the co-pay for the previous visit, which he refuses to do. He continues to verbally abuse the staff in front of other patients and rather loudly before he is escorted into an examination room. When you enter to greet him, he refuses to shake your hand and confronts you with the statement that you are not a competent physician and that he should report you to the state medical board for not further evaluating his tinnitus and for trying to make him pay for no treatment. While you are calmly listening to his tirade, he is pacing the floor in the examination room, all the while shouting intermittent profanities as you attempt to better understand the underlying issues that are so bothersome to him. Finally, he rushes out of the room, informing you that “he will be back tomorrow and he expects his problem to be taken care of completely.”

What is your next move?

Discussion

The range of presentations or actions that cause a patient to be considered “difficult” is broad. For the purpose of this discussion, the term “difficult” refers not to a difficult diagnosis or a difficult procedure, but rather any patient behavior that is frustrating, off-putting, worrisome, or interferes with the provision of the highest level of healthcare for that individual. Dealing with a difficult patient is common in the practice of medicine. Internal and external stressors occur in everyone’s life, and people deal with these stressors with various degrees of success. The spectrum of difficult patients is, fortunately, heavily weighted toward minimal difficulties, nominally seen in minor communication differences, cognitive dissonance, or failure to understand concepts, billing or scheduling frustrations, and so forth. We confront these minor difficulties with patients every day and, as problem solvers, we do our best to work with the patient and overcome whatever barriers exist to achieving optimal therapeutic goals And, we occasionally have to take responsibility for some commission or omission on our part that contributed to the difficulty. These low-level frustrations for the patient, and perhaps the physician, are part and parcel of a medical practice, and we learn to cope and do the best we can to mitigate them.

More infrequently, there are difficulties with a patient that arise along the more bothersome or serious part of the spectrum; these are represented, in part, by this clinical scenario. Here is a patient who is anxious about his unrelenting tinnitus, appears to have difficulty with patience, is not cognitive of his social misbehavior, and who, over a short period of time, has managed to disrupt your practice and cause concern to you, your patients, and your staff. His behavior and attitude must now be addressed.

A description of the various behaviors exhibited by moderately difficult patients might include the following: dependent, entitled, manipulative, unreasonable, abrasive, noncompliant, passive-aggressive, demanding, resistant, and anti-social. Every difficult patient will have his/her own behavior characteristic, or might exhibit a “blend” of several characteristics and behaviors. The patient may be quite well behaved in your presence but is disrespectful and demanding to your staff. Or, he may demand excessive amounts of time commitment and attention from both you and your staff. Perhaps the most important initial step in a physician’s response to dealing with a difficult patient is to recognize the disruptive signs early and manage them appropriately before they escalate beyond the point of salvage of the therapeutic relationship.

Obligation to Care

An important part of early recognition and subsequent management of the difficult patient is to understand, as well as possible, the effects of pre-existing mental and emotional disorders, coupled with internal and external stressors, that may affect a patient with a health issue. Life can be difficult, and for some people, it is very difficult. The effects of chronic depression and anxiety on an ill patient may be more than he or she can cope with. Stress from personal, marital, and family challenges, issues with work and/or finances, feelings of loneliness and isolation, and an inherent incapability to cope with uncertainties and frustrations are leading causes of acting-out behaviors and disruptions at the office. An additional consideration is that difficult or disruptive behavior can be caused or exacerbated by substance abuse, and that is one reason a physician should make that particular inquiry on the initial (and subsequent, if indicated) history and review of systems.

The ethics of caring for difficult patients rests in good part on our deontologic responsibilities to our patients—that is, we must be empathetic, honest, trustworthy, understanding, and non-judgmental. Indisputably, our primary obligation as physicians is to the well-being and proper care of our patients. Beneficence (doing good for the patient) must be balanced with its opposite, non-maleficence (do no harm). This is often a difficult balance, especially when dealing with the difficult patient, whose behaviors may cause us to reconsider our empathy and to focus instead on the difficulties they cause us. It is not unreasonable to state that at the root of every difficult patient is a human being with fears and concerns that are so overwhelming that he or she strikes out against others because of frustrations and inability to cope. In the difficult patient/physician relationship there is a need for the physician to be a stable point, which may help ground the patient sufficiently to achieve a grasp on the ineffectiveness of his behavior and its deterrence to his healthcare.

