Moving Us Closer To Osler
A Miller Coulson Academy of Clinical Excellence Initiative

Book review of “Changing how we think about ‘difficult’ patients”  


When caring for a patient whom I found challenging, I reminded myself that my negative reaction had less to do with the patient and more to do with me.  

My patient is a kind and very talkative person who cannot answer questions with a straight answer to save their life. Which, as the oncologist, is literally what I’m trying to do. 


I ask, “Did you have any diarrhea?” and hear all about a lunch date with friends last week. It takes many precious minutes of our limited time to get past the latest gossip to finally determine that there have been no concerning side effects. 


I recognize the unwanted emotion of resentment flaring up and take measured breaths to try to re-center myself before entering the next exam room. I’ve often wondered how many of my colleagues feel this emotion that’s antithetical to giving excellent patient care. 


It was with all this in mind that I read the book “Changing How We Think About Difficult Patients: A Guide for Physicians and Healthcare Professionals,” by Dr. Joan Naidorf. Naidorf is an emergency medicine physician of 30 years who wrote the book to “provid[e] insight and tools to manage our negative thoughts about difficult patients” and help “beleaguered colleagues . . . return to their benevolent guiding principles and find more enjoyment in their vitally important careers.” 


She writes, “Challenging patients will never stop appearing . . . You cannot change them or control them—the only person you can control is you.” It made me wonder how much the resentment we might feel has nothing to do with the patient but everything to do with us. 


Naidorf also says, “Negative thoughts about challenging patients can cause, in otherwise capable clinicians, a sense of inadequacy and incompetence. Do we perhaps resent our challenging patients because of the negative thoughts they trigger in us? . . . [Difficult patients] often make us question ourselves and we need to feel comfortable with the answers.” 


I realized it’s the discrepancy between expectations and reality that creates my negative emotions. Naidorf writes, “What if you could stop judging others so harshly and accept them exactly as they are?” Hmmm, I thought, the cessation of harsh judgment and implementation of acceptance applied to us, too.  


Perhaps patients who seem challenging can engender resentment because they make us feel like we’re not living up to our own unrealistic expectations. In that case, we need to change our expectations, which is easier said than done. Especially in a system that’s not designed to allow us to do so. 


Next time I see that patient, instead of harboring the unrealistic expectation that this will be the time they give a straightforward answer, I’ll remind myself that what’s in my control is how I react. I’ll focus on how amazing it is that their cancer is in remission instead of resenting the rambling conversation.  


Most importantly, I’ve learned to recognize that even if we have transient negative emotions, it doesn’t make us bad people or healthcare professionals. It only makes us human. 









This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.