Patients’ Disruptive Behaviors Impair Diagnostic Reasoning

A new study suggests that disruptive patients distract physicians’ attention, preventing them from focusing on actual medical conditions.

Researchers at Erasmus Medical Center (Rotterdam, The Netherlands) and Admiraal de Ruyter Hospital (Goes, The Netherlands) conducted a randomized experiment involving 74 internal medicine residents who diagnosed eight identical, written clinical vignettes that were set apart only by the patients’ behavior (either difficult or neutral); each participant diagnosed half of the vignettes in a difficult patient version and the other half in a neutral version in a counterbalanced study design. After diagnosis, the doctors were asked to recall the patient's clinical behavior.

The results showed that diagnostic accuracy scores were 20% lower for difficult patients’ vignettes, despite a similar amount of time spent on diagnosis. The residents also recalled fewer clinical and more behavioral issues in the difficult patients than in the neutral patients. The researchers suggest that difficult patients induce doctors to make diagnostic errors, apparently because they spend part of their mental resources on dealing with their behavior, thus impeding adequate processing of clinical findings. The study was published on March 14, 2016, in BMJ Quality & Safety.

“An estimated 15% of patients treated in doctors' offices are aggressive, disrespectful, overly demanding or distrustful. As might be expected, these behaviors provoke emotional reactions in doctors,” said lead author Silvia Mamede, MD, PhD, an associate professor with the Erasmus Institute of Medical Education. “Disruptive patients distract physicians by capturing their attention, preventing them from focusing more on actual medical conditions.”

“Patients can try to channel their emotion into polite comments; for example, ‘Thank you for seeing me; I am frightened by what I am experiencing and that is why I am here looking for something that might help.’ But real people … cannot always control their temper when suffering or in pain. More research is needed to figure out the best approaches,” wrote Donald Redelmeier, MD, senior core scientist with the Institute for Clinical Evaluative Sciences (Toronto, Canada), in an accompanying commentary.

Related Links:
Erasmus Medical Center
Admiraal de Ruyter Hospital