Medicine’s Favorite Misdiagnosis: The Difficult Patient

I’ve been thinking a lot about attribution bias lately — the reflex to explain someone’s behavior by pointing to their character instead of their circumstances. In medicine, this isn’t just a cognitive shortcut. It’s one of our favorite misdiagnoses, and it often shows up in the form of a single, damning label: the difficult patient.

Two encounters from my own practice keep coming back to me.

1. “The Meanest Person I’ve Ever Met.”

That was the handoff.

The wife was “the meanest person I’ve ever met.”

“Confrontational.”

“Always angry.”

“Impossible to deal with.”

This is a common setup: a pre-labeled human wrapped in warning tape, delivered with the expectation that I will treat her like a hazard.

But her husband was lying in an ICU bed because of a botched procedure that left him paralyzed. She was navigating trauma, grief, and a system that — because of medicolegal anxieties — had decided to keep her at arm’s length and speak around her instead of to her. Every door she knocked on had a sign that said You may enter; we will not tell you anything of substance.

When I met her, I didn’t find the “meanest person.”

I found a woman trying to save what was left of her life.

She wasn’t hostile. She was frantic.

She wasn’t aggressive. She was afraid.

She wasn’t difficult. She was drowning.

Nothing about her behavior was surprising once you considered the situation.

2. “Behavioral Issues” in an Incarcerated Patient

The second case came wrapped in a different set of labels: “behavioral issues,” “noncompliant,” “gets angry,” “hard to talk to.” An incarcerated Black man with sickle cell disease — a combination that, in the hospital, often guarantees dehumanization from the start.

He’d been spoken to over the shoulder, not face-to-face. Guards in the doorway. Clinicians darting in and out, clipboards between them and him. A patient assessed through a frame of suspicion before a single word was exchanged.

So I did something radical in its simplicity: I sat down. I looked him in the eyes. I spent twenty minutes listening.

He was delightful. Honest. Funny. Thoughtful.

A person.

The “behavioral issues” vanished the moment the assumptions did.

The Failure Isn’t the Patient. It’s the Attribution.

This is attribution bias at its most damaging: mistaking trauma for personality, mistaking fear for hostility, mistaking systemic failure for individual flaw.

In medicine, we love tidy trait-based stories — she’s mean, he’s manipulative, they’re noncompliant — because traits feel permanent. Predictable. Containable. But traits are the least accurate predictors of behavior, especially in crisis.

Most human behavior is not driven by character. It is driven by emotional state.

It’s driven by:

• fear

• pain

• powerlessness

• being unheard

• being dismissed

• being rushed

• being judged

• being visibly feared

• feeling unsafe

  
  

All of these are situational.

All of them are correctable.

None of them are personality traits.

Fixed Mindset Medicine vs. Growth Mindset Humanity

Attribution bias is rooted in a fixed mindset: the belief that people behave the way they do because of unchangeable internal qualities.

But humans are not static. Neuroscience makes this painfully clear. Our prefrontal cortex — the part that lets us reason, regulate, pause, and plan — is resource-hungry and fragile. When people are in crisis, their frontal lobes go offline and their limbic systems take the wheel. They become emotional, reactive, short-fused, protective. Not because they’re “bad” or “difficult,” but because they’re human.

In other words:

Behavior = situation × current state × available resources (not “behavior = personality”).

A growth mindset — the belief that behavior is modifiable and context-dependent — is not a soft, feel-good philosophy. It’s a neuroscientific reality.

It also makes us better clinicians.

The Stories We Tell Shape the Medicine We Practice

Once we label someone as “difficult,” we stop asking the essential questions:

What happened to them?

What are they afraid of?

What do they need to feel safe?

What system-level failures are shaping this interaction?

And maybe the hardest one:

Who would I like to be in their situation?

That question alone could dismantle half of the attribution bias in our hospitals.

The Truth Behind Most “Difficult Patients”

If I’ve learned anything, it’s this:

Patients are almost never difficult because of who they are.

They are difficult because of what they’re going through —and because of how the system is treating them.

Change the situation, and the behavior changes.

Change the framing, and the person emerges.

Change how we show up, and the whole encounter transforms.

We don’t have “difficult patients.”

We have difficult circumstances — and patients doing their best within them.