I recently had the opportunity to speak with a group of neurogastroenterologists who practice at a major referral center. These specialty physicians treat people with complex digestive disorders such as gastroparesis, abnormal motility, and irritable bowel disease. They also treat patients with illnesses categorized as “functional gastrointestinal disorders,” where no specific physical or lab abnormality can be identified. The people who have these disorders can get very frustrated and unhappy when diagnoses are vague or treatments feel inadequate.

The department chief, I’ll call him Dr. Patel, asked me to speak about improving interactions with some of their patients, who can be very “difficult.” He asked me to address a situation that he finds quite uncomfortable with the patients who are referred to him. He posed the following question, which I paraphrase:

“I work as the Motility and Neurogastroenterology ‘expert,’ and this means I get a lot of third and fourth opinion patients. And while many times I can come up with ideas, sometimes patients have used every single tool in the tool box. I struggle to communicate the limitations of modern-day medicine. It’s hard for someone struggling with chronic irritable bowel syndrome and abdominal pain to fathom that there really is not a whole lot more that can be done to help alleviate their symptoms. This leads to often a very curt encounter full of friction. I was hoping you could shed some light?”

I suspect many physicians who practice as specialists, such as Neuro GI, neurology, or rheumatology, also find themselves in similar situations. During my Grand Rounds presentation, I walked through ways to understand people who are dealing with chronic and debilitating medical issues. Understanding their thoughts and feelings does not excuse any bad behavior on their part, but it does make their actions more understandable. We can’t control what our patients think or feel. We can only offer ideas, evidence, and empathy.

What we can control, however, is how we think about our patients, even the angry, bitter, and hostile ones. In my book, “Changing How We Think About Difficult Patients,” I detail several ways for clinicians to improve our understanding of our challenging patient interactions so that we can feel less frustrated and more curious and empathetic. We can get better results for them and for us. It’s not a panacea, but it helps. Here’s what I told Dr. Patel and his group of specialists in training.

First, the patients

There’s a lot to unpack with this sort of scenario in the specialist’s office. Your patients have had their expectations raised unfairly by other docs, the world, and referral sources who were unable to “cure” them. The person comes into the office interaction with highly unrealistic notions of what can be done for them by the expert. As Dr. Patel noted, folks can be highly disappointed and even angry as they perceive they are, yet again, just “wasting” their time at the doctor’s office.

A lot of the patients referred to specialists are firmly entrenched in victim mentality. They perceive that no medications or strategies can actually help them. They blame the food, the medicines, the system, the nurses, and their physicians. To live as a victim, one must identify a villain, and the physician becomes the villain. Many of these patients complain that their doctors are not listening to them or taking their pain or other symptoms seriously. Understanding their mindset helps to temper your approach as the “specialist.”

Here are a few of my recommendations:

• Take the time to listen to the person’s entire history using active listening techniques and summarizing what they have said back to them. Try to minimize interruptions and gently redirect their conversation.
• Validate to them directly that you believe their pain, bloating, or vomiting is real. Tell the person in simple language that you know they are not making this up. They are not imagining their symptoms. Reassure them that you care. Some of this sounds trite, but your patients need to hear it.
• Do your own detailed physical examination.
• Review with the person the most serious concerns that the medical team has ruled out when an individual has these symptoms. For example, a patient will be concerned about a cancer diagnosis, and you can explain the specific tests that ruled out cancer. Go through all the biggies that have been excluded.
• Try to explain the meaning and implications of functional illness. This definition should be a well-practiced paragraph that rolls off the tongue. Just because you have not found any “positive” or abnormal tests does not mean the person does not have some painful or disabling illness.
• Explain that the severity of their symptoms is affected by what the patient is thinking and feeling. That’s because pain isn’t a purely physical issue. It’s also emotional. This means that treatment must target the brain in addition to the body. They will hear: the doctor thinks it’s all in my head. I recommend reassuring the person directly that you do not think this is all in their head.
• Share that pain researchers explain how one’s experience of pain is an elaborate story, told by the brain. In the presence of some illness or injury, the narrative is shaped by emotions, expectations, and environment. One can change the story and gain more control over the pain that one experiences.

Patients are resistant to psychological approaches because some of what specialists recommend, such as breathing techniques, meditation, and exercise, sounds useless to folks. They want a “magic bullet” that will cure them. As the specialist, you can offer testimonials about what approaches or techniques have assisted some of your patients. You can encourage patients to remember that although their symptoms can be intense, they also have periods where they feel somewhat better and can function. You can encourage them not to let their illness or symptoms define them as people or their purpose.

Shoring up the thoughts of the physician

Above are some of the unhelpful thoughts going on in the patients’ heads. We can’t control those. The only things we can control are what we as clinicians think and do. Here are some thoughts I can offer to you, the specialist physician, in this sort of scenario with a challenging patient:

• I have considered all the history, signs, symptoms, study results, and physical exam. I have fully considered the possibility that the previous diagnosis was incorrect.
• I have tried to validate the patient’s symptoms and concerns. I told the person that I believe them and their symptoms are real. I let them know that the frustration or disappointment they feel with their illness is quite understandable.
• I can find some points of truth about this person as a former school teacher, a golfer, a wife, a brother, or a mother. She likes to knit and read sappy romance novels. This person is more than an angry or frustrated patient.
• I remember that I am a confident and well-trained physician. I keep up with all the literature, and I can offer all the resources at my disposal, including mental health counseling.
• If my patient is disappointed or angry, I will not mirror his emotions. I can stay calm and courteous.
• I am mindful that not all my patient interactions are going to go well. Not everyone is going to like me. That’s OK. I like me, even on my bad days.
• Most of my patient interactions are pleasant, and most patients feel better and leave the consultation feeling satisfied.

I advise docs to allow themselves to feel the pain and disappointment of those occasional challenging patient interactions. The emotions only last a few minutes. Remember to breathe through it. Remember, even your worst day as a specialist is better than an overnight shift in the emergency department.

Joan Naidorf is an emergency physician.