American Society of Regional Anesthesia and Pain Medicine May 2018 - 23

Dealing With the Difficult Patient

P

ain is the subjective interpretation of nociceptive input: an
objective, noxious stimulus that is processed through the
lenses of a patient's particular affect and circumstances
to generate both a perception and a behavioral response. The
extrasomatic filters that make each patient unique can also
generate some of our greatest therapeutic challenges. But, when
does a patient transition from being a challenge, where he or
she can still be rewarding to treat, to being outright difficult to
work with? This article will address what may make a patient
encounter difficult, identify factors attributed to the patient and
the practitioner that interplay in such a situation, and suggest
strategies that can mitigate most instances so that the encounter
can have some positive influence in patient management.

Webster's New World Dictionary defines difficult as (1) hard to
do, make, change, manage, understand, etc.; (2) involving trouble
or requiring extra effort, skill, or thought; or (3) hard to satisfy,
persuade, please, etc.1 This is clearly a broad term open to
interpretation, yet certain patterns emerge that many of us routinely
encounter. Have you dealt with any of the following patients?
* The patient with multiple (convenient) allergies to many pain
medications except meperidine or a drug of their apparent
choice
* The patient with the superior mesenteric artery restricted-byligament compression who has high opioid requirements and
lots of family "support"
* The patient with an opioid-only agenda ("I've done all you
asked and it hasn't worked, so give me that prescription for an
opioid.")
* The patient who vents at you for all the abuse he or she has
suffered in the health care system and tells you the entire story
* The yeller whose volume and ferocity only increase as you
decline repeated requests for a special test, drug, or disability
rating
* The patient who refuses to follow your advice for more
investigation (eg, seeing the disability specialist or the pain
psychologist)
* The patient who perceives disability but does not qualify
administratively or legally
* The chronic appointment canceller who is noncompliant and
disruptive when he or she does show
Although many patients can be difficult to treat, what is distinctive
about patients with chronic pain? Chronic pain lingers, which
breeds failed expectations for treatment leading to cure among
physicians and patients alike. Frustration agitates the doctor-
patient relationship, where discussions leading to evaluation or
treatment decisions intensify and judgment and biases become
evident. Over time, patients adopt a belief that they are entitled
to certain tests, medications, allowances from work, among
others. Patients can develop (1) maladaptive changes in their

Russell E. Davenport III, MD
Anesthesia Resident

John C. Rowlingson, MD
Professor

Department of Anesthesiology
University of Virginia Medical Center
Charlottesville, Virginia

attitudes about ever regaining their health, (2) nonproductive and
even obstructive behaviors, (3) self-destructive lifestyles, and (4)
physioanatomic changes in the pain-processing and transmission
system, termed neuroplasticity, that essentially hardwire the
pain response pattern. Chronic opioid use and neuropathic pain
independently lower the set point threshold in the central nervous
system for a response to nociceptive input, such that patients with
longstanding pain or opioid use have an increased likelihood to
experience pain from a remarkably low stimulus intensity.
Pain catastrophizing can pose an added degree of difficulty for
patients and practitioners, so it must be identified in order to
provide relevant therapy. In the introduction to a special issue of
the Journal of Applied Behavioral Research on pain catastrophizing,
Gatchel defines this as "an exaggerated negative orientation
toward actual or anticipated pain experiences. . . . Current
conceptualizations most often describe it in terms of appraisal or as
a set of maladaptive beliefs."2 Pain catastrophizing influences the
severity of pain (both acute and chronic), the patient's functional
disability and quality of life, the incidence of depression, and
the patient's reported pain intensity. Brain imaging studies have
shown that this phenomenon has an organic basis, because pain
catastrophizing can affect activation of different cortical regions
during pain-inducing manipulations.2
In medical school, we have been trained to interview patients to
obtain their history; process the history, physical exam, and lab
results; collate those data with literature and consultation; and
provide feedback to patients about the working diagnosis and
differential diagnosis. However, studies have shown that empathy
(the appreciation for what the patient is going through) starts to
drop when third-year medical students begin to get actual patient
contact.3 A difficult patient becomes particularly challenging in the
setting of waning empathy. What can help is accruing experience

American Society of Regional Anesthesia and Pain Medicine
2018

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