The train wreck: Assessment and management of a complex medical patient

The difficult patient, like the illustrative train wreck about to be described, is a complex dilemma not infrequently confronted by physicians in the clinical setting. These patients come in many versions but typically involve complicated medical histories, extensive medication lists, and repeated medical visits without any apparent medical benefit. The patients do not always seem to want to get well and physicians are frequently unsure what to do to make them better, leading to ineffective care. Recurrent, vague complaints such as insomnia, back pain, dizziness, fatigue, or abdominal pain are superimposed on known medical conditions that are typically suboptimally treated. The pursuit of diagnoses to explain somatic complaints can distract from the care of other chronic conditions, adding frustration to the encounter. Clinical time constraints, productivity demands, and a desire to cure further result in conflicting expectations between the patient and the physician. In spite of a commitment to care, the physician working with a difficult patient may feel guilty when his or her efforts to treat a patient appear to be failing. Unsure of where to start or what to treat, the individual physician begins to experience a sense of helplessness, not so dissimilar from distress experienced by the patients themselves.