Working With Difficult Patients

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Changing How We Think about Difficult Patients

Author : Joan Naidorf
Publisher :
ISBN 13 : 9780996663212
Total Pages : 128 pages
Book Rating : 4.6/5 (632 download)

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Book Synopsis Changing How We Think about Difficult Patients by : Joan Naidorf

Download or read book Changing How We Think about Difficult Patients written by Joan Naidorf and published by . This book was released on 2022-02-07 with total page 128 pages. Available in PDF, EPUB and Kindle. Book excerpt: Physicians enter their professions with the highest of hopes and ideals for compassionate and efficient patient care. Along the way, however, recurring problems arise in their interactions with some patients that lead physicians to label them as "difficult." Some studies indicate that physicians identify 15% or more of their patients as "difficult." The negative feelings that physicians have toward these patients may lead to frustration, cynicism. and burnout. Changing How We Think about Difficult Patients uses a multi-tiered approach to bring awareness to the difficult patient conundrum, then introduces simple, actionable tools that every physician, nurse, and caregiver can use to change their mindset about the patients who challenge them. Positive thoughts lead to more positive feelings and more effective treatments and results for patients. They also lead to more satisfaction and decreased feelings of burnout in healthcare professionals. How does this book give you an advantage? Caring for difficult patients poses a tremendous challenge for physicians, nurses, and clinical practitioners. It may contribute significantly to feelings of burnout, including feelings of exhaustion, cynicism, and lost sense of purpose. In response, Dr. Naidorf offers a pragmatic approach to accepting patients the way they are, then provides strategies for providers to find more happiness and satisfaction in their interactions with even the most challenging patients and families. Here are just some of the topics the author discusses in detail: What Makes a "Good" Patient? The Four Core Ethical Principals of the Clinician-Patient Relationship The Four Models of the Physician-Patient Relationship What Challenges Anybody with Illness or Injury? How "Good" Patients Handle the Challenges of Illness and Injury Six Common Reactions to Illness and Hospitalization On "Taking Care of the Hateful Patient" Standards for Education in Medical Ethics De-escalation Strategies Cultural, Structural, and Language Issues Types of Patients Who Tend to Challenge Us The Think, Feel, Act Cycle Recognizing Our Preconceived Thoughts Three Common Thought Distortions About Patients Asking Useful Questions Getting Out of the Victim Mentality Guiding our Thoughts Through a Common Scenario Show Compassion, Feel Compassion If you're a healthcare provider or caregiver, Changing How We Think about Difficult Patients will give you the benefit of understanding your most challenging patients, and a roadmap to positively changing your mindset and actions to better deliver care and compassion for all.

Care of the Difficult Patient

Author : Peter James Manos
Publisher : Psychology Press
ISBN 13 : 9780415358231
Total Pages : 168 pages
Book Rating : 4.3/5 (582 download)

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Book Synopsis Care of the Difficult Patient by : Peter James Manos

Download or read book Care of the Difficult Patient written by Peter James Manos and published by Psychology Press. This book was released on 2006 with total page 168 pages. Available in PDF, EPUB and Kindle. Book excerpt: Whether patient problems stem from mental distress and ill health, historic substance abuse, demanding family members or abusive behaviour, difficult patients place extra demands on nurses both personally and professionally. This is a practical guide to dealing with these patients.

Working With Difficult Patients

Author : Franco De Masi
Publisher : Routledge
ISBN 13 : 0429924267
Total Pages : 294 pages
Book Rating : 4.4/5 (299 download)

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Book Synopsis Working With Difficult Patients by : Franco De Masi

Download or read book Working With Difficult Patients written by Franco De Masi and published by Routledge. This book was released on 2018-05-11 with total page 294 pages. Available in PDF, EPUB and Kindle. Book excerpt: In this book the author examines the series of connections that give rise to the intimate relationship between environment and individual in the construction of emotional suffering, emphasising both the undisputed pathogenic action of environmental stimuli and the active participation of whoever is obliged to suffer the negative situation. The author shows that the way in which one tries to escape suffering is what often seriously jeopardises growth. Working with Difficult Patients points out the intrinsic link between some forms of mental suffering and the distorted responses that the patient has received from his or her original environment. For this reason the author explores the concept of the emotional trauma in particular, since this trauma, which occurs in the primary relationship, often impels the child into relational withdrawal and towards constructing pathological structures that will accompany him or her for the rest of their life. The chapters are ordered according to a scale of increasing treatment difficulty, which is proportional to the potential pathogenicity of the underlying psychopathological structure.

