Different types of patients – different approaches to take
This page is largely written for health professionals – student and qualified.
It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has
Sir William Osler (1849-1919), Canadian physician
There are different types of patient, looked after different types of doctor (yes, we are not all the same!). We will now describe the different characteristics – non-behavioural and behavioural – of patients that you may encounter in clinical medicine.
Before we start ..
Rule Number One
Treat all patients equally – whatever their age, race, gender, culture or views.
Rule Number Two
Never judge a patient (or anyone). It is not your role.
Demographic and biomedical characteristics
There are 7 ways of describing these characteristics of a patient.
- Age. This is the most important characteristic by far. Why? It has a huge effect on the range of diagnoses (‘differential diagnosis’) that may cause a symptom (or syndrome, i.e. group of symptoms)
- Gender. Some diseases are more common in men (or women). Some only occur in men (prostate cancer) or women (uterine cancer)
- Sexuality. Some diseases are more common in homosexual people (e.g. HIV/AIDS)
- Ethnicity. Some diseases are more common in certain ethnic groups (e.g. diabetes, hypertension, hyperlipidaemia and all of the metabolic syndrome in Black/Asian people; and COPD in white people)
- Culture/religion. This is largely irrelevant. Nonetheless it is important to respect all cultures/religions. Be mindful that in some cultures/religions, undressing (especially a woman or child) in front of a stranger (you) is embarrassing. A chaperone is required when undressing someone of the opposite sex or a child
Note 1. Some people don’t like being naked, whatever the culture/religion
Note 2. But (the big BUT) you should not let these issues stop you from doing a full examination of the appropriate part of the patient, and that part should be fully undressed. - Social background (e.g. educational level, language and social deprivation). Almost all diseases – acute and chronic – are more common in people from lower socio-economic groups. Patients’ educational level and language skills may also affect outcome, so should be noted and allowances made
- Size and muscle mass. Obesity is a primary risk factor for diabetes, hypertension, hyperlipidaemia and all of the metabolic syndrome. A higher muscle mass will increase blood creatinine levels.
Behavioural characteristics
‘Pleasant’
These are ‘good’ people that are (a) the easiest to care for as you would expect but (b) often the least challenging. And all doctors like a challenge!
But there are still certain cautions to consider, like: (a) getting too attached, (b) the desire to be too reassuring and optimistic when realism may dictate otherwise, (c) the wish to please the patient and honour requests that may not be in the best interests of his/her medical care.
Courageous
These are the patients we all deeply admire for their strength, perseverance and acceptance in the face of adversity. We do not know where they get this from, but we all wish and hope we have it ourselves when we need it.
Angry
Not pleasant initially, but usually manageable if you know how. The difficulty is in controlling your instinctive reaction to be angry in return. If you handle it well, usually the anger is short-lived, and there will still be a happy ending. Keep our hands down.
Manipulative
They are frequently more challenging than many of the others. Unfortunately, these patients have learned certain behaviours that have resulted in getting personal attention, and obtaining the desired self-centered results.
They usually do not regard themselves as manipulative – and don’t respond well to attempts to change their behaviour.
They do not always tell the truth, and may be using you for a second opinion, whilst not telling about the first opinion.
Demanding
Also referred to as ‘high-maintenance’. They request lots of extra attention, more so than their condition usually requires. They require much more time and energy than average.
Once again, they are not usually aware of this, and should not be judged harshly. They will tell the truth and are easier than manipulative ones.
Direct
Those who tell it like it is. If they don’t agree with what you’re doing, they will immediately let you know. They want to be in control and are quite upset if they are not (or if they don’t perceive that they are). They are not necessarily angry; they are just very vocal about their disagreements.
All-knowing
May or may not have had a brief medical background, but whatever you are discussing with them, they seem to have some limited knowledge about it that leads them to believe that they know a lot about it. They bring in articles for you to read, so that you can become as knowledgeable about their conditions as they are.
