Difficult Doctor-Patient Relationship Research Articles

Prevalence, Impact, and Prognosis of Multisomatoform Disorder in Primary Care: A 5-Year Follow-up Study

To determine the prevalence, impact, and prognosis of multisomatoform disorder (MSD) over a 5-year period in a primary care population. Although somatization is prevalent in primary care, patients rarely meet Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) criteria for somatization disorder. MSD, defined as > or = 3 bothersome, medically unexplained somatic symptoms, has been proposed as a more inclusive disorder. A total of 500 adults presenting to a primary care clinic with a physical symptom were screened with the Primary Care Evaluation of Mental Disorders. Symptom count was assessed with the Patient Health Questionnaire 15-item somatic symptom scale. Additional baseline measures included functional status and symptom characteristics. Follow-up surveys at 2 weeks, 3 months, and 5 years assessed functioning, symptom outcome, psychiatric diagnoses, and patient satisfaction. Physician surveys assessed encounter difficulty. Utilization was obtained from our health database. MSD had an 8% prevalence at both baseline (n = 38/500) and at 5 years (n = 33/387). MSD persisted in 21% of those with MSD at baseline, and developed in 7% of those without MSD at baseline. MSD at baseline was a predictor of MSD at 5 years (relative risk (RR) = 2.7, 1.5-5.1). MSD patients were more likely to have comorbid mental disorders (RR = 1.5, 1.1-2.3) and be rated "difficult" by their clinicians (p = .02). They also reported worse functional status at all time points assessed (p < .001 for all), were less likely to experience symptom improvement, and had higher utilization rates (34.1 versus 23.1 visits; p = .006). MSD identifies a group of patients who are less likely to experience symptom improvement and have significant functional impairment and higher utilization rates.

The patient-physician relationship and medical utilization.

The goal of this study was to (1) explore the relationship between medical utilization and characteristics of the patient-physician relationship and (2) evaluate the relationship between physician perception of patient difficulty, chronic medical problems, and patient somatizing tendencies. Patients in an academic family practice center were asked to complete a demographic data sheet, the PRIME-MD Patient Questionnaire, and the Barrett-Lennard Relationship Inventory regarding their relationship with their physicians. Their physicians completed the Difficult Doctor-Patient Relationship Questionnaire. Patient charts were examined for number of office visits and phone calls in the previous year, as well as number of chronic problems and medications. The study was conducted from September 2000 to November 2001. Forms were completed by 165 patients and 20 physicians. Forty-three patients who were approached refused to participate. Patient ratings on the Barrett-Lennard Relationship Inventory were not related to utilization measures. Physician ratings of difficulty were significantly related to phone calls and visits (p < .05), as well as PRIME-MD Patient Questionnaire somatization tendencies (p < .05) but not to number of chronic problems. Patient and physician ratings were not significantly correlated. Gender (p < .001), marital status (p < .04), education (p < .03), and employment status (p < .002) were all related to utilization measures. Medical utilization was associated with somatizing tendencies of patients and the physicians' perception of patient difficulty. Physicians rated patients as difficult if they tended to somatize but not if they had a number of chronic problems.

Physicians’ difficulty with emergency department patients is related to patients’ attachment style

Doctors experience 10–20 percent of patient interactions as being personally difficult, but the sources of difficulty are incompletely understood. In particular, physician-perceived difficulty has not been studied from the perspective of an established model of interpersonal relationships. Our objective was to determine whether a relationship exists between patients’ attachment style and the degree of difficulty experienced by their attending physician in an Emergency Department in Pretoria, South Africa. Patients of an Emergency Department ( n=165) completed the Experiences in Close Relationships—Revised Questionnaire to measure attachment anxiety and attachment avoidance. Their physicians ( n=26), blind to the attachment measure, rated perceived difficulty using the Difficult Doctor–Patient Relationship Questionnaire. Four categories of attachment style were identified by cluster analysis of attachment scores. Patients were divided into difficult and non-difficult groups using a cut-off score. Two percent of patients with a secure attachment style were experienced as difficult, whereas the prevalence of difficulty in the insecure styles was ‘preoccupied’ 17 percent, ‘dismissing’ 19 percent and ‘fearful’ 39 percent ( χ 2 =16.383, df=3, p=0.0009), supporting the hypothesis that the physician's perception of patient difficulty is related to the patient's attachment style. The degree to which physicians serve attachment functions for patients in crisis merits further investigation.