Most would concede that there is an obvious difference between the long-term relationship a patient has with his or her primary care physician and the shorter, more focused relationship developed with a specialist. That is not to say that specialists such as otolaryngologist-head and neck surgeons do not develop long-term patient relationships; they are just a bit different from the more encompassing one that typifies primary care medicine. Specialists may need to establish a meaningful relationship rather quickly, one that involves sufficient trust and communication to perform often serious surgical procedures on patients. Most patients understand this relationship and are comfortable with it; however, some patients may be uncomfortable with the limited relationship and require more time and effort than most. Occasionally, it may be helpful to point out this difference in the patient/physician relationship to your patient early on to establish the parameters of the encounters and to assure the patient that you will be keenly attentive to his otolaryngologic needs.

The Approach

In general, the ethical and professional approaches to interacting and managing a difficult patient scenario involve the following steps:

1. Recognize the developing situation and limit its progression, if possible. Since this particular patient in the scenario was referred by his primary care physician, it is important to re-contact that physician to discuss the patient’s behavior and seek advice about the situation, inquiring as to what the primary care physician might recommend. In fact, the primary care physician may be able to work with the patient to get the situation under control or recommend further consultation from a psychiatric colleague, especially if there is a long-standing reciprocal relationship.
2. Approach the patient in a nonthreatening, calm manner. Invite the patient to sit down in a quiet room with you. Offer the patient water, coffee, tea, or a soft drink to reduce the tension and to recognize the patient as a person with value.
3. Before discussing the patient’s actions and behavior, spend some time getting to know him better, especially regarding what is going on in the patient’s life currently, and try to find some common interest you might share. Set limits to the discussion, however—“I have XX minutes free now; can we just talk together during that time?” Often, it is better to listen more, facilitating the patient’s narrative or explanations.

1. Tactfully move the discussion toward what it means to have a positive patient/physician relationship and how important mutual respect and shared decision-making are to the relationship. Indicate some actions that threaten the relationship, including, but not limited to, the difficult behaviors the patient has been exhibiting. Explain to him how his behavior negatively affects others, including the staff and other patients being seen.
2. Encourage the patient to tell you what has bothered him about the care you have provided to date, and elaborate on what can you do, within your professional guidelines, to be more helpful and responsive. Take responsibility for any short-comings you can acknowledge.
3. Indicate the necessary boundaries that exist for both patient and physician that appropriately define the relationship, and seek his/her agreement on these boundaries. If needed, you can commit the boundaries to paper and both of you can sign. If the patient refuses to accept the boundaries, the relationship is not likely to work. Be honest with the patient about the fact that, for various reasons, the patient/physician relationship is not always workable, even after the issues have been discussed and attempts to improve the relationship have been tried but failed. If the patient is willing to work within the boundaries you bilaterally agree to, then you can recommit to the relationship.
4. You must frankly indicate some boundaries that just cannot be violated, such as disrespect and harassment of the staff, non-payment of bills, lack of impulse control, threatening and demanding behavior, and disruption of the office environment. You may have others to relate, depending on the circumstances of the patient’s behavior.
5. Finally, you must clearly articulate the consequences of failing to follow the boundaries you have set out to the patient, including dismissal/termination from your practice (See “Termination the Patient Relationship,” p, 24). If the discussion goes badly at this point, you may have to indicate to the patient that you have done all you can do to improve the situation and that a beneficial patient/physician relationship is no longer possible. Give the patient time to process this before having him escorted from the office. If the discussion has turned very worrisome, then it may be necessary to have security or the police escort the patient to his transportation.

We must clearly keep in mind that our primary effort is to salvage the patient/physician relationship and develop a manageable, workable agreement that enables you to care for the patient in a professional manner, with reciprocity by the patient. Most patients will comply with the boundaries and will do their part; some, however, will vacillate between compliance and passive-aggressive behavior or will simply not comply. Don’t hesitate to have a discussion with a colleague regarding the situation, to seek advice and counsel regarding the validity of your approach and other possible options to consider.

The Dangerous Patient

One last caution on managing the difficult patient must be considered. While your primary responsibility is to the patient, there are additional responsibilities to other patients present in the office, clinic staff, professional colleagues, your family, and, indeed, to yourself. Rarely, a difficult patient will become dangerous or violent. This situation must be controlled or contained quickly, before anyone, including the patient, is hurt. While the anger of a violent patient may primarily be focused on the physician, collateral damage may occur, involving anyone nearby. When the situation appears to be dangerous, you must quickly contact security or the police to deal with the patient, remove him from the premises, and protect all who are at risk for harm. It is appropriate for every medical office to have an action plan in place for such a situation, with safe rooms or an egress plan provided, as well as a hot line to 911 for police response.

Finally, while the practice is admittedly very controversial, this author would recommend that an office that has been threatened by a violent or dangerous patient consider having one physician with a conceal-carry permit for a handgun in his or her office to provide a self-defense option.

Dr. Holt is a professor emeritus in the department of otolaryngology-head and neck surgery at the University of Texas Health Science Center in San Antonio.