ORIGINAL ARTICLE

The ‘‘hateful’’ patient

Lodovico Balducci

Received: 12 August 2013 / Accepted: 27 August 2013 / Published online: 12 September 2013

� Springer-Verlag Italia 2013

Abstract Successful patient–physician interactions are

paramount to effective patient care. Difficult patients may

be nocuous to themselves and to the care of other patients,

as they disrupt the function of the medical team. This

article illustrates the diagnosis and the management of the

‘‘hateful patient’’ using a case report. The hateful patient

was described as ‘‘the name doctors dread to have in their

daily roster on in the list of patients to call back.’’ The

patient described in the report fulfilled three of the four

profile of the hateful patient: dependent clinger, entitled

demander, and manipulative help rejecter. The case study

highlights the opportunity represented by the management

of the hateful patients and the psychodynamic interactions

with such patients.

Keywords Hateful patient � Difficult patient �Patient-provider interactions

Case presentation

Mrs. Jones, I won’t be able to care for you anymore!

During the next month you will be allowed to contact

me only for emergencies, and thereafter you will be

on your own. You have a month to find another

oncologist willing to take care of you.

The patient hearing these words was elderly, small and

dressed in odd clothes; her hair was unkempt with fading

color of yellow dye and two inches of gray-white roots. At

my flanks were a representative from the hospital’s Patient

Relations Department and a security officer. She was no

match for my ‘‘bodyguards,’’ three imposing men, two in

white coat, the symbol of absolute power in the world of

medicine, and the third strapping a holster and pistol.

Silently, without meeting anyone’s eyes, she collected her

meager belongings, the same battered purse she had carried

for the years I had known her and the crumpled brown

paper bag for her lunch. Closely trailed by the security

guard, she walked toward the door.

The eyes of my staff were alight with satisfaction. I

could read their thoughts only too well…. Finally!

The doctor had stood up for his nurses, nurse assis-

tants, secretaries and receptionists. He had fired the

obnoxious woman who for 3 years had harassed and

abused them and disrupted the function of the clinics!

My own reaction was quite unsettling. I felt a unique

discomfort; memories of a childhood experience came

pounding to the surface as I watched my patient being led

away. When I was 3 years old, I had witnessed a dog

catcher seize one of the many stray dogs roaming the roads

of post-war Italy. In a matter of seconds, the animal that had

frightened an entire neighborhood was rendered powerless

and afraid in his own hapless struggle against the catcher’s

net. His menacing barks had turned into wails comparable

to the cries of a lost and desperate child. How quickly this

threatening creature was reduced to a state of abject fear and

powerlessness! In those moments, for the first time, I

became confusedly aware of the fragility, instability and

unpredictability of life, including human life. After having

been buried for more than 50 years, those memories and

feelings resurfaced at the spectacle of Mrs. Jones’ dismissal.

I had consigned that woman to the dogcatcher, as I had lost

any hope of being able to manage her myself.

L. Balducci (&)

Moffitt Cancer Center, 12902 Magnolia Dr, Tampa,

FL 33612, USA

e-mail: lodovico.balducci@moffitt.org

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J Med Pers (2013) 11:113–117

DOI 10.1007/s12682-013-0157-y

As was her custom, Mrs. Jones had stormed into the

clinic that morning. Without regard for the other patients

awaiting their turn, she pushed ahead.

‘‘I need to see Dr. Balducci right now. I don’t have

time to waste with your stupid paper work,’’ she

yapped at the receptionist, and walked into the clinic

hallway looking for me. She brushed aside the nurse

who tried to stop her.

‘‘Don’t bother me, you silly girl! I have an emergency

and I need to see the doctor. Why should I talk to

you? Who do think you are? The queen of shit?’’

She then proceeded to sit in the first empty consultation

room she could find. At that moment, I had been in the

middle of a poignant conversation with another patient,

communicating to this distraught man and his wife of

45 years that his cancer had progressed, the last attempt to

stop it with chemotherapy had failed, and the time had

come to set his affairs in order as he would die within

months, save for a miracle.

