A cohort study assessing difficult patient encounters in a walk-in primary care clinic, predictors and outcomes.
BACKGROUND
Previous studies have found that up to 15% of clinical encounters are experienced as difficult by clinicians.


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


METHODS
Prospective cohort study.


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


METHODS
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.


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).


CONCLUSIONS
Both patient and physician characteristics are associated with "difficult" encounters, and patients involved in such encounters have worse short-term outcomes.
General Medicine Division, Tripler Army Medical Center, Honolulu, HI, USA.
Sherri A
SA
Hinchey
Jeffrey L
JL
Jackson
D000553:Ambulatory Care / Q000379:methods* / Q000523:psychology* / Q000639:trends; D000554:Ambulatory Care Facilities / Q000639:trends*; D015331:Cohort Studies; D005260:Female; D005500:Follow-Up Studies; D005544:Forecasting; D006801:Humans; D008297:Male; D008875:Middle Aged; D010817:Physician-Patient Relations; D011320:Primary Health Care / Q000639:trends; D011446:Prospective Studies; D011795:Surveys and Questionnaires; D016896:Treatment Outcome
Gen Hosp Psychiatry. 1997 Sep;19(5):315-23
9328776
Ann Intern Med. 1992 Mar 1;116(5):414-8
1736775
J Gen Intern Med. 1991 Nov-Dec;6(6):535-43
1765870
Med Care. 1989 Mar;27(3 Suppl):S178-89
2646488
J Health Soc Behav. 1975 Jun;16(2):213-25
1159292
JAMA. 1994 Dec 14;272(22):1749-56
7966923
Arch Intern Med. 1999 May 24;159(10):1069-75
10335683
Fam Pract. 2001 Oct;18(5):495-500
11604370
Fam Med. 2008 Jun;40(6):407-11
18773778
J Gen Intern Med. 1996 Jan;11(1):1-8
8691281
J Gen Intern Med. 1991 May-Jun;6(3):241-6
2066830
Soc Sci Med. 1984;19(11):1235-8
6523166
Mil Med. 1999 Mar;164(3):194-7
10091492
Psychosom Med. 2007 Apr;69(3):270-6
17401055
Acad Med. 2005 Jan;80(1):29-32
15618088
Psychosom Med. 2002 Mar-Apr;64(2):258-66
11914441
Psychosom Med. 2008 May;70(4):430-4
18434494
JAMA. 1997 Feb 19;277(7):553-9
9032162
BMC Health Serv Res. 2006 Oct 06;6:128
17026762
J Clin Epidemiol. 1994 Jun;47(6):647-57
7722577
N Engl J Med. 1978 Apr 20;298(16):883-7
634331
JAMA. 1993 Aug 18;270(7):835-40
8340982
Mil Med. 1999 Feb;164(2):112-5
10050567
J Gen Intern Med. 2006 Jul;21(7):671-7
16808764
Ann Intern Med. 1978 Mar;88(3):366-72
629502
CMAJ. 1995 May 1;152(9):1423-33
7728691
Mil Med. 1988 Jan;153(1):21-5
3126417