When talking to the patient is difficult: The physician's perspective

The aim of the study was to analyze the difficult doctor-patient relationship from a doctor's perspective. A qualitative-interpretative approach was employed to analyze representations of difficult visits collected by means of written narrations. Two main scenarios were identified: (i) a 'personal scenario' in which the doctor had difficulties from a purely personal perspective; and (ii) a 'professional scenario' in which the doctor had difficulties as a professional when the 'other' resists or in facing the 'other' who resists. A further scenario was identified in which problems were generated by the family of the patient. Results suggest that the relation between doctor and patient may be very complex. Difficulties may be internal to the doctor, hence intra-psychic, depending on being both a professional and a human being. Difficulties may also be external between two psychological subjects (labeled as inter-psychic), where interaction of the 'you' and the 'other' becomes a battleground, a wall of opposition, or alternatively a place of experimentation with relationships. Furthermore, external difficulties may also be between more than two persons (labeled as inter-personal), by the possible multiplicity of the 'other'. This happens in particular when the 'other' is represented by the family.

Anxiety and depression in an internal medicine resident continuity clinic: difficult diagnoses.

To determine the prevalence of anxiety and depression in a residents' clinic and if these diagnoses are associated with patients being perceived as difficult, as well as how often these diagnoses are documented in the patients' charts. This was a cross-sectional study conducted in a general internal medicine residents' clinic. A total of 135 patients were given the Primary Care Evaluation of Mental Disorders questionnaire (DSM-IIIR version) and their physicians filled out the Difficult Doctor-Patient Relationship Questionnaire after the visit. Charts were reviewed for documentation of a diagnosis of anxiety or depression. Major depression was present in 26 percent, dysthymia 16 percent, major depression in partial remission 9 percent, generalized anxiety disorder 13 percent, and panic disorder 7 percent. Overall, 38 percent had at least one and 21 percent had more than one diagnosis. Of patients with one psychiatric diagnosis, 9 percent were classified as difficult versus 100 percent of patients with four diagnoses. Documentation of depression was noted for 43 percent of patients with major depression but only 9 percent with an anxiety disorder. Anxiety and depression were very common among the patients in this clinic, and increasing numbers of diagnoses were associated with patients being classified as difficult. Residents diagnosed depressive disorders as often as practicing physicians in other studies, but anxiety less well. The high prevalence of mental disorders has implications for resident education in that they need to be prepared to care for these patients, but residents also may benefit from exposure to sites with more typical prevalences of these illnesses.

The effect of unmet expectations among adults presenting with physical symptoms.

Unmet patient expectations are common and have been associated with decreased patient satisfaction. To assess the prevalence and effect of unmet expectations in patients presenting with physical symptoms. Prospective cohort study. Primary care walk-in clinic. Most patients were seeing a particular provider for the first time. 750 adults whose principal reason for the clinic visit was a physical symptom. Patients completed previsit questionnaires that assessed symptom characteristics, the patient's expectations of the visit, functional status (Medical Outcomes Study Short Form-6), and mental disorders (Primary Care Evaluation of Mental Disorders [PRIME-MD]). Patient questionnaires given immediately after the visit and 2 weeks after the visit assessed patient satisfaction with the visit and unmet expectations; the 2-week questionnaire also assessed symptom outcome and functional status. Postvisit physician questionnaires measured encounter difficulty (Difficult Doctor Patient Relationship Questionnaire) and what the physician did in response to the patient's symptom. Nearly all patients (98%) had at least one previsit expectation, including a diagnosis (81%), an estimate of how long the symptom was likely to last (63%), a prescription (60%), a diagnostic test (54%), and a subspecialty referral (45%). Immediately after the visit, the most common unmet expectations were for prognostic information (51%) or diagnostic information (33%). Only 11% of patients had an unmet expectation of a diagnostic test, subspecialty referral, prescription, or sick slip. Unmet patient expectations were more common after encounters experienced as difficult by the clinician and in patients with underlying mental disorders. Patients with no unmet expectations had less worry about serious illness (54% vs. 27%; P < 0.001) and greater satisfaction (59% vs. 19%; P < 0.001), and patients who reported receiving diagnostic or prognostic information were more likely to have symptom alleviation (relative risk, 1.2 [95% CI, 1.02 to 1.3]) and functional improvement (functional status score, 25 vs. 23; P = 0.01) at 2 weeks. Patients who seek care for physical symptoms and do not leave the encounter with an unmet expectation are more likely to be satisfied with their care and to have less worry about serious illness. Diagnostic and prognostic information are particularly valued by patients and may be associated with greater improvement in symptoms and functional status 2 weeks after the visit.