As I was walking the subdued and tearful couple to the

door, Mrs. Jones grabbed her chance, and grabbed my arm.

‘‘Come in doctor! I have waited for you more than long

enough!’’ As I shook my arm from her clutch, I instructed

the receptionist to call patient relations. For me, this was

the straw that broke the camel’s back. I experienced this

unruly woman’s intrusion into my ministration of care and

comfort to a mourning couple as a sacrilege. And the

emergency that prompted her furor?

She just had had a mammogram, after which a well-

intentioned technician had told her that there was an abnor-

mality in her film and advised her that she needed to talk to

her doctor as soon as possible. In reality, her cancer had

improved. The technician was not aware that we obtained a

mammogram every 6 months to check the progression of the

cancer. She was accustomed to performing screening

mammograms for individuals without a history of cancer to

obtain a diagnosis of cancer at an early stage when breast

cancer is still curable with surgery. In those circumstances,

any abnormality is indeed a cause of immediate concern,

albeit not of an emergent nature. However, Mrs. Jones had

cancer metastatic to her bones and we followed her mam-

mogram for the same reason we followed her bone scan, to

gauge the effectiveness of the hormonal treatment.

A similar scene had taken place virtually every time she

had a mammogram. To no avail we had recommended to

the mammography technicians not to talk to the patient

about her results. Mrs. Jones came to my care after being

fired by another oncologist who had grown impatient with

her outbursts. My staff and I were known for our ability to

manage difficult patients and a social worker asked us to

see if we could summon some compassion for this

distraught lady. She told the story of Mrs. Jones’ life cir-

cumstances. She was a woman who cared for a 15-year-old

grand-daughter because the child’s father was in prison and

her mother had turned to drugs. She had had another infant

grandchild, who had suffered a beating by a babysitter and

was severely brain injured. She had held this child in her

arms after he was removed from life support and rocked

him for hours as he slowly died. Perhaps, a team who had

patience and empathy would be able to manage her care

and any emotional problems she bore.

In the years since Mrs. Jones was accepted into our care,

we had tried our best. Yet, continuous episodes of sharp

words and explosions of anger and vitriol aimed at virtually

every team member occurred on a regular basis. She

seemed particularly adept at sensing an individual’s unique

vulnerabilities and utilized sarcasm, ridicule and accusa-

tions targeted at those areas mostly likely to disarm and

offend. The most grievous episode occurred when she

caused a most compassionate nurse with an immaculate

personal record, to be ‘‘disciplined.’’ As is often the case

with ‘‘difficult’’ patients, we made a behavioral contract

with Mrs. Jones in the presence of the social worker and of

a patient relation representative. The goal: to prevent the

disruption she had caused in the team and in the clinics.

Under this pressure and fear of dismissal, she agreed to the

terms of the behavioral contract. She agreed to call a

designated Patient Relations team member of her choice

before she contacted the medical staff. One day, Mrs. Jones

called this Patient Relations Rep and was informed by an

administrative assistant that that representative was absent.

This well-intentioned secretary informed the nurse and

asked her to call the patient back. When the nurse refused

to do so, as it was not in accord with the terms of the

behavioral contract we had so carefully crafted, the sec-

retary informed the hospital director. The hospital director

had the nurse disciplined. This nurse had lived her pro-

fession as a vocation, not simply a job. It was not unusual

for her to visit sick and dying patients in their homes.

Thanks to Mrs. Jones, to a uniformed secretary who

thought she was advocating for the patient’s best interests,

and a heavy-handed administrator, this saintly nurse carried

in her permanent record a reprimand for heartlessness. This

episode was only one of so many in which the patient’s

behavior caused harm and havoc.

A confession

‘‘Madame Bovary c’est moi.’’

‘‘I am Madame Bovary’’ states Gustave Flaubert, the

author of the novel Madame Bovary, a novel that inaugu-

rated the modern European narrative. Flaubert was admit-

ting to a depth of identification with the flaws of his

114 J Med Pers (2013) 11:113–117

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principal character, a character that reviewers at the time

considered ‘‘essentially disgusting.’’

