title: Why patients' disruptive behaviours impair diagnostic reasoning: a randomised experiment.
abstract: 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.
  
  
  
  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.
  
  
  
  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.
  
  
  
  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.
authors.affiliation: Institute of Medical Education Research Rotterdam, Erasmus Medical Center, Rotterdam, The Netherlands.
authors.forename: Sílvia
authors.initials: S
authors.lastname: Mamede
authors.affiliation: Department of Psychology, Erasmus University Rotterdam, Rotterdam, The Netherlands.
authors.forename: Tamara
authors.initials: T
authors.lastname: Van Gog
authors.affiliation: Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands.
authors.forename: Stephanie C E
authors.initials: SC
authors.lastname: Schuit
authors.affiliation: Department of Internal Medicine, Admiraal de Ruyter Hospital, Goes, The Netherlands.
authors.forename: Kees
authors.initials: K
authors.lastname: Van den Berge
authors.affiliation: Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands.
authors.forename: Paul L A
authors.initials: PL
authors.lastname: Van Daele
authors.affiliation: Department of General Practice, Erasmus Medical Center, Rotterdam, The Netherlands.
authors.forename: Herman
authors.initials: H
authors.lastname: Bueving
authors.affiliation: Department of Psychology, Erasmus University Rotterdam, Rotterdam, The Netherlands.
authors.forename: Tim
authors.initials: T
authors.lastname: Van der Zee
authors.affiliation: Institute of Medical Education Research Rotterdam, Erasmus Medical Center, Rotterdam, The Netherlands.
authors.forename: Walter W
authors.initials: WW
authors.lastname: Van den Broek
authors.affiliation: Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands.
authors.forename: Jan L C M
authors.initials: JL
authors.lastname: Van Saase
authors.affiliation: Department of Psychology, Erasmus University Rotterdam, Rotterdam, The Netherlands.
authors.forename: H G
authors.initials: HG
authors.lastname: Schmidt
mesh_terms: D000328:Adult; D003933:Diagnosis; D003951:Diagnostic Errors / Q000523:psychology* / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D008297:Male; D010817:Physician-Patient Relations; D000066553:Problem Behavior / Q000523:psychology
keywords: Decision making; Diagnostic errors; Medical education