Have you ever felt like a “difficult patient?” It might not be all in your head if you think a doctor is getting impatient or annoyed with you.
Often times we come across patients that we term as “difficult”, just as many patients can recall doctors whom they would say are difficult to work with as well. This kind of patients can evoke feelings of anxiety, dread, frustration, and even anger and seem to breakdown the doctor-patient relationship leaving the doctor feeling like the patient cannot be helped, does not want to be helped, or is sabotaging his/her care. “Difficult patients” can be seen as a problem to be tolerated or terminated from practice, though the real difficulty lies in the relationship, not simply the patient and there are techniques and strategies to help clinicians improve that relationship and retain its therapeutic nature.
Who are ‘difficult’ patients?
Angry – smileless faces, furrowed brows, clenched fists, and wringing of the hands are some of the signs that can show that something is wrong with the patient. When we see these signs, we try to uncover the source of anger for the patient and pay attention to the way his or her emotions relate to the medical issues at hand. For example, a patient who is in pain and has been waiting for an hour because the doctor has been tending to a hospital emergency (and has been briefed so…) might be quite angry (reasonable enough…) when the doctor finally gets to the room. A sincere explanation and apology by the doctor such as, “I can understand why you are upset, and I appreciate your waiting for me,” would go a long way toward easing the patient's frustration and getting back to business.
It is normal to feel a certain way after all especially if you are in pain and feel let down. However, there are patients that will remain forever angry despite lack of a trigger and choose to always be on the opposing end of the hospital staff. Some patients are in a habit of yelling insults and can even be physical with the staff, to an extent that assistance from law enforcers to forcefully remove them is sought. For their own safety, doctors will naturally shy away from seeing this kind of patients of if they do the care can be compromised.
Somatizing patients – These patients often present with long standing, multiple vague or exaggerated symptoms. They often “doctor-shop” and have done multiple diagnostic tests without any significant results being yielded. Keys to productive encounters with somatizing patients include describing the patient's diagnosis with compassion and emphasizing that regularly scheduled visits with a primary physician will help to mitigate any concerns. Be sure to effectively manage any comorbid psychological conditions as well. It is important to refrain from suggesting that “it's all in your head,” and avoid the cycle of vigorous diagnostic testing and referrals.
Manipulative patients – Patients often make requests that doctors think are inappropriate, such as requests for additional pain medicine, frequent or longer sick leaves, increased phone contact or clinic appointments, etc. These patients are often sweet-talkers, they ride on the privilege that the doctor gives them, often playing on the guilt of others, threatening rage, legal action or suicide. They tend to exhibit impulsive behavior directed at obtaining what they want which can be quite dangerous. The key to managing encounters with manipulative patients is to calmly explain and realize as the doctor that that sometimes it is okay to say “No.”
Ungrateful – Patients who, for medical or non-medical reasons, appear ungrateful or frivolously utilize medical care but never satisfied with anything are very hard to manage. They may continue to seek medical attention from you but never report anything positive despite the visible changes. They might start their sentence by saying “I don’t know if you will manage, but these are my issues…” They are generally hard to please and they throw doctors into a frozen state every time trying to explain that indeed we have moved from sate A to B. They hardly heed the advice they are given.
Patients who know it all – There are many ‘Dr. Google’ out there. And it either eases or complicates the consultation or the Doctor-Patient relationship. When we say empower yourselves in medical knowledge, it means ‘have an idea’ so that you do not ask the most basic questions, it saves time (and money). It means know your disease and learn how to live with it. It means understand your treatment and contribute towards it to save yourself some distress and complications.
IT DOES NOT MEAN GOOGLE AND COME UP WITH A DIAGNOSIS THAT YOU THINK FITS YOUR SYMPTOMS AND TELL THE DOCTOR HOW TO TREAT YOU.
These kind of patients are the most difficult to deal with and to manage and unfortunately they have been reported not to get much benefit from the doctors’ help because they come with already made-up minds. They perish out of ignorance rather than knowledge. Stay away from this and let the doctor be the doctor!
