Unit 3 Clinical correlate 8 Difficult Patient
Study questions:
A. Hahn SR, Kroenke K, Spitzer RL, Brody D, Williams JB, Linzer M, deGruy FV 3rd. The difficult patient: prevalence, psychopathology, and functional impairment. J Gen Intern Med. 1996 Jan;11(1):1-8.
Before addressing the intricacies of how patients become difficult in the eyes of their physician, it’s important to understand how prevalent difficult patients are, and what they have in common with each other. Through a survey administered through multiple clinics, the authors wanted to find out how many patients are considered difficult and what variables might be in common in difficult patients.
The authors found that approximately 15% of the patients were considered difficult by their physicians (determined by a 10 question survey). There were no common demographic characteristics in difficult patients, but there commonly was a psychiatric diagnosis. Difficult patients were twice as likely to have at least one psychiatric diagnosis compared to non-difficult patients. Additionally, patients with vague symptoms were more often found to be difficult. Interestingly, patients with multiple clear symptoms (eg, hypertension, diabetes, heart disease) were not as likely to be regarded as difficult. This suggests there is something in the vague symptoms that is often frustrating to a physician. Demographic variables of the physician had no association with patient difficulty. Physicians who were more interested in psychiatric diagnosis were more likely to have more difficult patients than physicians who were less interested. Difficult patients were more likely to utilize health care services more often, have functional impairment due to their disease, and were less satisfied with the medical care they received.
As illustrated in other studies (see below), it appears that difficult patients often arise from physician frustration with vague symptoms that are difficult to treat. The authors suggest focusing on diagnosing psychiatric diseases instead of ruling out any physical etiology, as well as recognizing their own reasons for finding the patient difficult. It appears that it is not the patient, but the vague and difficult symptoms, that cause frustration.
B. Hahn SR Physical symptoms and physician-experienced difficulty in the physician-patient relationship. Ann Intern Med. 2001 May 1;134(9 Pt 2):897-904.
While no physician expects every patient encounter to proceed smoothly and calmly, there are some types of encounters that physicians wish to avoid. Commonly, these encounters are with difficult patients. Previous research has shown that patients labeled as “difficult” commonly have psychopathologic disorders, an abrasive personality or personality disorder, and have multiple physical symptoms. However, this previous research has been largely descriptive in nature, with variable methods. The authors implemented their study in order to quantify the difficulty of the patient-physician relationship and assess the role multiple physical symptoms play in creating that difficulty.
Patients were assessed for both mental and physical symptoms as well as demographics, and physician-difficulty was assessed by a survey that asked questions about the physician’s subjective feelings and objective assessments about patients’ symptoms and examination.
Physicians rated 15% of their patients as difficult. Patients who were difficult were more likely to have psychiatric symptoms (with no difference detected between different psychiatric symptoms) or symptoms with an unclear pathophysiology (eg, irritable bowel syndrome). Through logistical regression, the authors found demographic and clinical variables (clinic site, age/sex of patient, etc) accounted for only 8% of the variance. Additionally, it was found that mental symptoms accounted for more difficulty in patients compared to physical symptoms.
The authors show that both physical and mental symptoms, when they present vaguely, often elicit physician frustration. For physicians that are used to knowing what is going on with their patient, symptoms with unclear pathophysiology can prove quite frustrating, especially when the physician is attempting to make a diagnosis and treatment plan. The authors suggest physicians approach symptoms from a more patient-centered perspective and address the psychosocial aspects of symptoms.
C. Jeffrey L. Jackson, MD, MPH; Kurt Kroenke, MD Difficult Patient Encounters in the Ambulatory Clinic Clinical Predictors and Outcomes Arch Intern Med. 1999;159:1069-1075.
This article approached the question of what makes a patient difficult in a similar vein as the two above, with similar results. By surveying both the patient and physician before and after the encounter, the authors were hoping to discover more about what makes a patient difficult.
The authors also found a 15% “difficult patient” rate, with similar demographics and physician variables between the difficult and nondifficult patient group. They found that difficult patients were more likely to have pain and functional impairment in physical and social realms, as well as having difficulty doing everyday tasks. When comparing the symptoms of difficult patients, the authors found that a depressive or anxiety disorder was most predictive of a difficult patient (OR: 2.4, 95% CI 1.5-3.9). Additionally, patients that had more than 5 symptoms and larger symptom severity were more likely to be difficult.
Interestingly, the authors also found that a poor physician psychosocial attitude score was predictive of having more difficult patients (OR: 3.9, 95% CI: 1.6-9.5). This suggests that a difficult patient to one physician may not be difficult for someone else. The authors also surveyed the patient and physician 3 months after the encounter. They found that the correlation between difficult patients and patient dissatisfaction has dissipated; however, when patients visited the clinic more often, they were more likely to be dissatisfied and be viewed as difficult.
In addition to suggestions from the two previous articles, this article suggests more research into how the physician’s psychosocial attitude is cultivated. While difficult patients clearly have more vague symptoms, this article shows that it’s not just the patient that makes the encounter difficult, but the physician contributes as well. By addressing both the vague symptoms and the physician’s attitudes about the symptoms, the number of difficult patients may be able to decrease.