Stressed Out about Difficult Patients

Author : Joan Monchak Lorenz
Publisher : HC Pro, Inc.
ISBN 13 : 1601460120
Total Pages : 155 pages
Book Rating : 4.6/5 (14 download)

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Book Synopsis Stressed Out about Difficult Patients by : Joan Monchak Lorenz

Download or read book Stressed Out about Difficult Patients written by Joan Monchak Lorenz and published by HC Pro, Inc.. This book was released on 2007 with total page 155 pages. Available in PDF, EPUB and Kindle. Book excerpt: Stressed Out About Difficult Patients provides practical, real world tips for nurses who are looking for help with challenging patients who may have psychiatric disorders or may simply be angry about being in the hospital.

Behavioral Medicine A Guide for Clinical Practice 5th Edition

Author : Mitchell D. Feldman
Publisher : McGraw Hill Professional
ISBN 13 : 1260142698
Total Pages : 608 pages
Book Rating : 4.2/5 (61 download)

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Book Synopsis Behavioral Medicine A Guide for Clinical Practice 5th Edition by : Mitchell D. Feldman

Download or read book Behavioral Medicine A Guide for Clinical Practice 5th Edition written by Mitchell D. Feldman and published by McGraw Hill Professional. This book was released on 2020-01-05 with total page 608 pages. Available in PDF, EPUB and Kindle. Book excerpt: Publisher's Note: Products purchased from Third Party sellers are not guaranteed by the publisher for quality, authenticity, or access to any online entitlements included with the product. The #1 guide to behavioral issues in medicine delivering thorough, practical discussion of the full scope of the physician-patient relationship "This is an extraordinarily thorough, useful book. It manages to summarize numerous topics, many of which are not a part of a traditional medical curriculum, in concise, relevant chapters."--Doody's Review Service - 5 stars, reviewing an earlier edition The goal of Behavioral Medicine is to help practitioners and students understand the interplay between psychological, physical, social and cultural issues of patients. Within its pages readers will find real-world coverage of behavioral and interactional issues that occur between provider and patient in everyday clinical practice. Readers will learn how to deliver bad news, how to conduct an effective patient interview, how to care for patients at the end of life, how to clinically manage common mental and behavioral issues in medical patients, the principles of medical professionalism, motivating behavior change, and much more. As the leading text on the subject, this trusted classic delivers the most definitive, practical overview of the behavioral, clinical, and social contexts of the physician-patient relationship. The book is case based to reinforce learning through real-world examples, focusing on issues that commonly arise in everyday medical practice and training. One of the significant elements of Behavioral Medicine is the recognition that the wellbeing of physicians and other health professionals is critically important to caring for patients.

Field Guide to the Difficult Patient Interview

Author : Frederic W. Platt
Publisher : Lippincott Williams & Wilkins
ISBN 13 : 9780781747745
Total Pages : 328 pages
Book Rating : 4.7/5 (477 download)

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Book Synopsis Field Guide to the Difficult Patient Interview by : Frederic W. Platt

Download or read book Field Guide to the Difficult Patient Interview written by Frederic W. Platt and published by Lippincott Williams & Wilkins. This book was released on 2004 with total page 328 pages. Available in PDF, EPUB and Kindle. Book excerpt: Written by physicians skilled at coaching colleagues in physician-patient communication, this pocket guide presents practical strategies for handling a wide variety of difficult patient interviews. Each chapter presents a hypothetical scenario, describes effective communication techniques for each phase of the interaction, and identifies pitfalls to avoid. The presentation includes examples of physician-patient dialogue, illustrations showing body language, and key references. This edition includes new chapters on caring for physician-patients, communicating with colleagues, disclosing unexpected outcomes and medical errors, shared decision making and informed consent, and teaching communication skills. Other new chapters describe clinical attitudes such as patience, curiosity, and hope.

