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Journal of General Internal Medicine

, Volume 26, Issue 6, pp 588–594 | Cite as

A Cohort Study Assessing Difficult Patient Encounters in a Walk-In Primary Care Clinic, Predictors and Outcomes

  • Sherri A. Hinchey
  • Jeffrey L. Jackson
Original Research

Abstract

Background

Previous studies have found that up to 15% of clinical encounters are experienced as difficult by clinicians.

Objectives

Explore patient and physician characteristics associated with being considered “difficult” and assess the impact on patient outcomes.

Design

Prospective cohort study.

Participants

Seven hundred fifty adults presenting to a primary care walk-in clinic with a physical symptom.

Main Measures

Pre-visit surveys assessed symptom characteristics, expectations, functional status (Medical Outcome Study SF-6) and the presence of mental disorders [Primary Care Evaluation of Mental Disorders, (PRIME-MD)]. Post-visit surveys assessed satisfaction (Rand-9), unmet expectations and trust. Two-week assessment included symptom outcome (gone, better, same, worse), functional status and satisfaction. After each visit, clinicians rated encounter difficulty using the Difficult Doctor-Patient Relationship Questionnaire (DDPRQ). Clinicians also completed the Physician’s Belief Scale, a measure of psychosocial orientation.

Key Results

Among the 750 subjects, 133 (17.8%) were perceived as difficult. “Difficult” patients were less likely to fully trust (RR = 0.88, 95% CI: 0.77–0.99) or be fully satisfied (RR = 0.78, 95% CI: 0.62–0.98) with their clinician, and were more likely to have worsening of symptoms at 2 weeks (RR = 0.75, 95% CI: 0.57–0.97). Patients involved in “difficult encounters” had more than five symptoms (RR = 1.8, 95% CI: 1.3–2.3), endorsed recent stress (RR = 1.9, 95% CI: 1.4–3.2) and had a depressive or anxiety disorder (RR = 2.3, 95% CI: 1.3–4.2). Physicians involved in difficult encounters were less experienced (12 years vs. 9 years, p = 0.0002) and had worse psychosocial orientation scores (77 vs. 67, p < 0.005).

Conclusion

Both patient and physician characteristics are associated with “difficult” encounters, and patients involved in such encounters have worse short-term outcomes.

Keywords

Symptom Outcome Structural Equation Modeling Model Poor Functional Status Somatization Disorder Unmet Expectation 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Notes

Acknowledgments

The opinions expressed in this article are those of the authors and should not be construed, in any way, to represent those of the US Army, the Department of Defense or the Department of Veterans Affairs.

Conflict of Interest

None disclosed.