Non-adherent – Every patient is special. We do not only take care of the patient’s disease but mind, soul and their surroundings as well. So that takes care of the psychological, religious, spiritual and social aspects of their lives. Where any part of that conflicts with the treatment plan we make time to sit them down, counsel them, be patient with them, counsel them again, bring their support structure like family if permitted, do more counseling until they understand the dangers of their choices. However, if we are happy that they understand the dangers but still choose not to adhere to the management plan, we respect their autonomy or power to do so. with severe symptoms, with an underlying mental disorder or who were less functional.”
Worried well patients, patients with poorly controlled chronic pain, who are non-compliant with medical regimens, seductive or manipulative, consume a lot of clinician-time and health care resources, somatisize, or are self-destructive or attention-seeking may also be labeled ‘difficult’. (Krebs et al., 2006; Elder et al., 2006)
well for patients of mine in similar situations. I would like to make a contract with you to see you every two to four weeks – often enough to see if there is anything truly new going on. If something significant develops that has not already been worked up, we will do more tests. We will meet frequently enough to provide you some assurance that we are not missing anything, and we will avoid uncomfortable and costly tests and procedures unless they are clearly necessary.”
Grieving patients. Recognizing the effect of grief on some patients' health requires familiarity with the normal stages of grief and the cultural context in which it occurs. Look for vegetative signs of depression and maladaptive behaviors that prevent progression through the normal grieving process, and treat them. Help grieving patients by validating their emotional experience and making sure they understand that grief is a process that takes varying degrees of time for different people. Encourage open communication, avoid inappropriate medication to suppress emotions, and caution against major lifestyle changes too early in the process.
“Frequent fliers.” These patients may stand out due to the sheer bulk of their medical charts. They may be lonely, dependent or too afraid or embarrassed to ask the questions they really want answered. They may also be patients with a large number of perfectly rational questions, the “worried well” or simply patients who have been given misinformation that needs clarification.
The first step to a productive interaction is to identify the underlying reasons for the frequent visits. Begin by acknowledging that you notice the pattern of frequent visits, and explain that you have seen other patients schedule frequent visits for different reasons, including concern about undiagnosed symptoms, a need for reassurance, a need for relief from chronic pain or a need to talk. Ask whether any of these reasons apply or whether the patient has other ideas as to the reasons for the frequent visits. Showing understanding of the patient's reasons often will foster an open discussion of the “reasons behind the reasons.” Contract with the patient for regularly scheduled return visits, and use patient education and support personnel as needed. Well-honed pain-management skills may also come in handy for patients who schedule frequent appointments due to chronic pain
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We have come a long way from the 19th century, when mental un-healthiness was not recognised as treatable. In those days mental health problems were viewed as a sign of madness, warranting imprisonment in often merciless and unhygienic conditions; and with that backdrop you would think twice before calling in sick because of stress or admit feelings of hopelessness or depression but that’s changing. That may sound like good news but it’s not.
Reasons why employees don’t show up for work can vary, but one thing is for certain; an organisation relies on its staff to get things done and when employees don’t show up for work it disrupts organisational plans, takes up the valuable time from management and lowers the company’s productivity. It’s always been that people miss work for several reasons, some understandable and legitimate and others less so but it’s important that we know the reasons so that such situations can be better managed.
Today stress is one of the most common causes of long-term absence and is especially prevalent amongst office-based staff. This is also related to absence due to depression or anxiety. Is this indicative of where we are as a society, a sign of the times which is that people are constantly pressurised and have less work-life balance?
The British Museum houses a tablet which provides a peek into work-life balance in ancient Egypt. It documents how many sick days and why 40 workers took time off from their workplace in 1250 BC. All sorts of fascinating reasons have been given for why people were away from their work, including a note about someone named Buqentuf, who needed time off for embalming and wrapping the corpse of his dead mother.
There were other reasons like some workers, such as a man named Pennub, missed work because their mothers were ill. Others had causes that we wouldn’t expect to hear as often today, such as men who stayed home to help around the house due to a “wife or daughter bleeding” – a reference to menstruation. But no mention of mental health, not because it didn’t exist, but it wasn’t labelled thus not reported.
