A difficult physician-patient relationship can have significant consequences for both the physician and the patient. Difficult relationships can lead to frustrating, dissatisfying, adversarial and expensive medical care. The difficult relationship is often a consequence of a breakdown in communication between physician and patient. Specific causes include technical communication barriers, difficulty in discussing certain topics, unmet or violated norms and expectations (both the physician's and the patient's) and a mismatch between the physician's and the patient's personality styles. Management goals for the difficult relationship include maintaining professional self-esteem, maintaining physician-patient continuity, minimizing the "medicalization" of the problem by limiting the use of tests and procedures, and minimizing hospitalization and referral. It is also important to remember that although the relationship may continue to be frustrating or conflictual, it can be effectively managed with appropriate strategies.