Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

The 9 types of manipulative patients

Jeffrey E. Keller, MD
Physician
June 7, 2019
Share
Tweet
Share

One of the more common complaints that I hear from medical practitioners in jails and prisons (especially new practitioners) is, “These manipulative patients are driving me crazy!” Well, to be honest, I ran into a lot of manipulative patients when I worked in the ER, as well. But it is true that many of our patients in jails are especially skilled in manipulation. They have practiced this skill their whole lives and have become proficient. Most people, including correctional professionals, are not naturally skilled at dealing with manipulation. This is often not a skill that we have needed before coming to work in a jail or prison. But once there, learning to manage manipulation is an essential skill if you want to be happy in correctional practice. I call the art of dealing with manipulation “Verbal Jiu-Jitsu.” In order to become a skilled practitioner of verbal jiu-jitsu, we must first start with an analysis of what “manipulation” actually is.

My definition of manipulation is this: in a medical encounter, it’s what happens after a patient wants something he shouldn’t have — like a narcotic, a special diet, gabapentin, an MRI, a double mattress — and won’t take “no” for an answer.

Then comes the manipulation, the attempt to coerce the practitioner into changing a “no” into a “yes.” Manipulation comes in many forms.

1. Exaggeration. “This is the worst pain in the world!” “I can’t stand it any longer!” “I am so much worse now than when I came to prison!” Exaggeration is an attempt to make this a special case, worthy of special consideration compared to other patients.

2. Belittling. “Only crappy doctors work in jails. No wonder you can’t understand how to treat my pain. My outside doctor gave me what I need – oxycontin. Now there was a good and kind doctor! You should be ashamed.” Belittling goes hand-in-hand with splitting.

3. Splitting. This consists of comparing you to someone else who would give the patient what he wants. The other person is commonly an outside practitioner. But splitting is especially effective when the other practitioner is someone within your own facility. “The other doctor who works at this prison gave an extra mattress to my cellie! And he is not in as much pain as I am!”

4. Threatening. This comes in various forms. First is the threat of physical violence. Inmates can get quite skilled at communicating physical threats without saying a word. A particular hard look of a tight jaw, narrowed eyes, tense muscles, and clenched fists – coming from a muscular guy with facial tattoos – can make anyone feel the hair stand up on the back of their neck, even if there is no way the inmate could/would ever act on the threat. The second type of threats are various forms of complaints. Basically, the inmate is saying, “If you don’t give me what I want, I’ll make your life miserable.” Complaints may start with written grievances (that you have to spend time and effort to answer), but then can quickly escalate to letters written to the ACLU, formal complaints written to your State Board of Medicine, pro se tort claims, even malpractice lawsuits. Everyone who has worked in corrections for a very long has heard these words: “You’ll be hearing from my lawyer!”

5. Fawning. Fawning is, of course, the exact opposite of threatening and belittling. “You’re the best doctor I have ever met! I tell all the other girls in the pod how great you are!” Many inmates are exceedingly good at fawning because, again, they have practiced their whole lives. A particularly insidious — and often effective — variation of fawning is flirting and sexual innuendo. “You always smell so good Dr. Smith. What cologne do you use?” I remember one inmate who told me, “Dr. Keller, you really know how to wear a suit. I worked at a clothing store, so I know.”

6. Filibustering. Filibustering is being so relentless in the demand that you finally relent. Filibustering is done in two distinct ways. Method one is this: “I won’t leave your office until you give me what I want! I will argue with everything you say.” An hour later, the patient is still haranguing you and your clinic schedule (as well as your nerves) are shot. Even more effective is the sequential strategy: “I will be in your clinic every week with the same complaint. Nothing you do (except for what I want) will ever work.” After 3, 5, or 10 visits for the same complaint of “intolerable headaches,” you might finally give in and write the prescription for gabapentin that the patient wants.

7. The straw-man victim. This is where the manipulator charges you with acting against a protected class rather than based on your clinical findings. “You’re only refusing me opioids because of my race/I am transgendered/my religion,” etc.

8. Champions. A “champion” is someone who pleads the patient’s case from the outside. The champion can be an attorney or an advocacy group, but most commonly is a family member. Champions use all of the manipulative techniques above, such as exaggeration, splitting, and incessant filibustering. Since champions are not incarcerated, they have access to many people whom inmates themselves cannot reach, such as the sheriff, the newspaper, and even the governor!

9. Self-harm. Self-harmers are patients who deliberately harm themselves to force you to do something they want. Examples of self-harmers include patients who cut themselves (“cutters”), patients who insert foreign bodies into their penis or anywhere they don’t belong (“inserters”), and diabetics who try to induce severe hypoglycemic or hyperglycemic events in themselves. Self-harmers are often particularly hard to deal with.

Like any other skill, dealing successfully with manipulation requires training, practice, and experience. A good start is to go through this list and have your response prepared and practiced in advance. What would you say if a patient belittles you or accuses you of racial bias?