The Difficult-to-Treat Psychiatric Patient

Author : Mantosh J. Dewan
Publisher : American Psychiatric Pub
ISBN 13 : 1585627887
Total Pages : 460 pages
Book Rating : 4.5/5 (856 download)

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Book Synopsis The Difficult-to-Treat Psychiatric Patient by : Mantosh J. Dewan

Download or read book The Difficult-to-Treat Psychiatric Patient written by Mantosh J. Dewan and published by American Psychiatric Pub. This book was released on 2008-08-13 with total page 460 pages. Available in PDF, EPUB and Kindle. Book excerpt: Why do some psychiatric patients fail to get better, even when in the care of competent clinicians? Treatment-refractory conditions are all too common in everyday clinical practice. Treatment resistance occurs across the full spectrum of psychiatric disorders, incurring enormous emotional, economic, and social costs. In the United States, treatment of depression alone costs more than $40 billion annually, and as many as 40% of patients with depression have a treatment-refractory form of the illness. This groundbreaking clinical guide starts where standard textbooks end, focusing on clinical strategies to be used after all basic treatment options, such as medication and psychotherapy, have failed. In this book expert contributors address the sequential clinical steps in treating difficult-to-treat psychiatric patients by offering a blend of evidence-based clinical recommendations, detailed case vignettes, treatment algorithms, and -- when necessary to go beyond the reach of evidence -- the clinical wisdom of leaders in the field. The chapters in this user-friendly, practical guide are organized by major disorder. Each chapter offers concrete recommendations on what to do when the usual first steps in therapy are ineffective, including evidence for biopsychosocial treatments alone versus in combination, generic versus specific therapies, and literature reviews and the latest expert wisdom. A sampling includes The management of the complex and often refractory bipolar disorder, which involves replacing or combining lithium treatment with anticonvulsants or atypical antipsychotic agents with adjuncts such as benzodiazepines, thyroid hormone, and electroconvulsive therapy, but also -- above all -- with careful attention to the therapeutic alliance. The importance of combined therapeutic modalities for patients with schizophrenia -- especially given managed care's cost-cutting strategies, which deprive many schizophrenic patients of effective treatment modalities such as family therapy or early use of an atypical antipsychotic. Combination treatments for anxiety, with medications adjusted over time as symptoms wax and wane, and early and appropriate interventions to mitigate internal and external environmental stressors. The emphasis on common sense, optimism, a sense of humor, and an iron constitution as the most important tools for clinicians wishing to work with the most severely ill patients with borderline personality disorder. The importance of individual differences in biological vulnerability, emotionality and expressiveness, cognitive schemas and beliefs, prior traumatic experience, resilience, and coping strategies for successful treatment of posttraumatic stress disorder. Packed with up-to-date information of immediate relevance, this volume will prove invaluable in both classroom and clinical practice, for everyone from beginning interns and residents to experienced psychiatric and medical practitioners and social workers.

Caring for Difficult Patients

Author : Joseph E. Koob
Publisher : Difficultpeople.org
ISBN 13 : 9780741437686
Total Pages : 172 pages
Book Rating : 4.4/5 (376 download)

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Book Synopsis Caring for Difficult Patients by : Joseph E. Koob

Download or read book Caring for Difficult Patients written by Joseph E. Koob and published by Difficultpeople.org. This book was released on 2007 with total page 172 pages. Available in PDF, EPUB and Kindle. Book excerpt: Caring for Difficult Patients: A Guide for Nursing Professionals, by Dr. Joseph Koob with Dr. Pam Koob provides a comprehensive perspective on how to work with difficult patients and situations that is relevant to all health-care professionals.

Aesthetic Applications of Intense Pulsed Light

Author : Lucian Fodor
Publisher : Springer Science & Business Media
ISBN 13 : 1849964564
Total Pages : 148 pages
Book Rating : 4.8/5 (499 download)

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Book Synopsis Aesthetic Applications of Intense Pulsed Light by : Lucian Fodor

