CCFP priority topic 28 of 105
Difficult Patient on the CCFP exam
8 key features, the mistakes that cost marks, and a practice question.
Checked by a Canadian family physician, MD, CCFP. Updated October 20, 2026.
What the exam tests
Key features
The CFPC’s 8 key features for Difficult Patient. Each one below has how the exam asks it, the common mistakes and the approach.
Practice question
Try one before you read
A real case from the bank, in the new short-menu format. Answer it first. Then read the key features.
Key feature 1 of 8
Personality disorder
Spot a personality disorder when it is the reason care with a patient keeps going wrong.
CFPC skill Clinical reasoningPhase Diagnosis
On the exam
A man of 81, polite for 25 years, now shouts at staff. Expect one best answer for the cause.
Pick the most likely cause of the change.
Common mistakes
Calling a late change in a calm man a personality disorder. That pattern starts early and lasts. Or missing it when the same fights repeat at every clinic.
Approach
- Know what it is: a lasting way of thinking, feeling and relating that starts by the teens or early adulthood.
- It shows in many settings, with many people, over many years. Not with one clinic, and not in one crisis.
- Years of calm visits argue strongly against it. A new change in an older adult points to dementia, delirium, depression or a medicine.
- Suspect it when the same fights repeat with many staff and clinics: sudden anger, fear of being left, splitting staff into good and bad.
- Naming it helps you plan steady, predictable care. It never ends your duty to look at new problems.
| Personality disorder | New change in behaviour | |
|---|---|---|
| When it starts | By the teens or early adulthood | Recently, in someone you knew as calm |
| Where it shows | Everywhere, with everyone, for years | Out of keeping with the person you know |
| Next step | Steady care and clear limits | Look for the cause: memory, mood, medicines, infection |
Key feature 2 of 8
What has changed
Find out what is going on in the patient's life and daily coping, and keep it current.
CFPC skill Patient-centred approachPhase History, diagnosis
On the exam
A woman with past cancer and old back pain is angry and calling daily. Expect a short menu (pick several from a list).
Pick what to ask about today.
Common mistakes
Digging into her childhood, schooling, family history or old pain treatments. The chart holds most of that, and none of it says what changed lately.
Approach
- Ask what has changed lately: home, money, work, family, who helps her.
- Ask how she copes day to day: washing, meals, shopping, medicines, getting around.
- Ask about new losses, new stress and safety at home.
- Check the chart for recent events: a new diagnosis, a new treatment, a hospital stay.
- Save prevention, family history and old conflicts for a calmer visit.
- In an older adult, ask family too, with the patient's consent.
Key feature 3 of 8
Long-term illness
Know that people with long-term illness will sometimes be hard to work with, and respond with extra warmth.
CFPC skill Patient-centred approach, professionalismPhase Treatment, follow-up
On the exam
A patient on cancer treatment, angry and calling often, wants more pain medicine. Expect one best answer.
Pick the response that keeps care going.
Common mistakes
Taking the anger as personal, or treating it as bad behaviour to punish. Anger often follows bad news, a setback or new pain.
Approach
- Expect anger and despair at diagnosis, relapse, new symptoms or loss of function.
- Name the feeling you see. Ask what is hardest right now.
- Separate the person from the behaviour. Stay warm, and stay firm on limits.
- Look for what drives it: pain, fear, low mood, money or housing trouble.
- Book regular visits, so the patient does not need a crisis to be seen.
- Do not let past conflict delay care today.
Key feature 4 of 8
Missed disease
Keep checking for fresh problems in patients whose visits are hard, so nothing real is missed.
CFPC skill SelectivityPhase Hypothesis generation, diagnosisSources Choosing Wisely Canada
On the exam
A woman with past breast cancer, on hydromorphone for old back pain, has new night pain mid-back. Expect a short menu (pick several from a list), then one best answer.
Pick the likely causes, then the first test.
Common mistakes
Calling it strain, opioid withdrawal or distress because of her history. New pain at one spot on the spine, with night pain and weight loss, means suspected cancer.
Approach
- Take each new symptom on its own. Ask what differs from the usual pain: place, timing, waking at night.
- Examine every time. Tenderness right over the spine bone is a new finding.
- Past cancer, new spine pain, night pain and weight loss: cancer is suspected.
- Back pain rarely needs imaging unless there is a red flag. Suspected cancer is one, so image now.
- Image the new painful level, not the old familiar one.
- A mental illness or long-standing pain can hide a new disease. Examine as you would for anyone.
- Treat the new pain while you find the cause. Do not cut the opioid dose now.
| Cause | Fits | Does not fit |
|---|---|---|
| Muscle strain | Pain after lifting, sore muscles | Night waking, weight loss, tender spine bone |
| Opioid withdrawal | Aching all over, restless | New pain at one spot on the spine |
| More pain from opioids themselves | Pain that spreads and is everywhere | New pain at one spot that wakes her |
| Cancer spread to bone | Night pain, weight loss, tender spine bone | Nothing here argues against it |
Key feature 5 of 8
Your own part
Notice your own feelings and what you add to the conflict.
CFPC skill ProfessionalismPhase Treatment, diagnosis
On the exam
Staff warn you that the next patient is impossible. Expect one best answer for your first step.
Pick what you do as the visit starts.
Common mistakes
Walking in with the label: raking over past fights, or rushing the visit. It proves to the patient that nobody here listens.
