Sometimes patients’ anger comes from a sense of entitlement. These patients can be manipulative and play on our guilt. We often respond by getting angry ourselves or wanting to “put them in their place”, which sets up a negative cycle.  It is best if we do not bring our own guilt to the table. We can also channel the sense of entitlement in positive ways. Every patient is entitled to the best possible care. The key is to remain aware of our emotions, try to understand the patient’s expectations, and react calmly.

If you ever become frightened that a patient’s anger or aggression might escalate into physical violence toward you or your staff, do not discount your concerns. Take whatever steps you need to protect yourself, such as alerting security or appropriate hospital personnel.

Whatever the reason for the anger, utilizing the Universal Upset Person Protocol can be very helpful in diffusing it and moving the patient encounter in a positive direction. (Table 1)

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Are there patients whose demands take a different form?

There are patients who have extensive emotional needs that we simply cannot fill. At the beginning, they can seem endearing and their requests can seem reasonable. We think, “I can help you and I’m surprised no one has been able to in the past.” These patients perceive the physician’s ability to meet those needs as inexhaustible and their behaviors escalate from appropriate request for reassurance to repeated cries for nurture, affection, medications, or attention.

Recognize your own feelings of resentment, guilt, or shame that you may not be meeting their needs. Then have an open discussion with the patient about your limitations of time and stamina. Set limits about when the patient can call you about or how long appointments will last. If you feel the patient might have a condition such as borderline personality disorder, consider a psychiatric referral.

Are there patients who are not angry or manipulative but nevertheless make excessive demands?

Some patients have somatic complaints but no findings to back them up. They tend to be high utilizers of care but may also reject help. Some may actually be diagnosable as having somatization disorder but others are simply not fluent in recognizing their stresses and feelings on an emotional level. Some have depression or personality disorders.

It is natural for physicians to be anxious that they might have “missed something” or to think that the patient is “faking it,” so be aware of your own reactions. Validate their concerns and do not let them think that you regard their ailments as “all in their head.” It may sound counterintuitive, but it can be helpful to see them more frequently, but with regularity, even once a month. Address symptoms as they arise and do a good physical exam. We tend to underestimate the value of hands on the patient. This approach will be reassuring to the patient, reduce phone calls and also the risk of expensive unnecessary tests.

Are there patients who are difficult but not outright demanding?

Self-destructive patients are very difficult. This includes those with severe addictions, patients who are not adherent with treatment recommendations, and patients who are physically self-destructive through acts like burning or cutting themselves. Caregivers often react by becoming anxious and frustrated, feeling angry, and wishing that these patients would simply go away.

It would be optimal to refer these patients to addiction or mental health services when available. Otherwise, organize a treatment team so you are not the only one treating this patient. You and your colleagues can support each other. You may also have to adjust your treatment goals. For example, a person with a severe addiction may not be able to discontinue completely but you can help that patient to reduce the fallout.