Abstract
“Difficult patients” are most often characterized by their personality, behavior, or pathology. Little research has been done to understand how some patients, because of their disadvantaged social position, are perceived as “difficult” by their physicians. Our qualitative, exploratory study was conducted to understand how social inequalities contribute to this perception of a “difficult patient.” It was based on 12 semi-structured interviews with physicians, in Montréal, Canada. Participants identified three main challenging factors: a perception of excessive time required to manage these patients; a feeling of ineffectiveness, despite this additional time spent; and the pressure to “do something” about needs they perceive as serious, despite this feeling of ineffectiveness. To adjust their practice to the specific circumstances of these disadvantaged patients, they feel it is important to establish good relationships with them, to set realistic objectives, and to increase interprofessional interactions. We discuss these findings in relation to three issues that contribute to this sense of difficulty: the social distance between physicians and patients, the social determinants affecting patients’ health, and certain aspects of the health care system that impede the above-mentioned adjustments in medical practice. By exploring, social inequalities in health care access not through the experience of patients, but rather through the perspectives of the physicians who feel unable to protect them, this analysis highlights that the scope of action required to address such inequalities far exceeds physicians’ practice.
Highlights
Representing around one in six patients (Hahn et al, 1996; Hinchey & Jackson, 2011; Jackson & Kroenke, 1999), difficult patients are most often characterized by their behaviors, medical problems, emotional distress, or mental illness
We judged that our sample’s information power was rather high because (a) the aim of our study was rather narrow, as it was set at the intersection of two research questions (“what is a difficult patient” and “how do social inequalities interfere with medical work”); (b) our sample specificity was dense; and (c) the quality of dialogue between researchers and participants was high, thanks to the complementary characteristics of the pairs of researchers who led the interviews
Questioned about the social inequalities that perturb their medical practice, the physicians spoke about poverty, low education, unemployment, and social isolation
Summary
Representing around one in six patients (Hahn et al, 1996; Hinchey & Jackson, 2011; Jackson & Kroenke, 1999), difficult patients are most often characterized by their behaviors (complaining, aggressive, demanding, manipulative, overconsuming of care), medical problems (often multiple in one patient, responding poorly to treatment and causing pain), emotional distress, or mental illness (often not recognized as such; Elder et al, 2006; Haas et al, 2005; Hahn et al, 1996; Hinchey & Jackson, 2011; Jackson & Kroenke, 1999) They are much less often characterized by their social status (such as gender, race, or socioeconomic status [SES]), and when they are, this status is not necessarily one of underprivilege.
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