Challenging Patient Interactions: What’s Really Behind the ‘Difficult’ Label — A Conversation with Dr. John Koo

A patient’s personality is often what makes each provider-patient interaction distinctive. Personality is the unique way of relating to self, others, and the world. In the medical setting, personality is important because it can affect how a patient presents with and manages their illness, relates to the clinician, and responds to treatments and procedures. Furthermore, personality features are often accentuated during times of stress, such as when one is ill or hospitalized. Therefore, as doctors, we often see the patient’s personality unmasked.

It is important for physicians to meet the patient’s personality. Personalities themselves may not change, so we must adjust our behavior to align with the patient’s perspectives. Specifically, we must make educated predictions about which comments and interventions may be best received, jeopardize the doctor-patient relationship, or facilitate collaboration toward optimal outcomes. However, this can be a challenge when a patient has a personality disorder or shows traits of certain personality disorders.

Patients with personality disorders may present unique communication and management challenges, as personality disorders are characterized by persistent patterns of thinking and behavior that can affect interpersonal relationships and medical interactions. As physicians, it can be challenging to connect with a patient with a personality disorder, as it can be difficult to see eye to eye with them, particularly when communication styles and expectations differ.

John Koo, MD, a board-certified dermatologist and psychiatrist, states, “When I think of the topic of difficult patients, I first think of patients with borderline personality disorder.” Borderline personality disorder (BPD) is characterized by a pattern of instability in interpersonal relationships, self-image, and affect. People with BPD exhibit a phenomenon called “splitting,” which is a polarizing way of categorizing others as either wholly good or wholly bad. In addition, they often have labile moods and intense emotions. They can show impulsive behavior, including self-harm, suicide attempts, substance abuse, and risky sexual behaviors.

In the medical setting, a patient with BPD will often show marked instability in how they experience their illness, and they can be strikingly emotional about the medical condition. There is also instability in their relationship with the physician. They often distrust health care providers because they have been perceived as dismissive and less attentive than they feel their condition warrants. They have likely seen many different doctors. Some may have had difficult experiences with previous practices. Prior providers who did not meet their needs medically and/or emotionally are often “split” and viewed negatively.

When approaching patients with BPD, it is important to recognize that their emotions and behaviors are due to fear of abandonment. We must be careful not to minimize their condition and to empathize with any emotional component of their disease, even if it seems out of proportion. Because these patients often feel abandoned, scheduling frequent follow-up appointments may help to promote a positive doctor–patient relationship. Although such patients are sometimes demanding, it is important not to provide unnecessary treatments or perform unnecessary procedures. Reasoning with these patients may sometimes be less effective and could leave the provider feeling negatively “split.” Instead, empathize with their concerns and acknowledge their perspective when explaining your management plan.

As illustrated in this example with BPD, if we can identify traits of a specific personality disorder and understand the underlying psychopathology, we can effectively adjust our demeanor, interactions, and medical management plan to align with the patient.