What was reported was a person such as Aapehti who was said to have been ill on a regular basis and also took time off when he was “making offerings to god”. Workers also took days off when they had to perform tasks for their superiors – which was apparently permitted in moderate amounts. For example, Amenmose was allowed time away from work when he was “fetching stones for the scribe: And what about other employees who had to excuse themselves from work to brew beer, an activity which was associated with some of their gods and rituals.
All fascinating stuff which provides insight into life at that time. But what insights can we gather from today’s sick leave records? One study recently undertaken gives us insight into the UK police force’s absenteeism. Figures obtained through the Freedom of Information Act from police forces in the UK showed that the number of days absent due to mental health problems increased by 9% in one year, from 457,154 in 2020 to 497,154 in 2021.
And here is the shocker. Police have taken a record 500,000 days off due to mental health issues. Zoe Billingham, a former police inspector, suggested there was a greater prevalence of mental health issues among emergency services, due to what they faced during the pandemic of coronavirus. “Police and other frontline services have protected us during the pandemic,” she said. “The pandemic was a great unknown. People were really scared of dying and coming into contact with the virus, and a lot of people did.”
It is a ‘mental health epidemic’ among police. Alistair Carmichael, Home Affairs spokesman for the Liberal Democrats, said: “Frontline police officers do an incredible job serving their communities. But we know that the stress of policing can take a heavy toll on the mental health of officers, in some cases leading to burnout.
Let’s look at another group. A poll by Gallup reported that in the last three years, 75% of young adults aged 18–22 have left their jobs because of stated mental health reasons. This study showed that employees (millennials and Gen Z) want employers who care about their wellbeing. Contributing factors to mental health stress centre around increases in uncertainty and include: Hybrid work environments and the side-effects: no socialization, no end time, no feedback, caring for others; changing rules around work often with poor communications & clarity; inconsistency & incompleteness of rule implementation: Uncertainty from these and other factors leads to anxiety and depression.
The real story here is not that burnout, stress, depression and anxiety are becoming the number one reasons for absenteeism but that for a large part they are preventable. We have the data telling us it’s the problem but still organisations are doing very little to proactively manage it. Sure, we have counselling services for staff who are struggling and wellness days to reinforce feelings of wellbeing, but this is not enough.
If we start caring and developing work cultures that do not create unintentional stress through how work gets done, that will go a long way to change the status quo. Simple things like ensuring your culture doesn’t thrive on fire drills and heroics to get things done and that emails do not come with expected responses after hours or over the weekend. If we can stop managers bullying, yelling or losing their cool when there is a performance or customer issue and begin giving people more control over their work – all of these are the kinds of stuff that contribute to weakened mental health and absenteeism.
To sum up, your staff’s stress levels are directly proportional to your business’s absentee levels. Ergo, lowering the former, will also reduce the latter. Stress down, productivity up and everybody wins out.
Contributing factors to mental health stress centre around increases in uncertainty and include: Hybrid work environments and the side-effects: no socialization, no end time, no feedback, caring for others; changing rules around work often with poor communications & clarity; inconsistency & incompleteness of rule implementation: Uncertainty from these and other factors leads to anxiety and depression.
In September 1978, General Atiku, Princess Diana had enrolled for a cookery course. That same month whilst she was staying at her parents’ home in Norfolk, her friends innocently asked about the health of her father John Spencer, the 8th Earl. Hitherto, the Earl’s health had never been a matter of concern but Diana somewhat inscrutably voiced a somewhat portendous outlook. “He’s going to drop down in some way,” she said. “If he dies, he will die immediately; otherwise he’ll survive.”
It came to pass, General. The following day, the telephone bell rang to the news that her father had collapsed in the courtyard of his Althorp Estate residence and that he had been rushed to a nearby hospital after suffering a massive cerebral haemorrhage. The medical prognosis was bleak: Earl Spencer was not expected to survive the night. Writes Andrew Morton in Diana Her True Story: “For two days the children camped out in the hospital waiting-room as their father clung on to life. When doctors announced that there was a glimmer of hope, Raine [second wife] organised a private ambulance to take him to the National Hospital for Nervous Diseases in Queen Square, Central London, where for several months he lay in a coma.”
