Difficult Patients:
Exploring the Patient Perspective
Wisconsin Research & Education Network
September 21, 2012
Caitlin Regner, BS, student researcher
Jennifer Edgoose, MD/MPH, Principal Investigator
(Jennifer.edgoose@fammed.wisc.edu)
Who are “difficult” patients?
What characteristics make a patient “difficult”?
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Mental health disorders
Multiple symptoms
Chronic pain
Functional impairment
Unmet expectations
Lower satisfaction with care
High users of health care services
Dr. Tom O’Dowd coined the term “heartsink patient”
BMJ, 1988
Who defines them?
Providers with:
• Greater perceived workload
• Lower job satisfaction
• Poorer psychosocial scores
• Less experience
• 9 versus 12 years (p=0.0002)
Why not just ignore them?
Because we can’t.
At least 1 in 6
patients are
“difficult” and so
we see them
every day.
Photo by Chat-Lunatique
Research Question
If physicians find their relationships with
difficult patients to be frustrating, if not
overwhelming, …
…do difficult patients also find these
relationships to be equally challenging?
Study Design
• Prospective cohort study
• Patient inclusion criteria:
• Patients of 12 family medicine residents
• 18 years or older
• Patients were assigned coded numbers.
• Patients were notified of study at clinic check-in.
• Residents indicated difficult patients for that day
• Only coded numbers were submitted to maintain
patient confidentiality
Study Design
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Survey completed through
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Option 1: interview by medical student
Option 2: written self completion
Basic Demographic Data collected:
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•
•
•
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Gender
English speaking or non-English speaking
Ethnicity/Race
Education Level
6 Questions developed
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Graded on a Likert Scale from 1-7
Comments optional for each question
Patient Questionnaire
1. In general, how easy is it for you to talk with
your doctor?
2. How easy do you think your medical problems
are for your doctor to deal with?
3. How much control do you feel you have over
your health care decisions?
4. How often do you feel your doctor addresses
your concerns during your appointments?
Patient Questionnaire
5. How often does your doctor ask you nonmedical questions to help understand your
concerns during your appointments?
(e.g. What is your occupation or job?; Where are you from?;
Who do you live with?; Do you have access to a car?; Do you
have problems paying for your medicines?)
6. What can we change to do a better job of
taking care of you at our clinic?
Results: Study enrollment profile
Eligible
Participated
Response Rate
Total
267
161
60%
Non Difficult
220
129
59%
Difficult
47
32
68%
Total Difficult Patients: 19%
Results: Comparison of survey responses based on difficulty status
Question
Difficult
Non-Difficult,
Mean (95% CI) Mean (95% CI)
N=32
N=129
P-Valuea
1. Ease of
communication
with provider
1.39 (1.11-1.68)
1.88 (1.65-2.11)
0.043*
2. Self-perception of
medical difficulty
2.63 (2.00-3.25)
2.60 (2.34-2.87)
0.95
3. Agency in
decision-making
3.08 (2.37-3.79)
2.48 (2.22-2.73)
0.057
4. Frequency of
medical concerns
being addressed
1.48 (1.16-1.81)
1.71 (1.48-1.95)
0.35
5. Frequency of
social concerns
being addressed
2.80 (2.11-3.48)
2.73 (2.41-3.05)
0.85
a
Two sample t-test comparison of means; *p < 0.05
Results: Difficult Patient Comments
• “I do whatever she tells me. There’s no point in coming in if
you don’t listen to your doctor.”
• “She is very worried about my health.”
• “Is very willing to take time. I never feel rushed.”
• “I LOVE DR. X!”
Results: Non-Difficult Patient Comments
• “Dr. X asks excellent questions and is open to your questions.”
• “My mom is 95 and speaks Spanish only, so there are some
communication issues.”
• “Take care of the problems that I tell you are wrong, not what
you think is wrong.”
• “Fewer questionnaires. This one wasn’t too bad.”