Download or read book Aesthetic Applications of Intense Pulsed Light written by Lucian Fodor and published by Springer Science & Business Media. This book was released on 2010-10-14 with total page 148 pages. Available in PDF, EPUB and Kindle. Book excerpt: The book is structured into eight chapters: 1. Skin anatomy. This chapter is intended to describe the pertinent anatomy related to IPL applications. In addition to the described main structural elements of the skin, the chapter has important points about skin aging and histological aspects which gives the reader a better understanding of the etiology of skin lesions and the need for Intense Pulsed Light (IPL) treatment. 2. Light-tissue interaction. This chapter describes the interaction between IPL and different skin structures. Target skin structures (chromophores) are described in detail. The results of this interaction are detailed as being important to understanding the goals and principles of IPL treatment. 3. IPL safety and legal issues. This chapter describes the needs of the environment for a safe treatment. The necessary equipment and things to avoid pitfalls which may lead to lawsuits are detailed. Several aspects of IPL legal issues are also described: how to avoid medical liabilities and how to manage them are also included in this chapter. 4. Patient selection. This chapter describes the pearls and pitfalls in selecting patients for IPL treatment. This is not an easy task and proper patient selection is extremely important to have satisfied patients. Problematic patient types are also described here. 5. Skin rejuvenation. This chapter starts with a description of skin aging. Intrinsic and extrinsic mechanisms are detailed. The most common skin lesions related to aging that can benefit from IPL treatment for rejuvenation are detailed. The chapter continues with treatment protocols which describe strategies for achieving optimal results. A review of the literature is included, presenting the treatment parameters of different studies and their results. 6. Hair removal. This chapter starts with a description of the hair follicle cycle, hair types and important structures for treatment. Treatment strategies are emphasized and detailed, starting from choosing the right parameters to post-treatment recommendations. A literature review is presented regarding treatment parameters and results according to different authors. 7. Vascular lesions treatment. This chapter describes the types of vascular lesions that can benefit from IPL treatment. The treatment protocol is emphasized and all the steps for performing this application are described in detail. A literature review is presented and different results are compared regarding treatment parameters. 8. Complications. It is inevitable that any medical treatment can end with complications. The possible complications of the most common IPL applications (skin rejuvenation, hair removal, pigmented and vascular lesion treatment) are detailed. The way to avoid them and how to handle them is also described. At the end of each chapter, there is a section on the practical points highlighting the most important points of the chapter. An extensive literature review of this technology is presented alongside numerous illustrations, tables and color pictures. The book will benefit any doctor or healthcare professional who uses IPL for cosmetic purposes, such as plastic surgeons, dermatologists, ophthalmologists, maxillofacial surgeons and otolaryngologists dealing with aesthetics of the face, as well as residents interested in learning the subject.

Difficult Conversations in Medicine

Author : Elisabeth Macdonald
Publisher :
ISBN 13 : 9780198527749
Total Pages : 260 pages
Book Rating : 4.5/5 (277 download)

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Book Synopsis Difficult Conversations in Medicine by : Elisabeth Macdonald

Download or read book Difficult Conversations in Medicine written by Elisabeth Macdonald and published by . This book was released on 2004 with total page 260 pages. Available in PDF, EPUB and Kindle. Book excerpt: In all branches of medicine, effective communication between health care professionals and patients, families and carers is essential to ensure first-class treatment. Increasing public awareness of health issues and the ready availability of health information have led the public to be more widely informed about common conditions and the treatments available. Patients therefore attend a medical consultation better informed so the need for improved communication skills is even greater. Skill is communication is a matter of personal ability which varies widely between individuals in the medical profession as in any other. In response, the aim of this book is to dispel the anxieties which contribute to poor communication. This book covers ethical and legal issues, planning difficult conversations, the patient's and doctor's perspectives, issues surrounding special groups such as children and the elderly, and coversations with patients from different cultural backgrounds. Outlines of possible clinical cases posing specific problems are included with guidance on how to handle them.

Oxford Textbook of Communication in Oncology and Palliative Care

Author : David William Kissane
Publisher : Oxford University Press
ISBN 13 : 0198736134
Total Pages : 457 pages
Book Rating : 4.1/5 (987 download)

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Book Synopsis Oxford Textbook of Communication in Oncology and Palliative Care by : David William Kissane

Download or read book Oxford Textbook of Communication in Oncology and Palliative Care written by David William Kissane and published by Oxford University Press. This book was released on 2017 with total page 457 pages. Available in PDF, EPUB and Kindle. Book excerpt: Communication is a core skill for medical professionals when treating patients. Cancer and palliative care present some of the most challenging clinical situations. This book provides evidence-based guidelines alongside case examples, tips, and strategies to achieve effective, patient-centred communication.

