March 18, 2016

Rude patient? Here's why you should be extra careful.

Daily Briefing

    So-called "difficult" patients—those who act angrily or rudely or demonstrate other disruptive behaviors—are more likely to be misdiagnosed, according to two new studies published Monday in BMJ Quality and Safety.

    Testing for bad behavior

    For the first study, researchers from the Netherlands asked 63 physicians in their final year of family medicine training how they would deal with six hypothetical scenarios. Each physician diagnosed both a patient described as behaving neutrally and another who was acting in a difficult manner.

    Difficult patients were defined as those who:

    • Act aggressively;
    • Act helplessly;
    • Have low expectations of support from their physician;
    • Ignore their physician's advice;
    • Make frequent demands; and
    • Question their providers' competence.

    Physicians were then asked to diagnose the patients for six conditions, three of which were deemed more complex.

    15 conditions that are often missed or misdiagnosed

    The second study by the same research team included 74 internal medicine residents who also made diagnoses based on hypothetical clinical situations. The patients' behavior was similarly described as difficult or neutral.

    Findings

    The first study found that physicians were 42 percent more likely to misdiagnose complex cases and six percent more likely to misdiagnose simple cases when dealing with difficult patients.

    The study found that physicians spent the same amount of time diagnosing patients whether they were difficult or neutral. However, accuracy improved in both complex and simple cases when physicians spent more time reflecting on their diagnoses.

    Medscape: How to handle 'difficult' patients

    Meanwhile, the second study found that doctors were 20 percent more likely to misdiagnose moderately complex cases when dealing with difficult patients.

    Why mistakes happen

    The Dutch researchers suggest that the mental energy required to deal with difficult patients can distract from how physicians process clinical information.

    "As might be expected, these behaviors provoke emotional reactions in doctors," says Silvia Mamede, an associate professor at the Institute of Medical Education Research Rotterdam at Erasmus Medical Center in the Netherlands. "Patients who behave disruptively ... may induce their doctors to make diagnostic mistakes."

    Coping methods

    In an editorial accompanying the studies, physicians Donald Redelmeier and Edward Etchells recommend ways to improve accuracy when diagnosing difficult patients.

    In particular, Redelmeier and Etchells say physicians should engage in more consultation, reflection, and teamwork.

    They also suggest that providers consider using checklists or computer-assisted diagnostic tools, which can help to "restore order when a physician's thinking might be disrupted by negative emotions."

    Separately, Mamede says, "Physicians should be trained to deal with these disruptive behaviors explicitly and effectively" (Dotinga, HealthDay/U.S. News & World Report, 3/15; Rice, "Vital Signs," Modern Healthcare, 3/14; Adaeze Anyaegbunam, STAT News, 3/14).

    Guarding against bias: Are you leading an evidence-based organization?

    Despite the shift toward broad acceptance of evidence-based practice (EBP) among medical staff, over half of physicians report not actually using guidelines day-to-day when they are available. As a result, organizations continue to see tremendous variation in clinical practice—as well as in costs and outcomes.

    Our infographic outlines four principles you can use to support EBP at your organization, along with action steps to implement each one and pitfalls to avoid along the way.

    GET THE INFOGRAPHIC

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