‘Noncompliant’
Frequently tend to be frustrating to health professionals, mostly because they usually do not do what you think is best for them. We sometimes wonder why they bother to seek our advice when they are not going to follow through with it anyway. Yes, give them another chance.
At the same time you need to stand up to them – e.g.
yes I will give you another prescription, but I need you to turn up for your appointments, have the blood tests I request, and answer your mobile phone.
Anxious
Usually require more reassurance than most. Sometimes, you may tend to be too reassuring to calm them down, only to find out later that s/he truly has a serious problem.
Hypochondriasis, phobias and panic attacks are more extreme examples of anxiety and can be very challenging.
Be very careful attributing patients’ symptoms to anxiety, stress or depression just because all the tests are normal. Look through the data again and/or ask for a second opinion.
Remember the boy/girl who cries wolf.
Psychosomatic (with medically unexplained physical symptoms, MUPS)
May be some of the most difficult diagnostic dilemmas that you will face. Their complaints seem very real, but a specific diagnosis cannot be found to explain the symptoms. They are usually younger and have seen too many doctors, and had too many tests, for their age.
The doctor is constantly asking himself if he’s missing something. Lots of resources are used in requesting various tests and procedures. Ultimately, when confronted with the diagnosis that the symptoms are psychosomatic, patients often become very upset and disbelieving.
You need to say firmly,
I know you have pain, and its serious, but we can find no serious cause. Further tests or referrals will not help.
Then you need to teach them how to live with (‘manage’) the problem, and stop looking for a diagnosis and cure.
Depressed
Very common and fairly easy to diagnose most of the time; but again, many patients are very resistant to this as a diagnosis for their symptoms, so it has to be approached cautiously.
The biggest difficulty with this type of patient is in recognising suicidal tendencies, which are sometimes denied by certain patients and not always easy to see in a 15-minute clinic visit.
Chronic pain
Those with non-cancer illnesses causing pain are even more of a challenge. There seems to be a fine, but very blurred, line between need and abuse, which is not always easy to see. Many of them truly are needlessly miserable and nonfunctional.
Dying patients are as much in need of our care at this time in their lives as ever, probably even more so. Although there is sometimes a tendency for us to withdraw, thinking there is not much else we can do. This is the time when they probably need you the most.
Frail elderly (‘geriatric’) patients
Also need special attention and consideration. Many are disabled, have 3 or 4 chronic illnesses, with depression and anxiety (related to their physical disease(s)); and are less able to carry out ‘normal tasks’ (dressing, having a blood test without falling).
They require a significant amount of patience, compassion, planning and time; from their carers, doctors and family. Take things slowly, don’t interrupt, don’t hurry them – learn from them. Ask them if they have any further questions, or are there things they don’t understand. That will be you one day.
Engagement
This is a very hard concept to define. But for a good outcome it is vital. It means ‘how much is the patient engaged with their disease and its treatment, and wants to (a) help themselves, and (b) help you help them’.
It can be present to variable degrees in most of the ‘types’ of patient described above. You need to assess it, and help them engage more if they are not. This sometimes requires gentle, polite but straight talking.
For example,
next time I really need you to bring an up-to-date tablet list. You will get better care if you do this. Will you do that for me please?”
Combination of patient characteristics
Rather, we often see various combinations of the above characteristics within many of our patients. For example, you may encounter a very pleasant, polite person who is also demanding and manipulative at the same time. In other words, people are complex and not a particular ‘type’.
Or you may see a person who is very anxious about his or her health but noncompliant when it comes to doing anything to improve the situation. This is part of what makes practicing medicine so interesting and challenging at the same time.
Note. Patient ‘type’
Despite the characteristics described above, it is important not to think of a patient as being of a particular ‘type’. It is better to think of them as Mr Smith or Mrs Patel with the following characteristics.
Summary
We have described different types of patients, with different approaches to take. We hope it has been helpful.
Other resources
Demographic and biomedical characteristics of patients
This paper by Pujalte, 2021 looked at patient characteristics and how they affected hospital care.
Lilly, 2023 looked at which doctor behaviours are found useful by patients, and improve their experience.
