Skip to Main Content
Skip Nav Destination

Learn how to care for difficult patients and yourself

August 30, 2021












Editor's note:For more coverage of the 2021 AAP National Conference & Exhibition, visit

The title of her presentation, “How to Work With Challenging Patients and Their Families,” makes Cora C. Breuner, M.D., M.P.H., FAAP, cringe a little.

She said she dislikes labeling people “challenging” because it’s not empathic or kind and does not uncover the reasons behind the behavior. For instance, parents may get angry out of fear for their child’s health, frustration that treatments aren’t working or because they lost a day’s pay to bring their child in.

“I believe, truly, that people who are coming to see us are not trying to be challenging,” said Dr. Breuner, professor in the Department of Pediatrics, Adolescent Medicine Division at Seattle Children’s Hospital and University of Washington.

She also can relate to such patients, saying she may have been considered a difficult patient while undergoing treatment for stage 4 breast cancer in 2017.

“There were a couple times where I was not super cool when I called in,” she said. For example, she became “snappy” with someone who refused to let her speak to her doctor shortly after the office closed. Later, she apologized, saying, “I'm really sorry I was short with you. It was not my intent. I just was terrified that I was going to die.”

During the session, Dr. Breuner will describe challenging behaviors, discuss the importance of taking into account a family’s experiences and offer advice on how to partner with them. It will be livestreamed from 8-9 a.m. EDT Saturday and will be recorded for attendees to view later.

Dr. Breuner’s interest in the topic predates her own experience as a patient. In 2010, she realized that as a pediatrician she was struggling with some patient encounters and needed some guidance. She looked in the literature and found a 1978 article by James E. Groves, M.D., in the New England Journal of Medicine that described four types of challenging behaviorsHowever, there was little related to pediatrics.

So in 2011, she co-authored an article in Pediatrics titled “Approaches to the Difficult Patient/Parent Encounter.” The article included four case vignettes that illustrated each type of behavior described by Dr. Groves: dependent clingers, entitled demanders, manipulative help rejecters and self-destructive deniers.

During her presentation, Dr. Breuner will describe each type and offer strategies for working with them effectively.

For example, dependent clingers initially shower the doctor with praise. Then, they start calling the office incessantly to ask questions or make repeated requests to be seen. If their calls aren’t returned quickly or they aren’t squeezed in for a visit, they get angry.

It’s important to set boundaries with these patients, said Dr. Breuner, a member of the AAP Section on Integrative Medicine Executive Committee and Section on Adolescent Health. Don’t add them on at the end of the day, be crystal clear about when they should call and have your staff respond instead of taking calls yourself.

It’s also vital for pediatricians to recognize their own physical and emotional responses to such families, Dr. Breuner said. Do you feel angry, exhausted, sad or hopeless when thinking about an upcoming visit or you’re with them?

She likens the situation to seeing a warning light in your car when you’re low on gas.

“So if you're driving your car around and the light is flashing, you don't drive past six gas stations, right?” she said.

Instead you fill up, which for you might mean eating lunch, going for a walk, calling a family member or taking a Zumba class.

“I've run out of gas literally and figuratively,” Dr. Breuner said. “I never want to do that again.”

Close Modal

or Create an Account

Close Modal
Close Modal