In his 1978 New England Journal of Medicine article, Graves defined four types of difficult patients: 1) dependent clingers; 2) entitled demanders; 3) manipulative help-rejecters; and 4) self-destructive deniers.6 This nomenclature has been adopted for general use, including in the pediatric literature.7,8
In exploring difficult encounters in the pediatric age groups, Breuner and Moreno have employed the Graves’ classification, applying it to difficult parents/caretakers.8 They and others recognize that, in addition to parent/patient factors, there are other determinants of disruptive behavior, specifically physician- and healthcare system–derived factors.7,8 Parent factors may include personality and behavioral traits that may be exacerbated by the complexities of a severe chronic illness in their children. Physician factors also may be derived from the physician’s personality, but cultural considerations as well as other external factors may also be underappreciated or unrecognized by the physician. Further, stresses imposed by the healthcare system and the current economic climate are also applicable to both the parent/patient and the healthcare provider.
In approaching such circumstances, the physician/healthcare provider must be cognizant of his or her limitations and must show understanding, even empathy, to the parent/patient. An active attempt to appreciate the nature of the responsible stresses experienced by the parent and patient is vital to achieving optimal healthcare outcomes. Indeed, success in such circumstances is more likely if the parent/patient and the healthcare provider share certain common points of view (i.e., agree on the state of health of the child, the need for medication, etc.) and communicate their concerns effectively.
As in other clinical encounters in pediatrics, the healthcare provider must take into account the family dynamics in thoroughly evaluating the clinical status of the child. A proper assessment of the family’s situation, including the physical and mental well-being of the caretakers, as well as the financial stresses imposed by the patient’s illness on the family, is essential in order to ensure that optimum care is provided to the child. Often, a team approach is needed, involving psychologists, social workers, patient advocates, and patient navigators. Also, referral to another rheumatologist for second opinion is especially helpful, particularly in parents/patients who have preconceived ideas about the child’s condition and the treatment plan. The physician must make every attempt to ensure that proper communication channels are open, as this will lead to better cooperation between the healthcare provider and the parent/patient.
However, if after attempts to alleviate the difficult encounters fail, termination of the patient–physician relationship may be in the best interest of both parties—although it should always be a last resort, because it is well documented that such outcomes result in an overwhelmingly negative experience for the patient.9,10