Physical symptoms and physician-experienced difficulty in the physician-patient relationship.

The practice of medicine has many expected and accepted challenges, but all physicians experience some patients as difficult to a degree that transcends these expectations. Physician-experienced difficulty is associated with a syndrome of three characteristics: patient psychopathology, abrasive interpersonal styles, and multiple physical symptoms. To assess the roles played by the number of physical symptoms and by specific symptoms in determining whether physician-experienced difficulty occurs. New analyses of epidemiologic survey data from the Primary Care Evaluation of Mental Disorders (PRIME-MD) 1000 Study. Four primary care clinics. 627 ambulatory patients seen by 27 physicians. Physician-experienced difficulty was measured by using the 10-item Difficult Doctor Patient Relationship Questionnaire (DDPRQ-10); patient-reported physical symptoms and physician-assessed psychopathology and somatoform symptoms were evaluated by using the PRIME-MD; and physical illnesses were measured by using a physician questionnaire. The number of physical symptoms and the number of somatoform symptoms correlated with difficulty (r = 0.39 and r = 0.37, respectively; P < 0.001), and the correlations remained significant after adjustment for physical and mental disorders (r = 0.20 for both correlations; P < 0.001). Difficult patients were more likely to have each of 16 physical symptoms; the odds of being difficult were greater for patients with 1 of 5 particular symptoms (stomach pain, fainting, loose stools/diarrhea, palpitations, and sleep problems), even after adjustment for physical and mental disorders. All 10 items on the DDPRQ-10 were influenced by physical symptoms, particularly those items that asked about physician frustration and whether patients were manipulative and time consuming. The association between physical symptoms and difficulty is due in part to the association between physical symptoms and mental disorders, but symptoms also contribute independently to difficulty. The independent component of symptom-associated difficulty may be due to 1) differences between patient and physician in expectations about treatment and 2) the part that symptoms play in conferring the "sick role" on a patient.

Clinical predictors of mental disorders among medical outpatients.

Mental disorders are common among primary care patients and often not detected by primary care physicians. We report on clinical cues that may allow physicians to target patients for psychiatric screening. Two hundred fifty consecutive adults presenting to a walk-in clinic completed previsit surveys assessing demographics, symptom characteristics, recent stress, functional status (Medical Outcomes Study Short Form-6), and mental disorders (Primary Care Evaluation of Mental Disorders [PRIME-MD]). Patients with positive findings for a mental disorder on the PRIME-MD underwent a semistructured interview. Immediately after the visit, physicians completed the Difficult Doctor Patient Relationship Questionnaire. Patients averaged 50.5 years of age (range, 18-92 years). Little more than half were women (53%); 43%, white; 44%, African American; 8%, Hispanic; and 6%, other. Twenty-six percent had an underlying mental disorder; 11% had more than 1 mental disorder. Sixteen percent had a depressive disorder; 6%, major depression; 11%, an anxiety disorder; 2%, panic disorder; and 9%, a somatoform disorder. Independent correlates of a mental disorder included reporting recent stress (odds ratio [OR], 6.7; 95% confidence interval [CI], 3.3-13.6), having 5 or more physical symptoms (OR, 4.0; 95% CI, 2.1-7.9), or reporting health to be less than very good (OR, 2.2; 95% CI, 1.1-4.3). There was a stepwise increase in the likelihood of having a mental disorder and number of correlates present. Among patients with no predictors, only 2% had an underlying mental disorder, compared with 72% among patients with all 3 clinical predictors. Patients who report recent stress, 5 or more physical symptoms, or poor health are more likely to have an underlying mental disorder. These clinical cues may allow clinicians to select patients in whom formal screening for mental disorders would be particularly fruitful.