Approach
- Notice your reaction: anger, dread, wanting to rescue, wanting to be rid of the patient.
- Ask what you add: running late, cutting in, a promise not kept.
- Read the label as a clue about the relationship, not a fact about the person.
- Sit down. Give time at the start. Listen without cutting in.
- Check that your feelings are not shaping your tests or doses.
- Talk it over with a trusted colleague if a patient keeps getting to you.
Key feature 6 of 8
Clear limits
Agree on firm, plain rules with a patient whose care is hard.
CFPC skill ProfessionalismPhase Treatment
On the exam
A patient on cancer treatment calls the clinic many times a day and threatens staff. Expect a short menu (pick several from a list).
Pick the parts of the care plan.
Common mistakes
Open access at any hour, which rewards crisis calls. Or a rule a patient with poor memory cannot hold in mind: find the cause first.
Approach
- Name one main contact, and book regular visits.
- Say what you will do and when: how calls are returned, how refills work.
- Write the plan down, give the patient a copy, and share it with staff so everyone says the same thing.
- Say plainly that threats and abuse toward staff are not accepted.
- Fit limits to the patient. If memory is poor, find out why, and involve family with consent.
- Review the plan at set times, not in a crisis. Limits are not punishment: illness still gets treated.
Key feature 7 of 8
Ending care
End your care of a patient only when that truly serves the patient, and do it safely.
CFPC skill Professionalism, patient-centred approachPhase Treatment
On the exam
Staff want a demanding patient taken off your list. Expect one best answer.
Pick whether to end care, and how.
Common mistakes
Ending care during cancer treatment or a housing crisis, or before you know why behaviour changed. That serves the clinic, not the patient.
Approach
- First try to fix it: talk, set limits, write a plan, and warn what will follow.
- Reasons that can hold: trust that cannot be repaired, or threats or violence.
- Reasons that do not hold: a new illness, one complaint, or anything human rights law forbids.
- Do not end care while urgent needs are open, unless there is a real safety risk.
- If you end it: tell the patient, give time to find a new doctor, cover urgent care meanwhile, arrange refills and results, and send records.
- Write down why and what you did. Check your provincial college's policy.
Key feature 8 of 8
Threats and demands
With a patient who makes threats or demands, keep everyone safe, then agree on what the patient needs.
CFPC skill Patient-centred approach, professionalismPhase Treatment
On the exam
A man of 81 got lost and hit a car last week. He is angry you raised driving. Expect one best answer.
Pick what you say and do now.
Common mistakes
Dodging the subject, putting it off, or booking a road test while he keeps driving. Lying to keep the peace is wrong too.
Approach
- Check safety first: sit near the door, tell staff, keep help close. Leave if threats grow.
- Stay calm and speak slowly. Name the feeling: “You are angry, and this is hard news.”
- Ask what matters most to him. Often it is staying independent.
- Be honest about what cannot change. Never lie to avoid a fight.
- Build the plan on the shared goal: rides, transit, family help.
- Unsafe driving already shown: advise him to stop now, and report as your province requires.
- Do not trade a refill or a test for calm.
Flashcards
Answer it first, then check.
KF 1Polite for 25 years, a man of 81 is now hostile. Personality disorder?
No. That pattern is lifelong. A late change points to dementia, delirium, depression or a medicine.
KF 2A patient known for conflict is angrier than usual. What do you ask first?
What has changed lately: home, money, supports, health and how they cope each day.
KF 4New night back pain and weight loss after breast cancer. Image now or wait?
Image now. Suspected cancer is a red flag, even in someone with years of back pain. Source: Choosing Wisely Canada
KF 4She has new pain at one spot on the spine and wants an early refill. Taper?
No. Find the cause and treat the pain. Withdrawal aches all over, not at one spot.
KF 5Staff tell you the next patient is impossible. What do you do first?
Notice your own reaction. Then sit down and listen as if you had heard no label.
KF 6A patient calls the clinic many times a day. What plan helps most?
Regular booked visits, one main contact, and a written plan that all staff follow.
KF 7A patient on cancer treatment yells at staff. Do you end care?
Not as a first step. Set limits and a written plan. Ending care now leaves urgent needs uncovered.
KF 8He got lost driving and hit a car. He is angry. Wait for a calmer visit?
No. Advise him to stop driving now, and report as your province requires.
FAQ
Is “difficult patient” a diagnosis?
No. It describes a relationship. Look at four parts: the patient, the illness, the setting and you. Each can drive the problem, and each needs its own fix.
Does the exam want me to label a personality disorder?
Only when the pattern is lifelong and shows everywhere. A label can close your mind. Marks go to a fresh history, a fresh exam, and a clear plan.
Does setting limits mean refusing opioids?
No. Limits set how care runs: who, when and how. A new, real cause of pain still gets found and treated. Cutting the dose then leaves the pain untreated.
Can I stop seeing a patient who threatens my staff?
Safety comes first. Real threats or violence can be grounds to end care. Check your provincial college's policy, write down what happened, and get advice before you act.
Sources
Written from the CFPC Assessment Objectives and Canadian guidelines first. Checked by a Canadian family physician, MD, CCFP.
Last reviewed October 20, 2026For exam study. Not advice for a patient in front of you.
- Assessment Objectives for Certification in Family Medicine, 2nd editionCollege of Family Physicians of Canada · 2020
- Choosing Wisely recommendationsChoosing Wisely Canada