‘‘C’est Moi,’’ I could state with regard to Mrs. Jones. ‘‘I

am Mrs. Jones.’’ My discussion of the case would be nei-

ther complete nor honest, without acknowledging my

emotional involvement in the case. At times in my life I

had been as needy and as disruptive to other people as Mrs.

Jones. Before being diagnosed with and treated for

depression, I blamed everybody but myself for my mel-

ancholy. I expected immediate attention from ministers,

friends, counselors and health-care providers. I repeatedly

had abused them verbally for being unable to cater to my

needs. I was blessed because the people from whom I

sought help were able to overcome the hostility I engen-

dered and surrounded me with an affection that helped me

to survive and gain self-confidence. Thanks to therapy and

medications I eventually become insightful about my

shortcomings. I promised myself I would provide the same

acceptance and unconditional love to the ‘‘copies’’ of

myself that I would surely meet in life. It seemed to me that

in the case of Mrs. Jones, I had fallen short of my promise.

This failure to be true to my commitment represented

more than a personal disappointment. Instead of my pro-

fession being an opportunity and avenue to redeem my

personal debts, it became instead an impediment to healing

Mrs. Jones and myself.

I learned some important lessons in caring for Mrs.

Jones.

Whether we like it or not, we are bound to become

emotionally involved in the care of some of our patients. In

the case of Mrs. Jones, my own attitude was dissonant from

that of the rest of my staff. I wished to protect Mrs. Jones as

I had seen in her an opportunity in some form to pay back

the debts I had contracted in my early life, to be as caring

of Mrs. Jones as others had been toward me. However,

other team members experienced Mrs. Jones as a night-

mare. A nightmare the doctor had the power to stop. They

saw me as unwilling to do so because I was a wimp, a

wimp who could bury his head in the sand because he was

not exposed to the venom of her bites on a daily basis. This

dichotomy created a tension within the team, the full extent

of which I became aware only too late, at a point when the

situation had become irreversible and the dismissal of Mrs.

Jones had become the only effective solution.

While I am not sure that the staff would have tolerated

Mrs. Jones any better if I had engaged in more personal

disclosure, perhaps they would have understood that I was

not ignoring their pleas, was not smugly attempting to

preserve my image as a compassionate and caring physi-

cians at their expense and overlooking the abuse they were

enduring. It is possible that awareness could have reduced

the tensions that were building and allowed a less con-

tentious discussion about this patient.

In the same vein, I must confess to the feeling that I had

fired Mrs. Jones for the wrong reason. She had intruded

upon my interaction with a couple in mourning over the sad

reality that within a few months their liaison of half a

century would be severed forever.

‘‘Stupid, intrusive witch’’ I could not help thinking

‘‘Your time has come! Today I am going to teach you

a lesson that you will never forget until the day you

die… and for me, that day can never be too soon!’’

In other words I fired her because I was angry with her. I

was judgmental of her. It was ‘‘C’est moi’’ no longer. I did

what a doctor is never supposed to do, according to the

textbook of medical ethics. I judged the mourning patient

worthier of my attention than the welfare of Mrs. Jones.

Irrespective of whether ‘‘firing’’ her was the right thing to

do for a host of sound reasons, the truth is that I based my

decision on the wrong ones. I based it on my outrage that

she had interfered with the care of another patient. I lost

sight of the essentials in those moments of reaction.

The second important lesson is that good intentions in

medicine can sometimes be as devastating as malicious

ones, when a person acts without knowledge of the facts.

All the personnel in our center are instructed to be helpful

and compassionate. It was this attempt at compassion that

led the radiology technician to give Mrs. Jones a recom-

mendation to ‘‘talk to your doctor right away,’’ a recom-

mendation that started a chain of events leading to the

patient’s discharge from our care. It was an effort to be

compassionate and helpful that led a secretary to make a

phone call that led to an undeserved stain on the record of

one of our most unselfish nurses.

