Primary care involves managing people as well as managing disease; clinicians are experts in communication and most clinicians derive enormous satisfaction from enabling their patients to live healthier lives. But there are some conversations which can be a struggle. Perhaps the patient does not listen to your advice, they don’t understand the way the health system works, they miss appointments, they present frequently in crisis but refuse help, they don’t seem to respond to our questioning as expected. They may be labelled a ‘vague historian’, be aggressive or agitated, not attend hospital appointments, have unrealistic expectations, have safeguarding issues, have addiction or mental health problems, personality disorders, traumatic histories…the list of difficult conversations is potentially unlimited.

This chapter explores further:

What constitutes an easy or a difficult conversation and how to use this to prepare more effectively for the latter.

Reasons why people find it hard to engage with offers of help and how to consider the patient’s perspective.

Considering whether primary care, in relation to the reader, functions as a psychologically informed environment (PIE).

Methods available to manage high conflict consultations, which can be learned.