MedicalResearch.com Interview with:
Sílvia Mamede, MD, PhD
Institute of Medical Education Research Rotterdam
Rotterdam, The Netherlands
MedicalResearch.com: What is the background for this study? What are the main findings?
Dr. Mamede: Doctors are often engaged in clinical encounters that are emotionally charged. Patients who feel anxious about their problems often respond emotionally in their interaction with their doctors. Most of these encounters fall within the limits of what is to be expected in clinical practice, but some patients behave in ways that make the doctor-patient interaction particularly distressing. Aggressive or disrespectful patients, frequent demanders, patients who don’t trust their doctors’ competence or ever-helpless patients are known, in the medical literature, as “difficult patients”. Doctors have reported to encounter these so-called “difficult patients” in around 15% of the outpatient consultations. As it might be expected, these patients’ behaviors provoke emotional reactions in doctors. The potential negative effect of these reactions on the doctor’s diagnostic accuracy has long been discussed in the medical literature. However, there was no empirical evidence that this happened. We conducted two studies to fill this gap.
In the two studies, doctors diagnosed clinical cases that were exactly the same except for the patient’s behaviors. In the first study, we used complex and simple cases. Even though the cases were the same, doctors made 42% more mistakes in disruptive than in non-disruptive patients when the cases were complex, and 6% more mistakes when the cases were simple. In the second study, we used cases deemed to be at an intermediate level of complexity. Doctors made 20% more mistakes in difficult compared to neutral patients. These findings show that disruptive behaviors displayed by patients seem to affect doctors’ reasoning and induce them to make diagnostic errors. The findings of our second study suggest that disruptive behaviors “capture” the doctor’s attention at the expense of attention for the clinically relevant information. We came to this conclusion because when asked to recall the information from a case afterwards, doctors who were confronted with a difficult patient remember more information about the patient’s behaviors and less information of the clinically relevant symptoms than doctors confronted with the natural version of the same patient. Recall of information is considered a measure of the amount of attention given to such information.
MedicalResearch.com: What should clinicians and patients take away from your report?
Dr. Mamede: Physicians and patients should be aware that physicians, as anybody else, have emotions that can interfere with thinking. Since the response of physicians to disruptive behaviors is partially unconscious, it is not enough to simply be aware of the potentially negative effects of disruptive patients to avoid them. They may be trained, however, to deal with difficult patients. Our findings are particularly relevant for medical education: prospective physicians should be trained to deal with these disruptive behaviors explicitly and effectively: An aggressive patient can be calmed; a patient who displays lack of trust in his doctor can be referred to another doctor. Patients should be aware that it is also their responsibility to ensure that the clinical encounter occurs in a climate of trust and mutual respect. This is a precondition for accurate diagnosis and treatment and, if it does not exist, the patient may suffer as our research indicates.
MedicalResearch.com: What recommendations do you have for future research as a result of this study?
Dr. Mamede: The influence of affective factors on physicians’ clinical reasoning and diagnostic performance has been largely neglected in research on diagnostic errors. Our studies show that such influence may be more relevant than usually considered. We hope they open the door for further exploring this issue.
MedicalResearch.com: Thank you for your contribution to the MedicalResearch.com community.
Do patients’ disruptive behaviours influence the accuracy of a doctor’s diagnosis? A randomised experiment
H G Schmidt, Tamara van Gog, Stephanie CE Schuit, Kees Van den Berge,Paul LA Van Daele, Herman Bueving, Tim Van der Zee, Walter W Van den Broek,Jan LCM Van Saase, Sílvia Mamede
BMJ Qual Saf bmjqs-2015-004109Published Online First: 7 March 2016 doi:10.1136/bmjqs-2015-004109
Note: Content is Not intended as medical advice. Please consult your health care provider regarding your specific medical condition and questions.
Note: Content is Not intended as medical advice. Please consult your health care provider
Dr. Sílvia Mamede (2016). Doctors Make More Mistakes When Patients Are Difficult or Disruptive MedicalResearch.com