As worthy as it is, patient advocacy, grounded on wrong

information, may lead to tragedy.

I give to you as examples: it is thanks to vocal patient

advocacy that millions of men have been rendered impo-

tent, fatigued, and may have experienced early death from

the unnecessary treatment of prostate cancer. Thanks to the

same sort of advocacy, a hundred thousand women have

unnecessarily undergone high-dose chemotherapy for the

adjuvant treatment of breast cancer, the costs and compli-

cations of which may have included unnecessary suffering

and even death.

Clinical definition of the hateful patient

No doubt, Mrs. Jones fulfilled three of the four profiles of

what has been termed the ‘‘hateful patient’’ (Table 1). She

was clearly dependent upon me and my staff. She inter-

fered with the clinic function both with her unnecessary

phone calls and with her unpredictable emotional storms.

As such, she generated feelings of aversion in staff who

J Med Pers (2013) 11:113–117 115

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came to dread any interactions with her. The recommended

solution to this condition is to ‘‘set limits,’’

This was the goal of engaging in a behavioral contract

with Mrs. Jones. But the contract proved not enough, as

Mrs. Jones was also manipulative. She was very clever in

selling her side of the story to a staff member who did not

know her well. She did just that with the mammography

technicians from whom she successfully obtained infor-

mation that we had interdicted from her. She manipulated

when she pulled on the heart strings of the secretary of the

Patient Relations office who became outraged on the

patient’s behalf and judged the nurse to be cold-hearted.

She manipulated the social worker who had induced us to

undertake her care with her story of being a destitute single

grandmother, whose cancer care had been assigned to a

brutish practitioner insensitive to her tragedy. This type of

manipulation resulting in conflict and resentment among

members of the same team is typical of the so-called

‘‘borderline personality.’’ [2] The traditional wisdom

regarding management of this disorder counsels an agree-

ment among all professionals involved to maintain a uni-

fied front; under no circumstances should pre-established

management rules be broken. However, this goal is real-

istic only in relatively small clinics or in a hospital ward,

with a limited number of personnel. This goal is not easily

achievable in a center such as ours that employs approxi-

mately 4,000 individuals.

Mrs. Jones was also an ‘‘entitled demander,’’ as she

expected that her concerns be addressed immediately

irrespective of other patients’ needs and of staff time. The

approach to this type of patients requires ‘‘setting limits’’

such as an agreement that she/he will never walk into the

clinics without being pre-announced, every visit can take

only a limited time (15–20 min), and she will always call

the same person and not try to go around the system. A

contract of this type was set and almost immediately

broken.

The only profile of the ‘‘hateful patient’’ that Mrs. Jones

did not fulfill was that of the self-destructive denier. The

prototype of this type of patient is an abused woman who is

incapable of leaving the abusing partner [3].

Patients of this profile include those who do not take

their medications, but refuse to tell you why they do not

and refuse the help others try to provide. I had a number of

cases in which the drug company might have helped the

patient pay for an expensive medication if the patient

revealed her/his income. In the two cases in which a patient

refused to do so, the result was death.

The term ‘‘hateful patient’’ and his/her profile were first

described by Groves in 1978, but the term has been rarely

used [1]. Groves defines such a patient. ‘‘The hateful

patient is the patient physicians dread to see on the

appointment list or on the list of patients to call back.’’

This definition is still valid today, though the profiles

may need to be fine-tuned and updated. For example, the

author ignores countertransference as a mechanism by

which a patient may be perceived as ‘‘hateful.’’ In such

cases, it is the power of deep-seated memory and emotion

that the patient’s behavior elicits from the physician, rather

than the patient’s behavior that makes him/her

‘‘dreadful.’’[4].

The last reference I could find regarding ‘‘the hateful

patient’’ in a medical title was in 2006 [5]. The authors of

this article tried to re-define the hateful patient in light of

the medical advances and the changes in medical structure,

though they did not change the basic definition or profile

provided by Groves. The literature is practically mute on

evidence-related management of these patients.

Revisiting my shortcomings in the management of Mrs.