When We Do Harm

Author : Danielle Ofri, MD
Publisher : Beacon Press
ISBN 13 : 0807037885
Total Pages : 274 pages
Book Rating : 4.8/5 (7 download)

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Book Synopsis When We Do Harm by : Danielle Ofri, MD

Download or read book When We Do Harm written by Danielle Ofri, MD and published by Beacon Press. This book was released on 2020-03-23 with total page 274 pages. Available in PDF, EPUB and Kindle. Book excerpt: Medical mistakes are more pervasive than we think. How can we improve outcomes? An acclaimed MD’s rich stories and research explore patient safety. Patients enter the medical system with faith that they will receive the best care possible, so when things go wrong, it’s a profound and painful breach. Medical science has made enormous strides in decreasing mortality and suffering, but there’s no doubt that treatment can also cause harm, a significant portion of which is preventable. In When We Do Harm, practicing physician and acclaimed author Danielle Ofri places the issues of medical error and patient safety front and center in our national healthcare conversation. Drawing on current research, professional experience, and extensive interviews with nurses, physicians, administrators, researchers, patients, and families, Dr. Ofri explores the diagnostic, systemic, and cognitive causes of medical error. She advocates for strategic use of concrete safety interventions such as checklists and improvements to the electronic medical record, but focuses on the full-scale cultural and cognitive shifts required to make a meaningful dent in medical error. Woven throughout the book are the powerfully human stories that Dr. Ofri is renowned for. The errors she dissects range from the hardly noticeable missteps to the harrowing medical cataclysms. While our healthcare system is—and always will be—imperfect, Dr. Ofri argues that it is possible to minimize preventable harms, and that this should be the galvanizing issue of current medical discourse.

The Comprehensive Textbook of Healthcare Simulation

Author : Adam I. Levine
Publisher : Springer Science & Business Media
ISBN 13 : 1461459931
Total Pages : 718 pages
Book Rating : 4.4/5 (614 download)

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Book Synopsis The Comprehensive Textbook of Healthcare Simulation by : Adam I. Levine

Download or read book The Comprehensive Textbook of Healthcare Simulation written by Adam I. Levine and published by Springer Science & Business Media. This book was released on 2013-06-18 with total page 718 pages. Available in PDF, EPUB and Kindle. Book excerpt: The Comprehensive Textbook of Healthcare Simulation is a cohesive, single-source reference on all aspects of simulation in medical education and evaluation. It covers the use of simulation in training in each specialty and is aimed at healthcare educators and administrators who are developing their own simulation centers or programs and professional organizations looking to incorporate the technology into their credentialing process. For those already involved in simulation, the book will serve as a state-of-the-art reference that helps them increase their knowledge base, expand their simulation program’s capabilities, and attract new, additional target learners. Features: • Written and edited by pioneers and experts in healthcare simulation • Personal memoirs from simulation pioneers • Each medical specialty covered • Guidance on teaching in the simulated environment • Up-to-date information on current techniques and technologies • Tips from “insiders” on funding, development, accreditation, and marketing of simulation centers • Floor plans of simulation centers from across the United States • Comprehensive glossary of terminology

The Patient in Room Nine Says He's God

Author : Louis Profeta
Publisher : John Hunt Publishing
ISBN 13 : 184694354X
Total Pages : 191 pages
Book Rating : 4.8/5 (469 download)

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Book Synopsis The Patient in Room Nine Says He's God by : Louis Profeta

Download or read book The Patient in Room Nine Says He's God written by Louis Profeta and published by John Hunt Publishing. This book was released on 2010 with total page 191 pages. Available in PDF, EPUB and Kindle. Book excerpt: A young Jewish doctor prays to a coma patient's Blessed Mother on Christmas Eve, only to have the woman suddenly awakened; there is the voice that tells a too-busy ER doctor to stop a patient walking out, discovering an embolus that would have killed him. The late-night passing of a beloved aunt summons a childhood bully who shows up minutes later, after twenty-five years, to be forgiven and to heal a broken doctor. This ER doctor finds God's opposite in: a battered child's bruises covered over by make-up, a dying patient whose son finally shows up at the end to reclaim the man's high-top sneakers, the rich or celebrity patients loaded with prescription drugs from doctor friends who end up addicted. But, his real outrage is directed at our cavalier treatment of the elderly, If you put a G-tube in your 80-year-old mother with Alzheimer's because she's no longer eating, you will probably have a fast track to hell.

