Difficult Patients: Exploring the Patient Perspective

Caitlin Regner, BS, student researcherJennifer Edgoose, MD/MPH, Principal Investigator

(Jennifer.edgoose@fammed.wisc.edu)

Wisconsin Research & Education NetworkSeptember 21, 2012

Who are “difficult” patients?What characteristics make a patient “difficult”?• 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?

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Because we can’t.

At least 1 in 6 patients are

“difficult” and so we see them

every day.

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

• Survey completed through• Option 1: interview by medical student• Option 2: written self completion

• Basic Demographic Data collected:• Gender• English speaking or non-English speaking• Ethnicity/Race• Education Level

• 6 Questions developed• 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 non-medical 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 RateTotal 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

QuestionDifficult

Mean (95% CI)N=32

Non-Difficult, Mean (95% CI)

N=129P-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

• “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: 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: Non-Difficult Patient Comments

Results: Gender profile of the study participants

MaleN=56

FemaleN=105 P-valuea

Non-Difficult 49 80

Difficult 7 25

Difficult (%) 12.5% 23.8% X=2.93; p=0.087

a Chi-square statistics

Results: Comparison of survey responses based on gender

QuestionMale,

Mean (95% CI)N=56

Female,Mean (95% CI)

N=105P-Valuea

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 decision-making 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

WhiteN=110

BlackN=31

AsianN=10

AmericanIndian

N=3

P-valueb

Non-Difficult 89 23 9 2

Difficult 21 8 1 1Difficult (%) 19.1% 25.8% 10.0% 33.3% X=1.66;

p=0.65

a 7 subjects did not select a race categoryb Chi-square statistics

Results: Comparison of survey responses based on race

QuestionWhite,Mean(SD)

N=110

BlackMean(SD)N=31

Asian,Mean(SD)N=10

Am.Indian,Mean(SD)N=3

P-Valuea

3. Agency in decision-making

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***

a One-way Analysis of Variance (ANOVA)* p < 0.05; *** p < 0.001

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

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A study is underway exploring a tool to assist providers in working with difficult patients.

US

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)

Bibliography1. Hahn SR, Kroenke K, Spitzer RL, Brody D, Williams JB, Linzer M, de Gruy FV 3rd. The

difficult patient: prevalence, psychopathology, and functional impariment. J Gen Internal Medicine. 1996 Jan; 11(1):1-8.

2. Mathers N, Jones N, Hannay D. Heartsink patients: a study of their general practitioners. BrJ Gen Pract. 1995;45(395):293-296.

3. Hahn SR. Physical Symptoms and Physician-Experienced Difficulty in the Physician-Patient 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 walk-in 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.

8. An PG, Rabatin JS, Manwell LB, Linzer M, Brown RL, Schwartz MD Burden of difficult 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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