Raine was so fiercely protective of her beloved husband that she had the nurses see to it that his own children did not come near him in this critical condition in his elitist private room. ‘I’m a survivor and people forget that at their peril,” she would later tell a journalist. “There’s pure steel up my backbone. Nobody destroys me, and nobody was going to destroy Johnnie so long as I could sit by his bed – some of his family tried to stop me – and will my life force into him.” But if Raine had steel in her, General, so did the implacable Spencer children, more so the eldest of them all. “During this critical time,” Morton goes on, “the ill feeling between Raine and the children boiled over into a series of vicious exchanges. There was iron too in the Spencer soul and numerous hospital corridors rang to the sound of the redoubtable Countess and the fiery Lady Sarah Spencer [the Earl’s firstborn child] hissing at each other like a pair of angry geese.”
As Diana had correctly predicted, her father was not destined to die at that juncture but healthwise he was never the same henceforth. First, he suffered a relapse in November that same year and was moved to another hospital. Once again, he teetered on the brink. He was drifting in and out of consciousness and as such he was not able to properly process people who were visiting him, including his own daughters when nurses relented and allowed them in. Even when he was awake a feeding tube in his throat meant that he was unable to speak. Understandably, Diana found it hard to concentrate on the cookery course she had enrolled in a few days before her father suffered his stroke.
But Raine, General, was determined that her husband survive come rain or shine. Morton: “When his doctors were at their most pessimistic, Raine’s will-power won through. She had heard of a German drug called Aslocillin which she thought could help and so she pulled every string to find a supply. It was unlicensed in Britain but that didn’t stop her. The wonder drug was duly acquired and miraculously did the trick. One afternoon she was maintaining her usual bedside vigil when, with the strains of Madam Butterfly playing in the background, he opened his eyes ‘and was back’. In January 1979, when he was finally released from hospital, he and Raine booked into the Dorchester Hotel in Park Lane for an expensive month-long convalescence. Throughout this episode the strain on the family was intense.”
Altogether, Earl Spencer had been in hospital for 8 straight months. The lingering effects of the stroke left him somewhat unsteady on his feet when he escorted his daughter down the aisle at St. Paul’s Cathedral in 1981 for her marriage to the Prince of Wales.
R.I.P. EARL SPENCER
It was not until March 29, 1992, General, that Earl Spencer finally gave up the ghost. He was admitted in hospital for pneumonia but what killed him days later was a heart attack. Rumours of his death actually began to make the rounds the day before he passed on. At the time, Diana was on a skiing holiday in the Austrian Alps along with her estranged hubby Prince Charles and their two kids William and Harry.
When Diana was told of her dad’s death, she insisted that under no circumstances would she return to England on the same flight as Charles, with whom she was barely on talking terms. “I mean it, Ken,” she told her body minder Ken Wharfe. “I don’t want him with me. He doesn’t love me – he loves that woman [Camilla]. Why should I help save his face? Why the bloody hell should I? It’s my father who has gone. It’s a bit bloody late for Charles to start playing the caring husband, don’t you think so?”
Naturally, General, Charles was alarmed, particularly that his efforts to use one of his right-hand-men to reason with the Princess had been rebuffed. He therefore prevailed over Wharfe to try and ram sense into his wife. “Lord Spencer’s death was a major news story,” writes Ken Wharfe, “and if the Prince and Princess did not return to Britain together then nothing, not even compassion for the grief-stricken Diana, would stop the journalists from going for the jugular. The truth about the Waleses would be immediately and blindingly obvious to the most naive journalist … Returning to the Princess’s room, I told her bluntly that this was not a matter for debate. ‘Ma’am, you have to go back with the Prince. This one is not open for discussion. You just have to go with it’.’’
