Challenging situations in physician-patient relationship

Abstract

Background: Following the World Health Organization (WHO) recommendations to seek efficiency in the learning process1, the Primary Care Department of Paris-Est University (UPEC) has adopted a competency-based learning model. At the UPEC, clinical writing notes (CWN) are required from challenging clinical training situations faced by residents. This study aims to describe the relationship difficulties with the patients encountered by UPEC's Family Medicine residents, based on their CWN. Methods: This is a retrospective qualitative/quantitative study. The CWN of UPEC's Family Medicine residents of the same cohort (52 residents) were collected over their 3-year residency program in 6 different locations. At least two relationships difficulties notes for every 6 months of training were required by the residents. 734 notes of patient–resident relationship difficulties were analyzed. For each note, the main patient–resident relationship difficulty was identified and coded according to the French repository of 11 major families of clinical situations2, then organized according to the encountered difficulties and training location. Results: The most frequent relational difficulty was related to the management of patients with unjustified requests. Request for prescription of sick leaves, antibiotics3, and investigations were frequently a source of relational difficulties (Table 1). The situations causing relational difficulties were facility-dependent. In the emergency department: inpatient patients and patients with non-urgent medical conditions. In inpatient department: workload and lack of supervision. In Ambulatory clinic: unjustified patients’ requests for prescription and patients questioning the legitimacy of the resident as a physician. Faced with their difficulties, the residents described 3 types of patients: introverts, extroverts, and uncivil. The residents adopted a two-step strategy: the involvement phase, and then in case of failure, the detachment phase (Table 2). Conclusion: The relational difficulties encountered by Family Medicine residents at UPEC with their patients are facility dependent and frequently related to patients’ unjustified requests.