Handling (or even firing) the difficult patient

There are difficult dermatologists and difficult patients, but only one of these varieties pays the bills of the other. That's why there's plenty of incentive for dermatologists to assume -- in the best tradition of quality customer service -- that the patient is always right.

But what if the patient isn't right, persists in being extremely wrong, and proceeds to make everyone's life in the clinic harder? 

Dermatologists know the type. One patient will insist that every brown spot or wrinkle must be gone and threaten to alert the world via Yelp if she doesn't get free touch-ups for life. Another patient will disrupt the office with inappropriate remarks. Then there are those who are certain they know more than the dermatologist because they've gone on the Internet even though they lack an "M.D." after their names. 

How can dermatologists avoid turning ideal patients into difficult ones? And what should they do when a patient starts becoming a major pain?  

A panel of veteran dermatologists tackled this topic at the 2016 CalDerm Symposium, a continuing education seminar offered by the California Society of Dermatology & Dermatologic Surgery.

Here are tips gleaned from the panel discussion and follow-up interviews with Dermatology Times.

Next: Weed out touchy patients at the beginning

Weed out touchy patients at the beginning.

When a patient comes in and says they've been upset by multiple doctors but they hear you are great, that's always a red flag. Sometimes I choose not to treat patients rather than firing them later. It's more tactful. -- Arisa Ortiz, MD, FAAD, a dermatologist in San Diego and assistant clinical professor at the University of California at San Diego.

Next: Be honest about expectations

Understand the value of 'easy' procedures.

I try to be honest as to the expectations of the outcomes and guide patients toward easy things. When you go into the world of neck tightening and these other challenging things, it’s hard even with patients who believe the glass is half full. -- E. Victor Ross, MD, a dermatologist with Scripps Clinic in San Diego.

Next: Build Rapport

Build rapport to prevent poor communication.

Some patients, especially millennials, like to self-diagnose through Google searches. They come asking for advice, but they already have in mind what they want or what they think they have. 

The most important thing for them, and for all patients, is to build rapport. Once you establish that relationship and the patient trusts you, they're most likely to be on board for your treatment plan and believe what you tell them. 

One thing you can do is sit with them. It's important to take time to listen to the patients, even if you know what they're saying isn't correct. Just listen to them and let them finish. And make sure to sit. When you sit down, it gives them the impression that you're spending more time with them, and it makes them feel like you're not in a rush. -- Dr. Ortiz

Next: Keep track of personal facts

Keep patients' personal facts on file.

The other key to building rapport is taking note of personal facts about patients. Are they getting ready for a wedding or going on vacation? I usually just make a note in their chart to ask how their trip was or something else that's personal. It helps them feel like you're taking an interest in them. -- Dr. Ortiz

Next: Charge patients less for touch-ups

Redo procedures for free or at a discount.

Say you've done Botox, and the patient has some slight asymmetry 3 weeks later. I'll do a free touch-up with a small amount of Botox.  

But if I treat 150 brown spots and the patient complains that 3 are still there 6 months later, I'll say that we need to charge you again. There's not a lifelong guarantee. 

If they're persnickety, we'll charge them a touch-up fee of $175 instead of $500. That will mollify some of the patients. -- Dr. Ross

Next: Use photos to prove your case

Use photos to prove your case when needed.

I like to go to the "before" and "after" photos. Two minutes of showing them the photos saves me from having to give free treatments away. -- Sabrina Fabi, M.D., a dermatologist in San Diego.

Next: The last resort

At last resort, feel free to fire a patient.

Ninety-nine percent of our patients are normal people with normal responses to what we do for them. But we have fired some patients. 

They're usually nasty people who are demanding. They're rarely mean to me, but they can be tough with the nurses and the support staff. 

For example, we had a psoriasis patient who just made everybody mad by telling bad jokes and making sexual innuendo. He said, "You're firing me?" And we said, "Yes we are."