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Managing Patients with Big Shot Syndrome

Dealing with Entitled Patients
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“…heads are going to roll…”

Those are the words which greeted me from an imposing woman painfully squeezed into a tiny, very expensive, pastel yellow suit (Chanel, I think) at the urgent care center in which I moonlighted after office hours. She was demanding immediate attention, claiming to be an important somebody in Washington, D.C., so important that I can’t remember the connection. It was time, she said, for injection of her fertility medications, and if it didn’t happen right now, “Heads are….” as above. She claimed that her OB/Gyn in D.C. told her she could drop into a hospital ER wherever she happened to be in her travels and be serviced. [Sidebar: That probably wasn’t true, but no physician should promise a patient that they will be seen, on demand, for certain services or by a physician at an unrelated, anonymous facility.] She told me that she and her very-important husband, also of obscure Washingtonian notoriety, wanted three children. It would just be so much more efficient if they had triplets, she explained, because they had aggressive career plans.

Self-restraint is one of the most-practiced and valuable skills in my repertoire. I stood in the exam room with her, hands in the pockets of my white coat. I was expressionless and silent while she ranted. I did not, (almost-irresistibly) tell her that this was not the behavior of a woman who was ready for motherhood.

Finally, she took a breath. In a conversational voice I said to her, “You will not speak to my staff like this.” I stood in silence for a moment, letting it sink in. No one is going to bully my staff. They need to know that you’ve got their backs. I asked a few questions, validated her story and the medication she brought in with her, and had the nurse inject her. After waiting to ensure there was no immediate reaction to the injection I discharged her.

In preparation to write this, I read suggestions from other physicians about managing patients with big-shot syndrome. For narcissists who name-drop to gain favor, “I know the CEO…” the suggested doctor’s response could be something like, “Me, too, we had lunch the other day. Our kids…”. No thanks. I don’t talk about colleagues, administrators, staff and personal relationships with a patient. I don’t have a need to play “mine’s bigger than yours.”

There was a suggestion to use “million-dollar phrases.” When an arrogant patient flaunting money expects special treatment, come back with an “Ok, Mr. ……. [Buffet, Forbes, Zuckerberg, etc.]” Again, no thanks. It’s my job to break through the posturing, through the defenses and fears, to use the patient’s vulnerability in his or her care. It can have a powerful effect on outcomes. Have you noticed that the bristliest patients often need the most tender loving care?

Managing patients with a sense of entitlement

Don’t:

  1. Give in to unrealistic demands just to keep the peace. The demands will get more and more unreasonable. There will be no peace.
  2. Expect the disordered patient’s behavior to improve in response to the effective treatment you provide.
  3. Try to use logic to argue your way out of their demands. That will only be interpreted as invalidating their feelings and create endless-loop discussions.
  4. Stay in any situation or room in which violence is threatened.
  5. Rush into making or denying commitments or decisions. It’s reasonable to say, “I’ll have to think about it.”
  6. Miss legitimate needs and concerns. The entitlement behavior is one of the legitimate concerns.

Do:

  1. Recognize a sense of entitlement in your patient and understand it as pathologic. It’s a symptom to be evaluated. It shouldn’t be taken personally.
  2. Realize that you can’t meet all the needs of all patients. That is especially true of patients with a sense of entitlement. Acknowledge the good you do, without excessive self-criticism. A dissatisfied patient doesn’t mean that care was unsatisfactory. Doing the right thing won’t always feel good to you and/or your patient.
  3. Talk to others whom you trust about what is being asked before saying “yes” or “no.” Demanding patients can cause a loss of perspective and distort judgement. Ask a colleague for a reality check.
  4. Know your patient very well before addressing the entitlement directly. You’ll have a greater chance of favorable change if you have established a relationship over time.
  5. Support your staff – thank them for their professionalism with difficult patients.

Remember: Self-restraint…self-restraint…self-restraint. It takes too much energy to shoot yourself in the foot and then have to apologize.

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About Faith A. Coleman M.D.

Dr. Coleman is a graduate of the University of New Mexico School of Medicine, and holds a BA in journalism from UNM. She completed her family practice residency at Wm. Beaumont Hospital, Troy and Royal Oak, MI, consistently ranked among the United States Top 100 Hospitals by US News and World Report. Her experience includes faculty appointments to a family practice residency and three medical schools, as well as Director of Women's and Children's Health Promotion Programs with the NE Texas Public Health District.

Dr. Coleman is the Expert on Gifted Children for the New York Times, parenting writer for Demand Media Studios, as well as health and medical writer for several online information services. She writes professional management material for health care providers and about the personal experience of being a physician. Faith treasures most the role of mother. Her passions include the well-being and education of children and families.