At long last persuaded, General, Diana said, “Okay Ken, I’ll do it. Tell him I’ll do it, but it is for my father, not for him – it is out of loyalty to my father.” But what in truth got Diana to change tack was the intervention of the Queen, who personally called her at Charles’ own request. That, however, General, was only as far as Diana was prepared to play ball: as far as engaging with Charles in conversation was concerned, that was simply inconceivable. “There was an icy silence for the rest of the two-hour journey,” writes Wharfe. “Nothing was said during the entire flight. The Princess did not want to speak to her husband and he, fearing a furious or even hysterical outburst, did not dare even to try to start a conversation. Whatever the discomforts of the journey, however, it was soon clear that the PR spin had worked. The next day it was reported that Prince Charles was at Diana’s side in her hour of need. Yet as soon as the Prince and Princess arrived at Kensington Palace they went their separate ways – he to Highgrove, and she to pay her last respects to her father.”
Lord Spencer was 68 when he died. He was a remote descendant of King Henry VIII.
PRINCE CHARLES FINALLY OWNS UP TO ADULTERY WITH CAMILLA
In June 1994, when Diana and Charles had been separated for exactly one-and-half years, Prince Charles was interviewed in a BBC documentary by Jonathan Dimbleby. The interview was billed as intended to mark Charles’ 25 anniversary as Prince of Wales but it was in truth a not-to-cleverly-disguised riposte to Diana Her True Story, the highly controversial 1992 collaboration between Diana and Andrew Morton.
In the interview, which was watched by 13 million people, Charles, General, openly admitted for the first time that he had committed adultery with Camilla Parker-Bowles, who he hailed as, “a great friend of mine who has been a friend for a very long time and will continue to be a friend for a very long time”. Diana had been requested to feature in the interview alongside her husband but she parried the overture on the advice of her aides, which was spot-on as she would have been greatly embarrassed by her hubby’s unsavoury confession in her own face and on national television.
The Prince’s candid confessional was followed weeks later by a book titled The Prince of Wales: A Biography, which was written by the same Jonathan Dimbleby. The book was even frankier than the interview. In it, Charles put it bluntly that she had never once loved Diana and that he married her only because he was coerced into doing so by his notoriously overbearing father. Charles also made it known that as a child, he had been bullied by his abusive father, virtually ignored by his mother, and persecuted by a wife he portrayed as both spoiled and mentally unstable. Both Diana and his parents were revolted by the bare-knuckle contents of the book though Dana need not have been irked considering that it was she herself who had fired the first salvo in the Morton book.
BASHIR INTERVIEW BODES ILL FOR DIANA
If Diana’s collaboration with Morton was a miscalculation, General, Prince Charles’ Dimbleby interview was equally so. For in November 1995, the wayward Princess hit back with her own tell-all interview on BBC’s current affairs programme called Panorama. “She wanted to get even with Prince Charles over his adulterous confession with the Dimbleby documentary,” writes Paul Burrell, her final butler, in A Royal Duty.
The interview was conducted by journalist Martin Bashir who was attached to BBC, and was watched by 23 million people, conferring it the distinction of having attracted the largest audience for any television documentary in broadcasting history. In the interview, Diana voiced concern about there having been “three of us in this marriage and so it was a bit crowded”, the intruder obviously being Camilla. Diana also gave Charles a dose of his own medicine by confessing to her own adulterous relationship with James Hewitt, of whom she said, “Yes, I adored him, yes, I was in love with him”. Hewitt had at the time documented his affair with Diana in lurid detail in a best-selling book and Diana thought he had ill-conceivedly stabbed her in the back.
And as if to rub salt into the wound, General, Diana cast serious doubts on her husband’s fitness to rule as future King and therefore his eventual accession to the British throne. Unfortunately for her, the interview sealed her fate in so far as her marriage was concerned. “In her headstrong decision to co-operate with Bashir,” says Burrell, “she had never considered, perhaps naively, the implications that Panorama had for her marriage.” Indeed, just four weeks after the interview, the Queen, after consultation with the Prime Minister and the Archbishop of Canterbury, wrote personally to both the Prince and Princess of Wales requesting that they divorce sooner rather than later.
It was a dream-come-true for at least two parties to the triangle, namely Charles and Camilla. But did it also constitute music to the ears of Princess Diana too, General?