References

  1. 1.
    Jackson JLKK. Difficult patient encounters in the ambulatory clinic: clinical predictors and outcomes. Arch Intern Med. 1999;159:1069–75.PubMedCrossRefGoogle Scholar
  2. 2.
    Hahn SR KK, Spitzer RL, Brody D, Williams J, Linzer M, deGruy FV. "The difficult patient": prevalence, psychopathology, and functional impairment. J Gen Intern Med. 1996;11:1–8.Google Scholar
  3. 3.
    Hahn SR, Thompson, KS, Wills TA, Stern V, Budner NS. The difficult doctor-patient relationship: somatization, personality and psychopathology. J Clin Epidemiol. 1994;47(6):647–57.PubMedCrossRefGoogle Scholar
  4. 4.
    Jackson JL. KK. Prevalence, impact and prognosis of multisomatoform disoder in primary care: a 5-year follow-up study. Psychosom Med. 2008;70(4):430–34.PubMedCrossRefGoogle Scholar
  5. 5.
    KW LEHB, Von Korff M, Bush T, Lipscomb P, Russo J, Wagner E. Frustrating patients: physician and patient perspectives among distressed high users of medical services. J Gen Intern Med. 1991;6:241–46.CrossRefGoogle Scholar
  6. 6.
    Walker EA KW, Keegan D, Gardner G, Sullivan M. Predictors of physician frustration in the care of patients with rheumatologic complaints. Gen Hosp Psychiatry. 1997;19:315–23.PubMedCrossRefGoogle Scholar
  7. 7.
    Krebs EE. GJ, Konrad TR. The difficult doctor? Characteristics of physicians who report frustration with patients: an analysis of survey data. BMC Health Serv Res. 2006;6(128):1–8.Google Scholar
  8. 8.
    Steinmetz DTH. The difficult patient as perceived by family physicians. Fam Pract. 2001;18:495–500.PubMedCrossRefGoogle Scholar
  9. 9.
    Lorber J. Good patients and problem patients: conformity and deviance in a general hospital. J Health Soc Behav. 1975;16:213–225.PubMedCrossRefGoogle Scholar
  10. 10.
    Johnson JE JT, Pinholt EM, Carpenter JL. Content of ambulatory internal medicine practice in an academic army medical center and army community hospital. Military Med. 1988;153:21–25.Google Scholar
  11. 11.
    Jackson JL SJ, Cheng E, Meyer G. Patients diagnosis and procedures in a military internal medicine clinic; comparison with civilian. Military Med. 1999;164(3):194–97.Google Scholar
  12. 12.
    Jackson JL OMP, Kroenke K. A psychometric comparison of military and civilian medical practices. Mil Med. 1999;164(2):112–5.PubMedGoogle Scholar
  13. 13.
    Kroenke KSR, Williams JBW. The PHQ-15: validity of a new measure for evaluating the severity of somatic symptoms. Psychosom Med. 2002;64:258–66.PubMedGoogle Scholar
  14. 14.
    Rubin HR GB, Rogers WH, Kosinki M, Mchoney CA, Ware JE. Patients ratings of outpatient visits in different practice settings: results of the Medical Outcomes Study. JAMA. 1993;270:835–40.PubMedCrossRefGoogle Scholar
  15. 15.
    Ashworth CD WP, Montano D. A scale to measure physician beliefs about psychosocial aspects of care. Soc Sci Med. 1984;19(11):1235–8.PubMedCrossRefGoogle Scholar
  16. 16.
    Levinson W. RD, Mullooly JP, Dull VT, Frankel RM. "Physician- patient communication: the relationship with malpractice claims among primary care physicians and surgeons. JAMA. 1997;277(7):553–9.PubMedCrossRefGoogle Scholar
  17. 17.
    Hosmer DW LS. Applied Logistic Regression. New York, NY: John Wiley & Sons, 1989.Google Scholar
  18. 18.
    Byrne B. Structural Equation Modeling with AMOS. Basic Concepts, Applications and Programming. London: Lawrence Erlbaum Associates, 2001.Google Scholar
  19. 19.
    Browne MW CR. Alternative Ways for Assessing Model Fit in Testing Structural Equation Models. In: Bollen KA LJ, editor. Newbury Park Sage, 1993:136-62.Google Scholar
  20. 20.
    Hoelter J. The analysis of covariance structures: goodness of fit indices. Sociological Methods and Research. 1983;11:325–44.CrossRefGoogle Scholar
  21. 21.
    Carmines EG MJ. Analyzing Models with Unobserved Variables in Social Measurement. Beverly Hills: Sage, 1981.Google Scholar
  22. 22.
    AJ KLE, Meenan RF. Effect sizes for interpreting changes in health status. Med Care. 1989;27:S178–S89.CrossRefGoogle Scholar
  23. 23.
    Jackson JL, Kroenke K. Prevalence, impact, and prognosis of multisomatoform disorder in primary care: a 5-year follow-up study. Psychosom Med. 2008;70(4):430–4.PubMedCrossRefGoogle Scholar
  24. 24.
    Smith RC, Lyles JS, Gardiner JC, Sirbu C, Hodges A, Collins C, Dwamena FC, Lein C, William Given C, Given B, Goddeeris J. Primary care clinicians treat patients with medically unexplained symptoms: a randomized controlled trial. J Gen Intern Med. 2006;21(7):671–7.PubMedCrossRefGoogle Scholar
  25. 25.
    Jackson JL. PM, Kroenke K. Outcome and impact of mental disorders in primary care at 5 years. Psychosom Med. 2007;69(3):270–6.PubMedCrossRefGoogle Scholar
  26. 26.
    Drossman D. The problem patient: evaluation and care of medical patients with psychocosial disturbances. Annals Intern Med. 1978;88:366–72.Google Scholar
  27. 27.
    Smith RC OG, Hoppe RB, et al. Efficacy of a one-month training block in psychosocial medicine for residents: a controlled study. J Gen Intern Med. 1991;6:535.PubMedCrossRefGoogle Scholar
  28. 28.
    Stewart M. Effective physician-patient communication and health outcomes: a review. CMAJ. 1995;152(9):1423–33.PubMedGoogle Scholar
  29. 29.
    Smith R. Patient-Centered Interviewing: An Evidence Based Method. 2nd ed. Philadelphia: Lippincott Williams and Wilkins, 2002.Google Scholar
  30. 30.
    Leiblum SR SE, Seehuus M, DeMaria A. To BATHE or not to BATHE: patient satisfaction with visits to their family physician. Fam Med. 2008;40(6):407–11.PubMedGoogle Scholar
  31. 31.
    Delbanco T. Enriching the doctor-patient relationship by inviting the patients perspective. Ann Intern Med. 1992:116-414.Google Scholar
  32. 32.
    Boyle D. DB, Platt F. Invite, Listen and Summarize: A Patient-Centered Communication Technique. Acad Med. 2005;80:29–32.PubMedCrossRefGoogle Scholar
  33. 33.
    Spitzer RL WJ, Kroenke K, Linzer M, deGruy FV, Hanh SR. Utility of a New Procedure for Diagnosing Mental Disorders in Primary Care. The PRIME-MD 1000 study. JAMA 1994;272:1749-56.Google Scholar
  34. 34.
    Ware JE NE, Shelbourne CD, Stewart AL. Preliminary tests of a 6-item general health survey: a patient application in measuring functioning and well being. In the Medical Outcomes Study Approach Durham Duke University Press 1992.Google Scholar
  35. 35.
    Groves J. Taking care of the hateful patient. N Engl J Med. 1978;80:1211–15.Google Scholar

Copyright information

© Society of General Internal Medicine 2011

Authors and Affiliations

  1. 1.General Medicine DivisionTripler Army Medical CenterHonoluluUSA
  2. 2.General Medicine DivisionZablocki VA Medical CenterMilwaukeeUSA
  3. 3.Dept of MedicineMilwaukeeUSA

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