Challenging patients and the art of empathy

On a fine afternoon, my nurse came in and gave me a heads-up. “Doctor, the next one’s a bit of a handful. Made a fuss scheduling, complained about her old doctor endlessly at reception … doesn’t seem like a picnic.” I smiled reassuringly, reminding her (and myself) that non-judgmental care is the cornerstone of medicine. However, my mind let out a little sigh, knowing that the next half hour was not going to be easy.

The patient, a woman in her mid-fifties, entered with a forced smile. “Thank goodness I finally see you!” she exclaimed, her initial relief quickly morphing into a list of complaints. She complained that parking was difficult, making appointments were inconvenient, the registration process was tedious, and she had waited outside my room for over half an hour before seeing me. I offered sincere apologies even as my mind strategized how to navigate the brewing storm.

Her medical history unfolded like a well-rehearsed script. She had experienced viral conjunctivitis a few months ago, which seemingly led to nummular corneal lesions. The previous doctor treated her with low-dose steroids and lubricants. A routine fundus examination showed an increased cup disc ratio, leading to her being labeled a ‘glaucoma suspect’. She wasn’t too happy with that diagnosis.

She had done her internet research and found that steroids can cause glaucoma. She believed the previous doctor led her to develop glaucoma. She also complained about the doctor’s ‘exorbitant’ consultation fee. I completed the examination, including an OCT assessment of the retinal nerve fiber layer, ganglion cell analysis, and visual field test. Her intraocular pressures were within an acceptable range, and there was no evidence of glaucomatous disc or ganglion cell changes. She did have a large disc with physiological cupping, which I patiently explained was the rationale behind the previous doctor’s diagnosis. I explained that she was not a steroid responder because her intraocular pressure remained well below the normal range throughout her conjunctivitis and recovery episodes.

Throughout the consultation, she attempted to dominate the conversation by talking about the internet articles she had read and the dangers of the steroid she had learned about. I explained to her the role of low-dose steroids in nummular keratitis, which can shorten the recovery period. Her impatience was palpable, a constant undercurrent demanding immediate validation of her self-constructed narrative.

“I’m sure you are surprised to know that I have learned about the side effects of steroids.”

“I am not any common patient you see in your clinic. I know about my condition in and out.”

“You can talk to me in medical terms. I understand them all.”

At times, there were clear attempts to downplay my expertise.

“How often do you come across patients like me?”

“How sure you are this is not glaucoma?”

“How come you seem to be supporting another doctor who prescribed steroids for me?”

“Do you think I need to seek a second opinion from another glaucoma specialist?”

The situation demanded a delicate balance: Acknowledging her concerns without endorsing misconceptions and maintaining professionalism while setting firm boundaries. Finally, the consultation concluded with an unexpected truce. She seemed mollified, even scheduling a follow-up. My surprised nurse remarked, “No problems at the payment counter. She must have really liked you!” I smiled, the tension slowly ebbing. It wasn’t about winning her over, I realized, but about navigating the storm with empathy and unwavering professionalism.

As you read this, I’m sure most of you can relate to my situation. Often, although not that frequently, we come across patients who exhibit a little over-the-edge self-importance and admiration-seeking behavior. Psychologists describe narcissistic personality disorder as exaggerated feelings of self-importance, a need for admiration, and a lack of empathy. Think of it: aren’t we all narcissistic at some point? Patients with narcissistic traits always fall under the “difficult” patient category.

Some possible behaviors we may encounter include:

Dominating the conversation: They may monopolize the conversation, talking excessively about themselves and their concerns while showing little interest in the doctor’s input or expertise.

Seeking validation: They may constantly seek validation for their appearance or perceived knowledge about eye health, expecting the doctor to affirm their outlook or intelligence.

Minimizing the doctor’s expertise: They may downplay or dismiss the doctor’s recommendations or explanations, believing they know better or that their opinions are more important.

Impatience or frustration: They may become impatient or frustrated if the consultation doesn’t focus solely on their needs or if they perceive any delays or inconveniences.

Expressing entitlement: They may expect special treatment or privileges during the consultation, such as demanding immediate attention or expressing dissatisfaction if they don’t receive preferential treatment.

Lack of empathy: They may show little empathy or concern for the experiences or perspectives of others, including the doctor or other patients in the waiting room.

Difficulty accepting criticism: They may become defensive or hostile if the doctors don’t agree with them or suggest any areas for improvement in their lifestyle habits.

It’s essential for us as health care providers to understand patients exhibit narcissistic traits to mask extremely fragile self-esteem constructs. We should approach them with empathy and professionalism. But it is equally important for us to take care of our boundaries.

As an ophthalmologist dealing with a narcissistic patient, here are some tips:

Maintain professionalism: Stay calm, composed, and empathetic, even if the patient’s behavior is challenging. A narcissistic person’s coping mechanism involves witnessing others fall into passive aggression. Don’t take up the bait, and maintain your patience!

Set boundaries: Clearly establish boundaries regarding acceptable behavior and treatment protocols. Enforce these boundaries consistently.

Focus on the patient’s health: Keep the focus on the patient’s medical needs and treatment plan rather than engaging in power struggles or ego battles.

Validate their concerns: Acknowledge the patient’s feelings and concerns, even if you disagree with their perspective.

Use clear and assertive communication: Be direct and assertive in your communication while remaining respectful and professional.

Avoid personalizing their behavior: Remember that narcissistic behavior is often a coping mechanism, and try not to take it personally.

Dealing with patients exhibiting narcissistic traits can be emotionally taxing. Yet, it’s a skill honed with experience, a reminder that sometimes, the most challenging interactions offer the most profound lessons in compassion and resilience. After all, isn’t that what medicine is about – navigating the complexities of human nature, one patient, one story at a time?

Puspha Raman is an ophthalmologist in Malaysia.

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