SOWING THE WIND ONLY TO REAP THE WHIRLWIND: Martin Bashir interviews Princess Diana in a BBC documentary which aired on Monday 29 November 1995. The interview incensed the Windsors: the following month, Queen Elizabeth ordered Charles and Diana to sever matrimonial ties. In her vengeful resolve to hit back at her husband following his own interview the previous year, Diana had foolishly sown the wind and reaped the whirlwind.
Islam is a way of life completed and perfected by the last and final Messenger of Allah, Prophet Muhammad (pbuh). The Holy Quran along with the practical teachings of the Prophet (pbuh) forms the basis of Islamic law, social, economic and political systems of Islam – in short the basis of a complete code of conduct for the entire life of a Muslim
Regrettably in this day and age there are certain views in non-Muslims that have a very negative ‘view’ of Islam. The bottom line is that if a Muslim says that two plus two is four, others can ‘argue’ to say three plus one is four, or two times two is four or the square root of 16 is four. The bottom line is no matter what we may think we all are ‘correct’. The fact is that we are all on this earth for a ‘limited’ time. Regardless of beliefs, tribe, race, colour or our social standing in life, we will all die one day or the other and we will “all” be called up thereafter to answer for our behaviour, beliefs, and our life on this earth.
To a Muslim the Holy Quran is the Divine Revelation which is all encompassing and lays down in clear terms, how we should live our daily lives including the need for humans to allow fellow humans certain basic rights at all times. Due to the limited space available I can only reflect on some of the major fundamental rights laid down by Islam:
Right to life
The first and foremost of fundamental basic human-rights is the right to life. “Whosoever kills any human being (without any valid reason) like manslaughter or any disruption and chaos on earth, it is though he had killed all the mankind. And whoever saves a life it is though as he had saved the lives of all mankind” (Quran Ch5: v 32). It further declares: “Do not kill a soul which Allah has made sacred except through the due process of law” (Quran Ch6: v 151). Islam further explains that this sacrosanct right to life is not granted only to its adherents (believers), but it has been granted to all human beings without consideration of their religion, race, colour or sex
Right to Equality
The Holy Quran recognises equality between humans irrespective of any distinction of nationality, race, colour or gender. “O Mankind We have created you from a male and female, and We made you as nations and tribes so that you may be able to recognise each other (not that you may despise each other). Indeed the most honourable among you before God is the most God-conscious”. (Quran Ch49: v 13). The Prophet Muhammed (pbuh) further explained this: “No Arab has any superiority over a non-Arab, nor does a non-Arab have any superiority over an Arab…… You are all the children of Adam and Adam was created from soil”. If there is any superiority for a man it is based on his piety, righteousness, sense of responsibility and character. Even such a person with these noble qualities would not have any privileged rights over others.
Right to justice
Allah Almighty has bestowed on all human beings, believer or non-believer, friend or foe the right to justice. The Holy Quran states: “We sent our messengers with clear teachings and sent down along with them the Book and the Balance so that society may be established on the basis of justice” (Quran Ch 57 : v 25). It further says “O Believers stand for the cause of God and as witness to justice and remember that enmity of some people should not lead you to injustice. Be just as it is nearest to God consciousness” (Quran Ch 5:v 8 ). This makes it obligatory that a believer must uphold justice in all circumstances, including to his enemies.
Right to freedom of conscience and religion
The Holy Quran clearly mentions that there is no compulsion in accepting or rejecting a religion. “There is no compulsion in (submitting to) the religion” (Quran Ch 2 : v 256). Every individual has been granted basic freedom to accept a religion of his or her choice. Therefore no religion should be imposed on a person.
Right to personal freedom
No person can be deprived of his or her personal freedom except in pursuance of justice. Therefore there cannot be any arbitrary or preventive arrest without the permission of duly appointed judge and in the light of a solid proof.
Right to Protection of Honour
Every person has been ensured basic human dignity which should not be violated. If someone falsely attacks the honour of a person the culprit will be punished according to the Islamic Law. The Holy Quran says: “Do not let one group of people make fun of another group”. It further states: “Do not defame one another”, the Quran goes on to say: And do not backbite or speak ill of one another” (Quran Ch 49 : v 11-12).