Jones, I developed a set of personal rules that I try to follow

anytime I encounter another ‘‘hateful patient’’ (Table 2).

If I had to treat Mrs. Jones again, I would immediately

ask the staff about the problems she generated, thank the

staff for their patience and understanding, and reveal to the

staff that Mrs. Jones represented for me a unique oppor-

tunity to pay back a sort of moral and spiritual debt I carry

from earlier times of my life. I would emphasize that I

would not expect their allegiance to my approach and my

reasons for it, but that I would wish for them to understand

that I tried to be kind to Mrs. Jones because of my coun-

tertransference toward her, not because I was insensitive to

their plight. I would also ask immediately for advice from

staff and the patient relations office regarding a plan to

reduce the negative impact of Mrs. Jones’ behavior on the

team. In particular, I would establish a common treatment

plan with the consensus of the whole staff, and I would

expect everybody including myself to stick to the plan

Table 1 Profile of the hateful patients and the emotions they

generate

Dependent clingers: aversion

Entitled demanders: counterattack

Manipulative help rejecters: depression

Self-destructive deniers: feeling of maliciousness

Table 2 A blueprint for the management of the hateful patient

1. Acknowledge immediately if the patient elicits negative feelings

on myself or the team

2. Have an open discussion of the patient during the team meeting

and explore solution, such as a psychiatric consult

3. Establish a treatment plan and a set of iron-clad rules

concerning patient management

4. Revisit periodically the patient progress during the staff meeting

5. Give positive reinforcement to the staff for their patience and

understanding toward the patient

116 J Med Pers (2013) 11:113–117

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which would include limited visit time, a single reference

person to receive all patients’ phone calls, and prevention

of unexpected appearances in the clinics. Furthermore, I

would explain to Mrs. Jones after her first outburst that as

much as I cared for her, I would have had to ‘‘fire’’ her if

she persisted in a behavior that was disruptive to our work

and to the welfare of other patients. Finally, I would avoid

firing her in a reactionary way because her behavior made

me particularly angry in a specific circumstance.

A final ethical question related to Mrs. Jones: ‘‘Are we

ever justified in dismissing a patient?’’ This question is not

specific to medicine. It could be paraphrased as ‘‘Is it ever

justifiable to start a war? Is it justifiable to execute a

criminal? Is it justifiable to cut the rope and let an alpinist

precipitate because he threatens to have everybody else

precipitate? Germane to this question is another one: How

much abuse, distress, and frustration a health-care profes-

sional or a home caregiver is expected to tolerate?

Clearly, however, a definitive answer to these questions

is not possible. The description of the ‘‘hateful patient’’

suggests an approach. It includes acknowledging that,

despite the ‘‘aequanimitas’’ preached by Osler, physicians

and other health professionals experience feelings toward

their patients and these feelings may be either an asset or a

liability in the delivery of health care. While one cannot

prevent emotional reactions, one may exercise volition to

avoid allowing them from interfering with the treatment.

Had I been more sensitive to the staff’s complaints and

demonstrated validation and appreciation at the onset, they

may have considered the treatment of Mrs. Jones a

worthwhile challenge instead of an unbearable burden. It

behooves every team member and especially the team

leader to identify with all determined speed the potential

‘‘hateful patient’’ and make of his/her management a pri-

ority discussion for the team meeting.

Conflict of interest None.

References

1. Groves JE (1978) Taking care of the hateful patient. N Engl J Med

298:883–887

2. Biskin RS, Pan J (2012) Management of borderline personality

disorder. CMAJ 184:1897–1902

3. Friedman HG (2012) Destructive women and the men who can’t

leave them. Pathological dependence or pathological omnipo-

tence? Am J Psychoanal 72:139–151

4. Nash SS, Kent LK, Muskin PR (2009) Psychodynamic in

medically ill patients. Harv Rev Psych 17:389–397

5. Strous RD, Ulman AM, Kotler M (2006) The hateful patient

revisited. Relevance to the 21st century medicine. Eur J Intern

Med 17:387–393

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