ADVERTISEMENT

Jeffrey E. Keller is an emergency physician who blogs at Jail Medicine. This article originally appeared in MedPage Today.

Image credit: Shutterstock.com

Prev

3 steps to reconnect to who you are behind the white coat

June 7, 2019 Kevin 0
…
Next

Bringing hospitality back to the hospital: lessons from a bartender

June 7, 2019 Kevin 0
…

Tagged as: Emergency Medicine

Post navigation

< Previous Post
3 steps to reconnect to who you are behind the white coat
Next Post >
Bringing hospitality back to the hospital: lessons from a bartender

ADVERTISEMENT

More by Jeffrey E. Keller, MD

  • I’m a jail physician. Here’s what likely happened to Jeffrey Epstein.

    Jeffrey E. Keller, MD

Related Posts

  • Are patients using social media to attack physicians?

    David R. Stukus, MD
  • You are abandoning your patients if you are not active on social media

    Pat Rich
  • Physician Suicide Awareness Day: Where are the patients? 

    Jennifer M. Sweeney
  • Is physician shadowing immoral?

    David Penner
  • A love letter to patients

    Marcie Costello
  • Patients are not passengers

    Christopher Noll, RN, MSN

More in Physician

  • Why doctors are reclaiming control from burnout culture

    Maureen Gibbons, MD
  • Why screening for diseases you might have can backfire

    Andy Lazris, MD and Alan Roth, DO
  • Why “do no harm” might be harming modern medicine

    Sabooh S. Mubbashar, MD
  • International doctors blocked by visa delays as U.S. faces physician shortage

    Arthur Lazarus, MD, MBA
  • How I redesigned my life as a physician without abandoning medicine

    Ben Reinking, MD
  • Why even the best employees are silently quitting health care

    Dr. Suhaib J. S. Ahmad
  • Most Popular

  • Past Week

    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • Here’s what providers really need in a modern EHR

      Laura Kohlhagen, MD, MBA | Tech
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
    • How community paramedicine impacts Indigenous elders

      Noah Weinberg | Conditions
    • Why doctors are reclaiming control from burnout culture

      Maureen Gibbons, MD | Physician
    • How to speak the language of leadership to improve doctor wellness [PODCAST]

      The Podcast by KevinMD | Podcast
  • Past 6 Months

    • Why tracking cognitive load could save doctors and patients

      Hiba Fatima Hamid | Education
    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
    • Here’s what providers really need in a modern EHR

      Laura Kohlhagen, MD, MBA | Tech
    • What the world must learn from the life and death of Hind Rajab

      Saba Qaiser, RN | Conditions
    • How medical culture hides burnout in plain sight

      Marco Benítez | Conditions
  • Recent Posts

    • Why doctors are reclaiming control from burnout culture

      Maureen Gibbons, MD | Physician
    • Would The Pitts’ Dr. Robby Robinavitch welcome a new colleague? Yes. Especially if their initials were AI.

      Gabe Jones, MBA | Tech
    • Why medicine must stop worshipping burnout and start valuing humanity

      Sarah White, APRN | Conditions
    • Why screening for diseases you might have can backfire

      Andy Lazris, MD and Alan Roth, DO | Physician
    • How organizational culture drives top talent away [PODCAST]

      The Podcast by KevinMD | Podcast
    • Why perinatal mental health is the top cause of maternal death in the U.S.

      Sheila Noon | Conditions

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

Leave a Comment

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

ADVERTISEMENT

  • Most Popular

  • Past Week

    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • Here’s what providers really need in a modern EHR

      Laura Kohlhagen, MD, MBA | Tech
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
    • How community paramedicine impacts Indigenous elders

      Noah Weinberg | Conditions
    • Why doctors are reclaiming control from burnout culture

      Maureen Gibbons, MD | Physician
    • How to speak the language of leadership to improve doctor wellness [PODCAST]

      The Podcast by KevinMD | Podcast
  • Past 6 Months

    • Why tracking cognitive load could save doctors and patients

      Hiba Fatima Hamid | Education
    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
    • Here’s what providers really need in a modern EHR

      Laura Kohlhagen, MD, MBA | Tech
    • What the world must learn from the life and death of Hind Rajab

      Saba Qaiser, RN | Conditions
    • How medical culture hides burnout in plain sight

      Marco Benítez | Conditions
  • Recent Posts

    • Why doctors are reclaiming control from burnout culture

      Maureen Gibbons, MD | Physician
    • Would The Pitts’ Dr. Robby Robinavitch welcome a new colleague? Yes. Especially if their initials were AI.

      Gabe Jones, MBA | Tech
    • Why medicine must stop worshipping burnout and start valuing humanity

      Sarah White, APRN | Conditions
    • Why screening for diseases you might have can backfire

      Andy Lazris, MD and Alan Roth, DO | Physician
    • How organizational culture drives top talent away [PODCAST]

      The Podcast by KevinMD | Podcast
    • Why perinatal mental health is the top cause of maternal death in the U.S.

      Sheila Noon | Conditions

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

Leave a Comment

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...