The Train Wreck: Assessment and Management of a Complex Medical Patient

  • Christopher L. Hunter
  • Jeffrey L. Goodie
  • Pamela M. Williams

The difficult patient, like the illustrative train wreck about to be described, is a complex dilemma not infrequently confronted by physicians in the clinical setting. These patients come in many versions but typically involve complicated medical histories, extensive medication lists, and repeated medical visits without any apparent medical benefit. The patients do not always seem to want to get well and physicians are frequently unsure what to do to make them better, leading to ineffective care. Recurrent, vague complaints such as insomnia, back pain, dizziness, fatigue, or abdominal pain are superimposed on known medical conditions that are typically suboptimally treated. The pursuit of diagnoses to explain somatic complaints can distract from the care of other chronic conditions, adding frustration to the encounter. Clinical time constraints, productivity demands, and a desire to cure further result in conflicting expectations between the patient and the physician. In spite of a commitment to care, the physician working with a difficult patient may feel guilty when his or her efforts to treat a patient appear to be failing. Unsure of where to start or what to treat, the individual physician begins to experience a sense of helplessness, not so dissimilar from distress experienced by the patients themselves.


Obstructive Sleep Apnea Sleep Apnea Continuous Positive Airway Pressure Depressed Mood Primary Care Provider 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    National Heart, Lung, and Blood Institute. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report. Bethesda, MD: National Institutes of Health; 1998.Google Scholar
  2. 2.
    Wadden TA, Phelan S. Behavioral assessment of the obese patient. In: Wadden TA, Sunkard AJ, eds. Handbook of Obesity Treatment. New York: Guilford Press; 2002:186–225.Google Scholar
  3. 3.
    Clark MM, Niaura R, King TK, Pera V. Depression, smoking, activity level, and health status: pretreatment predictors of attrition in obesity treatment. Addict Behav. 1996; 21:509–513.PubMedCrossRefGoogle Scholar
  4. 4.
    Gortner ET, Gollan JK, Dobson KS, Jacobson NS. Cognitive-behavioral treatment for depression: relapse prevention. J Consult Clin Psychol. 1998; 66:377–384.PubMedCrossRefGoogle Scholar
  5. 5.
    National Heart, Lung, and Blood Institute. Sleep Apnea: Is Your Patient at Risk. Bethesda, MD: National Institutes of Health; 1995. NIH Publication No. 95–3803.Google Scholar
  6. 6.
    Resick PA, Schnicke M.K. Cognitive Processing Therapy for Rape Victims: A Treatment Manual. Thousand Oaks, CA: Sage Publications; 2002.Google Scholar
  7. 7.
    Gustafson TB, Sarwer DB. Childhood sexual abuse and obesity. Obes Rev. 2004; 5:129–135.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2008

Authors and Affiliations

  • Christopher L. Hunter
    • 1
  • Jeffrey L. Goodie
    • 2
  • Pamela M. Williams
    • 3
  1. 1.Behavioral Medicine ServiceNational Naval Medical CenterArlingtonUSA
  2. 2.Department of Family MedicineUniversity Counseling CenterGaithersburgUSA
  3. 3.Department of Family MedicineUniformed Services University of the Health SciencesBethesdaUSA

Personalised recommendations