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Difficult patients really are harder to diagnose

Mental effort spent on patients’ disruptive behaviour instead of processing clinical information

Louise Prime

Tuesday, 15 March 2016

Patients whom doctors regard as ‘difficult’ are more likely than other patients to be misdiagnosed, regardless of how complex their case really is or how long doctors spend with them, according to research* published today in BMJ Quality and Safety. The authors of this and a second study**, published in the same issue, found that this happened because the mental effort that doctors had to spend dealing with the patient’s problematic behaviour distracted them from correctly processing the clinical information.

Researchers in the Netherlands commented that although it was often thought that diagnostic accuracy could be impaired by doctors’ emotional responses to ‘difficult’ patients, evidence had not been produced to support this theory. So they devised a study to do just this.

They gave 63 doctors, in the last year of their speciality training in family medicine, six clinical case scenarios: pneumonia; pulmonary embolism; meningoencephalitis; hyperthyroidism; appendicitis; and acute alcoholic pancreatitis. The last three were regarded as more complex cases.

However, for each clinical scenario, the doctors were presented with one of two versions that differed only in whether the patient portrayed was ‘neutral’ or ‘difficult’. The ‘difficult’ patients were: a demanding patient; an aggressive patient; a patient who questioned the doctor’s competence; another who ignored the doctor’s advice; one who didn’t expect the doctor to take him seriously; and one who was utterly helpless.

For all six clinical scenarios, the doctors had a brief description of the patient’s medical history, signs and symptoms, and clinical examination findings. They were told to make a diagnosis as quickly as they could; to write down which information supported or did not support their diagnosis; and to suggest an alternative diagnosis if their first was incorrect. After this they rated the patient’s likeability, on a Likert scale.

The researchers reported that, as expected, diagnostic accuracy was better in the simpler clinical cases. Even in the simple clinical cases, doctors were 6% more likely to misdiagnose a patient who was difficult than a neutral patient; and in one of the clinically complex cases, a misdiagnosis was 42% more likely in a difficult patient than in a neutral patient. The results were similar irrespective of the time that the doctor spent diagnosing the case, and although further reflection did improve diagnostic accuracy, it didn’t compensate for the effect of patients’ disruptive behaviours.

The results also showed that doctors rated ‘difficult’ patients significantly lower on the likeability scale than they did those with neutral behaviour.

The second study, by the same team, investigated reasons why difficult behaviour affected diagnostic accuracy. It found that doctors’ diagnostic accuracy was 20% lower for difficult patients even though they spent a similar amount of time on diagnosis but also found that, after making a diagnosis, doctors recalled fewer clinical findings for the difficult than the neutral patients – and recalled more behaviours.

This, said the researchers, suggested that the doctors were expending mental energy on dealing with problematic behaviour rather than on processing clinical information. Although they acknowledged that clinical vignettes might not reflect real life, they suggested that in real life the impact of difficult behaviour was likely to be even greater.

The called for medical students and doctors to be trained to become more aware of this problem, because “the fact is, that difficult patients trigger reactions that may intrude with reasoning, adversely affect judgements, and cause errors.”

The authors of an accompanying editorial*** called for doctors to engage in more reflection, teamwork, and consultation – and to consider checklists or computer assisted diagnostics – to mitigate the effects of difficult behaviours on diagnostic accuracy.

* Schmidt HG, Van Gog T, Schuit TCE et al. Do patients’ disruptive behaviours influence the accuracy of a doctor’s diagnosis? A randomised experiment. BMJ Qual Saf 2016;0:1–5. doi:10.1136/bmjqs-2015-004109

** Mamede S, Van Gog T, Schuit TCE et al. Why patients’ disruptive behaviours impair diagnostic reasoning: a randomised experiment. BMJ Qual Saf 2016;0:1–6. doi:10.1136/bmjqs-2015-005065.

*** Redelmeier DA, Etchells EE. Unwanted patients and unwanted diagnostic errors. BMJ Qual Saf 2016;0:1–3. doi:10.1136/bmjqs-2015-005150.

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