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Why Difficult Patients Make Correct Diagnosis Less Likely

ROTTERDAM, THE NETHERLANDS – As much time as you might spend trying to get it right, you’re more likely to get a diagnosis wrong when dealing with “difficult” patients.

That’s according to new Dutch studies published in BMJ Quality & Safety, which find that physicians often are distracted from processing clinical information by problematic behavior.

A study team led by Erasmus Medical Center researchers provided 63 physicians in the last year of their specialty training in family medicine with one of two versions of six clinical case scenarios. While one version featured a “difficult” patient with one of six conditions, another described the same patient with neutral behavior.

Difficult behaviors portrayed included the following:

  • a demanding patient,
  • an aggressive patient,
  • one who questions the doctor's competence,
  • one who ignores the doctor's advice,
  • one who doesn't expect the doctor to take him seriously, and
  • one who is utterly helpless.

The six conditions, meanwhile, were pneumonia, pulmonary embolism, meningoencephalitis, hyperthyroidism, appendicitis, and acute alcoholic pancreatitis.

With the last three cases designated as more complex, all included a brief description of the patient's medical history, their signs and symptoms, and the results of the physical examination.

Participants were asked to write down the most likely diagnosis as quickly as possible. They then were asked to review the same case, writing down the information for and against the diagnosis they had made, and to offer an alternative if they believe they had gotten it wrong the first time around.

At the end, they were asked to rate the likeability of the patient, using a validated (Likert) scale.

Diagnostic accuracy was higher for simpler cases, as expected, but the physicians were also 42% more likely to misdiagnose a difficult patient than a “neutral” one in a complex case, and 6% more likely to do so in a simple case.

Extra time spent on diagnosis didn’t change that, and, while further reflection improved diagnostic accuracy, it still didn't make up for the effect of disruptive behavior. In addition, the average likeability ratings were significantly lower for patients portrayed as '”difficult” than they were for those portrayed as behaving neutrally.

In a second study, researchers found that diagnostic accuracy was 20% lower for difficult patients, this time also including a patient who threatens the doctor and another who accuses the doctor of discrimination, even though the time spent on diagnosis was similar. Participants recalled proportionally fewer clinical findings — 30% vs. 32.5% — and more behavioral issues — 25% vs.18% — in those patients.

“Difficult patients’ behaviors induce doctors to make diagnostic errors, apparently because doctors spend part of their mental resources on dealing with the difficult patients’ behaviors, impeding adequate processing of clinical findings,” study authors concluded. “Efforts should be made to increase doctors’ awareness of the potential negative influence of difficult patients’ behaviors on diagnostic decisions and their ability to counteract such influence.”