Results: Gender profile of the study participants
Male
N=56
Female
N=105
Non-Difficult
49
80
Difficult
7
25
12.5%
23.8%
Difficult (%)
a
Chi-square statistics
P-valuea
X=2.93; p=0.087
Results: Comparison of survey responses based on gender
Question
Male,
Female,
Mean (95% CI) Mean (95% CI) P-Valuea
N=56
N=105
1. Ease of
communication with
provider
2.15 (1.74-2.57)
1.59 (1.40-1.77)
0.005**
2. Self-perception of
medical difficulty
2.98 (2.57-3.39)
2.41 (2.12-2.70)
0.024*
3. Agency in decisionmaking
2.86 (2.43-3.30)
2.46 (2.15-2.76)
0.130
4. Frequency of
medical concerns
being addressed
1.97 (1.55-2.39)
1.51 (1.31-1.71)
0.028*
5. Frequency of social
concerns being
addressed
2.72 (2.23-3.22)
2.76 (2.40-3.11)
0.910
aTwo
sample t-test comparison of means; *p < 0.05; **p < 0.01
Results: Racial profile for study participantsa
American P-valueb
Indian
N=3
White
N=110
Black
N=31
Asian
N=10
NonDifficult
89
23
9
2
Difficult
21
8
1
1
Difficult
(%)
19.1%
25.8%
10.0%
33.3%
a
7 subjects did not select a race category
b Chi-square statistics
X=1.66;
p=0.65
Results: Comparison of survey responses
based on race
White,
Mean
(SD)
N=110
Black
Mean
(SD)
N=31
3. Agency in
decisionmaking
2.47
(1.50 )
2.61
(1.67)
2.90
(1.73)
5.50
(2.12)
0.049*
4. Frequency
of medical
concerns
being
addressed
1.58
(1.05)
1.45
(1.18)
3.20
(2.30)
2.33
(1.15)
<0.001***
Question
a One-way
Analysis of Variance (ANOVA)
* p < 0.05; *** p < 0.001
Asian, Am.Indian,
Mean
Mean
P-Valuea
(SD)
(SD)
N=10
N=3
Results: Multivariate Analysis of
Gender, Race, Education and Difficulty
• Gender is a significant predictor for questions 1,
2 and 3 (p = 0.008; 0.015 and 0.046
respectively). Thus males report a harder time
talking with their doctor; think they are more
difficult for their doctor; and feel less in control
of their health care decisions.
Difficulty is NOT a predictor for these
questions surrounding patient-doctor
communication.
In summary
• While providers of difficult patients are
frustrated, patients are not.
• This is inconsistent with a previous study showing difficult
patients are “less satisfied” than non-difficult patients but
this study by Hinchey and Jackson applied the RAND-9
survey which looks at satisfaction from a standpoint not
specific to the doctor-patient relationship but includes
satisfaction about wait times, clinic location, phone
scheduling, and other more clinic-process oriented
inquiries.
Our survey may therefore explains why these
challenging patients are more likely to keep
returning to their providers.
What does this mean?
• We speculate that provider frustration lies in the
incongruity of patient and physician perspectives
about their relationship.
• Is the world view of patient and provider
discordant due to educational differences,
language and/or personality disorders?
• Schafer and Nowlis found that when analyzing 21 difficult
patients, 33% of difficult patients had at least one personality
disorder, particularly dependent personality disorders.
• Do providers feel guilt about their feelings
toward their patients and (over) compensate
with extra time and energy?
Limitations of the study
• Underpowered to state definitively :
• Difficult versus non-difficult patients do not feel
differently about their ability to communicate
effectively with their doctors.
• Limited number of control variables
• only controls for demographics
• no socioeconomic or health problem indicators
• Single clinic surveyed which may not be
generalizable to a broader population
Future research
• Ethnicity requires further exploration due to low
sample size; only 6 Hispanic patients
participated in this study.
• Education level is undergoing further analysis
Photo by Chat-Lunatique
US
A study is underway
exploring a tool to
assist providers in
working with difficult
patients.
Photo by giveawayboy
THEM
Thank you!
• Northeast Clinical Staff and Residents
• Jon Temte – SSRCA Director
• Mary Beth Plane – Director, DFM Research Services
• Larissa Zakletskaia – Data Base Administrator (DFM)
Bibliography
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difficult patient: prevalence, psychopathology, and functional impariment. J Gen
Internal Medicine. 1996 Jan; 11(1):1-8.
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3. Hahn SR. Physical Symptoms and Physician-Experienced Difficulty in the PhysicianPatient Relationship. Ann Internal Med. 2001 May 1; 129(9 pt. 2):897-904.
4. Jackson JL, Kroenke K. Difficult patient encounters in the ambulatory clinic. Arch Intern
Med. 1999;159:1069-1075.
5. Hahn SR, Thompson KS, Wills TA et al. The difficult doctor-patient relationship:
somatization, personality and psychopathology. J Clin Epidemiol. 1994:47:647-657.
6. Hinchey, SA, Jackson AL. A cohort study assessing difficult patient encounters in a walkin primary care clinic, predictors and outcomes. J Gen Intern Med. 2011 Jan 25.
7. Ashworth CD, Williamson P, Montano D. A scale to measure physician beliefs about
psychosocial aspects of patient care. Soc Sci Med. 1984;19:1235-1238.
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encounters in primary care: data from the minimizing error, maximizing outcomes
studey. Arch Int Med. 169:410-414.
9. Edgoose JYC. Finding the person behind the patient. Presentation given at the
Wisconsin Psychological Association 2012 Annual Convention, April 2012.
10. Schafer S, Nowlis DP. Personalisty disorders among difficult patients. Arch Fam Med.
1998;7:126-129.
Questions?
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