Difficult patients and diagnostic accuracy

Schmidt HG, van Gog T, Ce Schuit S, Van den Berge K, LA Van Daele P, Bueving

H, Van der Zee T, W Van den Broek W, Lcm Van Saase J, Mamede S. Do patients'

disruptive behaviours influence the accuracy of a doctor's diagnosis? A

randomised experiment. BMJ Qual Saf. 2016 Mar 7. pii: bmjqs-2015-004109. doi:

10.1136/bmjqs-2015-004109. [Epub ahead of print]

Abstract

BACKGROUND:

Literature suggests that patients who display disruptive behaviours in the consulting room fuel negative emotions in doctors. These emotions, in turn, are said to cause diagnostic errors. Evidence substantiating this claim is however lacking. The purpose of the present experiment was to study the effect of such difficult patients' behaviours on doctors' diagnostic performance.

METHODS:

We created six vignettes in which patients were depicted as difficult (displaying distressing behaviours) or neutral. Three clinical cases were deemed to be diagnostically simple and three deemed diagnostically complex. Sixty-three family practice residents were asked to evaluate the vignettes and make the patient's diagnosis quickly and then through deliberate reflection. In addition, amount of time needed to arrive at a diagnosis was measured. Finally, the participants rated the patient's likability.

RESULTS:

Mean diagnostic accuracy scores (range 0-1) were significantly lower for difficult than for neutral patients (0.54 vs 0.64; p=0.017). Overall diagnostic accuracy was higher for simple than for complex cases. Deliberate reflection upon the case improved initial diagnostic, regardless of case complexity and of patient behaviours (0.60 vs 0.68, p=0.002). Amount of time needed to diagnose the case was similar regardless of the patient's behaviour. Finally, average likability ratings were lower for difficult than for neutral-patient cases.

CONCLUSIONS:

Disruptive behaviours displayed by patients seem to induce doctors to make diagnostic errors. Interestingly, the confrontation with difficult patients does however not cause the doctor to spend less time on such case. Time can therefore not be considered an intermediary between the way the patient is perceived, his or her likability and diagnostic performance.

Courtesy of a colleague

Mamede S, Van Gog T, Schuit SC, Van den Berge K, Van Daele PL, Bueving H, Van

der Zee T, Van den Broek WW, Van Saase JL, Schmidt HG. Why patients' disruptive

behaviours impair diagnostic reasoning: a randomised experiment. BMJ Qual Saf.

2016 Mar 7. pii: bmjqs-2015-005065. doi: 10.1136/bmjqs-2015-005065. [Epub ahead

of print]

Abstract

BACKGROUND:

Patients who display disruptive behaviours in the clinical encounter (the so-called 'difficult patients') may negatively affect doctors' diagnostic reasoning, thereby causing diagnostic errors. The present study aimed at investigating the mechanisms underlying the negative influence of difficult patients' behaviours on doctors' diagnostic performance.

METHODS:

A randomised experiment with 74 internal medicine residents. Doctors diagnosed eight written clinical vignettes that were exactly the same except for the patients' behaviours (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 design. After diagnosing each vignette, participants were asked to recall the patient's clinical findings and behaviours. Main measurements were: diagnostic accuracy scores; time spent on diagnosis, and amount of information recalled from patients' clinical findings and behaviours.

RESULTS:

Mean diagnostic accuracy scores (range 0-1) were significantly lower for difficult than neutral patients' vignettes (0.41 vs 0.51; p<0.01). Time spent on diagnosing was similar. Participants recalled fewer clinical findings (mean=29.82% vs mean=32.52%; p<0.001) and more behaviours (mean=25.51% vs mean=17.89%; p<0.001) from difficult than from neutral patients.

CONCLUSIONS:

Difficult patients' behaviours induce doctors to make diagnostic errors, apparently because doctors spend part of their mental resources on dealing with the difficult patients' behaviours, impeding adequate processing of clinical findings. Efforts should be made to increase doctors' awareness of the potential negative influence of difficult patients' behaviours on diagnostic decisions and their ability to counteract such influence.