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The difficult patient encounter

INTRODUCTION

Data from physician surveys suggest that nearly one out of six outpatient visits are considered difficult [1]. Physicians who view a high number of their patients as difficult are more likely to be "burned out" and less likely to report work satisfaction than physicians who perceive having relatively fewer difficult patients.

The last 20 years have seen an increase in study of the “difficult patient” [1-19]. The literature warns against considering the patient as the only cause of the problem [1,13,14,16]. It suggests, rather, that the clinician and the clinician-patient relationship constitute the proper focus for understanding and managing difficult patient encounters [1-3,6-8,10-13,20-22]. The relationship and communication between clinician-patient are key factors in understanding and caring for patients who are perceived to be “difficult” [14]. Additionally, clinicians need to develop better understanding of their internalization of difficult patient encounters. The inscription on the temple of Apollo at Delphi provided clues to the problem of the difficult clinician-patient relationship centuries ago: "Know yourself."

FACTORS CONTRIBUTING TO DIFFICULT PATIENT ENCOUNTERS

The “difficult patient” can be defined as one who impedes the clinician's ability to establish a therapeutic relationship [17,23]. Another definition is: "a person who does not assume the patient role expected by the healthcare professional, who may have beliefs and values or other personal characteristics that differ from those of the caregiver, and who causes the caregiver to experience self-doubt" [24]. This definition highlights the literature's focus on patients' behaviors that deviate from expected patient roles, patient personal characteristics that conflict with providers' beliefs and values, and patient behaviors that are perceived to challenge providers' competence and/or control.

A number of studies have investigated the types of clinician-patient interactions that result in clinicians labeling patients as difficult.

  • In one study physicians identified 92 patients they perceived as difficult, by each clinician's own criteria. These were compared to 166 randomly selected controls [10]. Compared to controls, the “difficult patients” were older [15], more often separated or divorced, more likely to be women, had more acute and chronic problems, took more medications, underwent more x-rays and tests, were referred more often, and had more visits (6.8 versus 3.7 visits per year). Adjusting for age and sex, significant differences remained between the two groups for chronic problems, tests, medications, and visits.
  • A second study used the validated Difficult Doctor-Patient Relationship Questionnaire to rate 627 patients in four primary care clinics [5,6]. Physicians rated 15 percent of their patients as difficult, ranging from 12 to 20 percent at different clinics. Compared to nondifficult patients, patients perceived as difficult were more likely to have a mental disorder, especially multisomatoform disorder, panic disorder, dysthymia, generalized anxiety, major depression, and alcohol abuse or dependence. These patients also had more symptoms, greater functional impairment, higher health care utilization, and lower satisfaction with their care. There were no distinguishing demographic or physical symptom characteristics.

    Physicians in this study often disliked “difficult patients.” They were unenthusiastic about providing care, saw these patients as frustrating and time-consuming, felt manipulated by them, and did not look forward to return visits. In one-half of encounters with “difficult patients,” physicians harbored hopes that the patient would not return. Accounting for 23 percent of variance in difficulty scores, “difficult patient” status was strongly associated with the total number of mental disorders, somatoform and physical symptoms, multisomatoform disorder, and alcohol abuse. The authors propose that multiple physical symptoms, especially somatization, generate distress and frustration in physicians because of uncertainty about diagnosis and treatment. (See "Somatization: Epidemiology, pathogenesis, clinical features, medical evaluation, and diagnosis" and "Somatization: Treatment and prognosis" and "Primary care management of medically unexplained symptoms".)
  • A review from 1975 found that doctors and nurses described the "good patient" in the following terms: trusting, cooperative, noncomplaining, and nondemanding [25]. Patients who interrupted a caregiver's established routines and made extra work were considered difficult or problem patients. If “difficult patients” were perceived by staff as seriously ill, their complaining, emotionality, and need for attention were viewed as problematic but forgivable because the situation was beyond their control; these patients received the attention they wanted, especially if they expressed gratitude for it. Seriously-ill patients who were cheerful, cooperative, uncomplaining, and objective about their illness were viewed as "great" patients. Patients who were perceived as not being seriously ill but were complaining, emotional, and uncooperative were condemned by clinicians and often discharged early, tranquilized, or referred to psychiatry.

               

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Literature review current through: Mar 2014. | This topic last updated: Jul 12, 2013.
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