Problem Patients: The Dislike-Diagnosis

3. May 2016
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When patients are difficult, the probability of erroneous diagnoses increases. This is because their behaviour distracts doctors and prevents them from processing clinical information appropriately. A number of measures could help to avoid "emotion based" errors.

People who are perceived as dislikeable or “unpleasant” have a harder time in life: they are, for example, condemned to more severe imprisonment sentences [Paywall]. Medical journal articles [Paywall] suggest that the situation is similar for “difficult” patients: namely, that they more frequently receive false diagnoses and non-adequate treatment. However, until now, scientific evidence has been lacking for this assumption.

A research team led by Henk Schmidt and Silvia Mamede from Erasmus Medical Center in Rotterdam has now for the first time investigated in two studies how the behaviour of difficult patients affects diagnostic accuracy. The results were published by the researchers in the journal BMJ Quality & Safety. In their first study [Paywall] the researchers presented 63 doctors doing their last year of specialist training in general medicine with a number of case vignettes. In these, six different medical syndromes were described: three less complex, namely pulmonary embolism, pneumonia and meningitis, as well as three more complex examples, namely appendicitis, hyperthyroidism and acute pancreatic inflammation on account of increased alcohol consumption.

For each of the six case reports one version portrays a patient demonstrating difficult behaviour; in the other version neutral patient behaviour was described. The “problematic” case studies described patients who question the skills of the doctor involved, ignore their medical advice, behave aggressively or are very demanding or act completely helplessly.

This testing behaviour influenced the diagnosis of physicians quite clearly: the likelihood of a misdiagnosis with the complex medical conditions was 42 percent higher when the subject was a difficult patient. For less complex medical cases, the situation was nonetheless still such that patients received a misdiagnosis at least six percent more often. The differences between easy and difficult patients remained, even if the doctors had extra time to recheck the patient case, so as to reconsider their diagnosis. In addition, the physicians indicated liking the problem patients significantly less than in the uncomplicated version.

Problem behaviour demands mental resources

A second study [Paywall] by the research team involving 74 doctors doing residency training in internal medicine confirmed the results: here, the probability of an incorrect diagnosis with difficult patients was higher by 20 percent. At the same time, Schmidt, Mamede and her team examined in which way the problem behaviour affects diagnostic accuracy. They found in doing so that doctors with difficult patients – in comparison to uncomplicated patients – later recall less clinical detail and more about the patient’s behaviour, when compared to uncomplicated patients. “This suggests that the challenging behaviour demands the intellectual resources of physicians and prevents them from processing the clinical information appropriately”, the authors write.

It is true that the reaction of the doctors has been studied here only through textual case vignettes – something which significantly differs from a real doctor-patient discussion. “On the other hand, one would expect that the same effects in ‘real life’ would be even stronger”, the researchers underline. “Difficult patients probably provoke much stronger feelings in a real encounter and lead to more diagnostic errors”.

Physicians should admit their feelings

In everyday medicine complicated patients are not exactly rare: general practitioners report that about 15 percent of their patients are difficult to handle. Such patients were described by their therapists as “frustrating” or even “hated” – something that clearly showed their negative feelings towards the patient.

In their training doctors learn from the beginning to control their emotions so that they do not interfere with the doctor’s medical task. “Therefore, it is automatically assumed that doctors even when working with difficult patients ‘stay above it all’ and are not guided by subjective reactions and negative feelings”, the research team led by Schmidt and Mamede says. “But the fact is that difficult patients can trigger reactions which get in the way of a reflected matter-of-fact diagnosis”.

From the researchers’ point of view, physicians should therefore do the exact opposite: admit their feelings towards the patient. “It would be advantageous if doctors and medical students would learn to pay more attention to their own emotional reactions to a patient – and to realise that this may affect their clinical judgement”, say the researchers. “At the same time they should learn strategies to counteract such negative influences”.

Teamwork and structured diagnosis could help

Overall, this issue should be given more attention in medical studies and in clinical practice, write Donald Redelmeier and Edward Etchells of the Canadian University of Toronto in an accompanying editorial. Some ways to reduce the risk of misdiagnosis could include conscious reflection, teamwork and consultation with colleagues, as well as diagnostic checklists and computerised diagnostics.

A more structured diagnostic approach could help to avoid judgement errors occurring when the doctor is upset by a difficult patient. “Symptom checklists or computer programs that provide comprehensive differential diagnosis could contribute, even with such a case, to essential information not being overlooked”, write Redelmeier and Etchells. It has also been shown by a review study that computer based decision aids in particular can significantly increase diagnostic accuracy.

Furthermore, it is important not only to perceive one’s feelings, but also to make oneself aware of what this can mean. “A patient showing difficult behaviour sometimes leads the doctor to ‘want out’ and simply break off the session”, according to Redelmeier and Etchells. “This feeling could for the treating physician be a signal that there is a risk of providing an erroneous diagnosis”.

Anyone who is aware that their feelings can lead them to errors could, when working with difficult patients, gain reinforcement by working in a team or by pulling in a colleague for help. “Of course, a certain openness is needed for this – and for advice-dispensing colleagues a willingness to deal with the topic”, Redelmeier and Etchells stress. Besides these humanistic capabilities, one more thing would also be needed: sufficient time to implement such measures in daily medical practice.

Original publications:

Why patients’ disruptive behaviours impair diagnostic reasoning: a randomised experiment [Paywall]
Sílvia Mamede et al.; BMJ Qual Saf, doi:10.1136/bmjqs-2015-005065; 2016

Do patients’ disruptive behaviours influence the accuracy of a doctor’s diagnosis? A randomised experiment [Paywall]
H. G. Schmidt et al.; BMJ Qual Saf, doi: 10.1136/bmjqs-2015-004109; 2016

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