Improving Diagnosis in Health Care

Author : National Academies of Sciences, Engineering, and Medicine
Publisher : National Academies Press
ISBN 13 : 0309377722
Total Pages : 473 pages
Book Rating : 4.3/5 (93 download)

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Book Synopsis Improving Diagnosis in Health Care by : National Academies of Sciences, Engineering, and Medicine

Download or read book Improving Diagnosis in Health Care written by National Academies of Sciences, Engineering, and Medicine and published by National Academies Press. This book was released on 2015-12-29 with total page 473 pages. Available in PDF, EPUB and Kindle. Book excerpt: Getting the right diagnosis is a key aspect of health care - it provides an explanation of a patient's health problem and informs subsequent health care decisions. The diagnostic process is a complex, collaborative activity that involves clinical reasoning and information gathering to determine a patient's health problem. According to Improving Diagnosis in Health Care, diagnostic errors-inaccurate or delayed diagnoses-persist throughout all settings of care and continue to harm an unacceptable number of patients. It is likely that most people will experience at least one diagnostic error in their lifetime, sometimes with devastating consequences. Diagnostic errors may cause harm to patients by preventing or delaying appropriate treatment, providing unnecessary or harmful treatment, or resulting in psychological or financial repercussions. The committee concluded that improving the diagnostic process is not only possible, but also represents a moral, professional, and public health imperative. Improving Diagnosis in Health Care, a continuation of the landmark Institute of Medicine reports To Err Is Human (2000) and Crossing the Quality Chasm (2001), finds that diagnosis-and, in particular, the occurrence of diagnostic errorsâ€"has been largely unappreciated in efforts to improve the quality and safety of health care. Without a dedicated focus on improving diagnosis, diagnostic errors will likely worsen as the delivery of health care and the diagnostic process continue to increase in complexity. Just as the diagnostic process is a collaborative activity, improving diagnosis will require collaboration and a widespread commitment to change among health care professionals, health care organizations, patients and their families, researchers, and policy makers. The recommendations of Improving Diagnosis in Health Care contribute to the growing momentum for change in this crucial area of health care quality and safety.

Managing the Difficult Patient

Author : Robert E. Hooberman
Publisher :
ISBN 13 :
Total Pages : 408 pages
Book Rating : 4.3/5 (91 download)

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Book Synopsis Managing the Difficult Patient by : Robert E. Hooberman

Download or read book Managing the Difficult Patient written by Robert E. Hooberman and published by . This book was released on 1998 with total page 408 pages. Available in PDF, EPUB and Kindle. Book excerpt: The authors -- a psychologist and a medical doctor -- impart in this accessible volume a framework for examining the aspects of the practitioner-patient relationship and interactions that give rise to a sense of the "difficult" in healthcare. Drawing on psychodynamic theory, they elucidate the features of transference, defenses, and the working alliance that are relevant to physicians and other health care practitioners who find patients' emotional and interpersonal problems impacting medical treatment or underlying presenting complaints of somatic dysfunction. Ways of improving the collaboration between doctor and patient and thereby maximizing compliance with medical regimens are examined. Each chapter contains highlighted suggestions for the practical application of the theory to the physician's private practice.

Care of the Difficult Patient

Author : Peter Manos
Publisher : Routledge
ISBN 13 : 1134245599
Total Pages : 168 pages
Book Rating : 4.1/5 (342 download)

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Book Synopsis Care of the Difficult Patient by : Peter Manos

Download or read book Care of the Difficult Patient written by Peter Manos and published by Routledge. This book was released on 2007-04-11 with total page 168 pages. Available in PDF, EPUB and Kindle. Book excerpt: Developed collaboratively by a doctor and nurse team, this is the first text to deal specifically with nursing difficult patients. Whether patient problems stem from mental distress and ill health, historic substance abuse, demanding family members or abusive behaviour, difficult patients place extra demands on nurses both professionally and personally. Caring for difficult patients requires both technical and interpersonal skills along with an ability to exercise power and set limits. This text presents invaluable practical recommendations and advice, well founded in experience and supported by relevant literature, for nurses coping with challenging, real world situations. Including learning points, further reading, case studies and dialogue examples to highlight good (and bad) practice, the book covers pertinent issues such as psychiatric diagnoses, setting limits and establishing authority, death and dying, stress and work. It is ideal for pre- and post-registration nurses, providing concrete direction on the management of difficult patients.