Predictors of patient satisfaction

Correlates of patient satisfaction at varying points in time were assessed using a survey with 2-week and 3-month follow-up in a general medicine walk-in clinic, in USA. Five hundred adults presenting with a physical symptom, seen by one of 38 participating clinicians were surveyed and the following measurements were taken into account: patient symptom characteristics, symptom-related expectations, functional status (Medical Outcomes Study Short-Form Health Survey [SF-6]), mental disorders (PRIME-MD), symptom resolution, unmet expectations, satisfaction (RAND 9-item survey), visit costs and health utilization. Physician perception of difficulty (Difficult Doctor–Patient Relationship Questionnaire), and Physician Belief Scale. Immediately after the visit, 260 (52%) patients were fully satisfied with their care, increasing to 59% at 2 weeks and 63% by 3 months. Patients older than 65 and those with better functional status were more likely to be satisfied. At all time points, the presence of unmet expectations markedly decreased satisfaction: immediately post-visit (OR: 0.14, 95% CI: 0.07–0.30), 2-week (OR: 0.07, 95% CI: 0.04–0.13) and 3-month (OR: 0.05, 95% CI: 0.03–0.09). Other independent variables predicting immediate after visit satisfaction included receiving an explanation of the likely cause as well as expected duration of the presenting symptom. At 2 weeks and 3 months, experiencing symptomatic improvement increased satisfaction while additional visits (actual or anticipated) for the same symptom decreased satisfaction. A lack of unmet expectations was a powerful predictor of satisfaction at all time-points. Immediately post-visit, other predictors of satisfaction reflected aspects of patient–doctor communication (receiving an explanation of the symptom cause, likely duration, lack of unmet expectations), while 2-week and 3-month satisfaction reflected aspects of symptom outcome (symptom resolution, need for repeat visits, functional status). Patient satisfaction surveys need to carefully consider the sampling time frame as well as adjust for pertinent patient characteristics.

Difficult patient encounters in the ambulatory clinic: clinical predictors and outcomes.

One sixth of patient encounters are perceived as difficult by clinicians. Our goal was to assess clinical predictors and outcomes from such encounters. Five hundred adults presenting to a primary care walk-in clinic with a physical symptom completed surveys before the visit, immediately after the visit, at 2 weeks, and at 3 months. Patient measurements included mental disorders (PRIME-MD), functional status (Medical Outcomes Study Short-Form Health Survey [SF-6]), satisfaction (RAND 9-item survey), symptom resolution, visit costs, previsit and residual expectations of care, and health services utilization. Measurements from the 38 participating clinicians included the Physician's Belief Scale and physician perception of encounter difficulty (Difficult Doctor-Patient Relationship Questionnaire). Seventy-four patient encounters (15%) were rated as difficult. Patients in such encounters were more likely to have a mental disorder (odds ratio, 2.4; 95% confidence interval, 1.3-4.4), more than 5 somatic symptoms (odds ratio, 1.4; 95% confidence interval, 1.1-1.8), and more severe symptoms (odds ratio, 1.6; 95% confidence interval, 1.04-2.3). Difficult-encounter patients had poorer functional status, more unmet expectations (P=.005), less satisfaction with care (P=.03), and higher use of health services (P<.001). Clinicians with poorer psychosocial attitudes as reflected by higher scores on the Physician's Belief Scale experienced more encounters as being difficult (23% vs 8%; P<.001). Patients presenting with physical symptoms who are perceived as difficult are more likely to have a depressive or anxiety disorder, poorer functional status, unmet expectations, reduced satisfaction, and greater use of health care services. Physicians with poorer psychosocial attitudes are more likely to experience encounters as difficult.

A Psychometric Comparison of Military and Civilian Medical Practices

Our purpose was to compare the psychometric properties of military and civilian ambulatory internal medicine care. Military data came from two cohorts of patients presenting for primary care. Variables collected included mental disorders (the PRIME-MD study), previsit symptom-related concerns and expectations, functional status (Medical Outcomes Study SF-6 and SF-20 scales), postvisit unmet expectations, satisfaction with care (Medical Outcomes Study five-item survey), and physician-perceived "difficulty" (Difficult Doctor-Patient Relationship Questionnaire). This data set was compared with data abstracted from several civilian studies of ambulatory primary care. These studies used the same instruments and took place during the same period. Military and civilian patient populations were equally likely to have mental disorders, with no differences in the prevalence of disorders within the broad categories of mood, anxiety, somatoform, eating, or alcohol disorders. Civilian populations had a slightly higher rate of some specific diagnoses, including major depression, panic disorder, and generalized anxiety disorder. There was a similar distribution of previsit expectations of care and in the types of postvisit unmet patient expectations, with military patients having slightly lower rates of unmet expectations. Patients in both practice settings had similar self-reported ratings in the six domains of functioning (role, social, pain, emotion, physical, general health), with civilian patients reporting slightly worse overall self-rated health. Both settings had high rates of fully satisfied patients (40% "excellent" for both), with patients with unmet expectations in both groups much less likely to be fully satisfied. There was also a similar proportion of encounters rated as difficult by the clinician (military, 11%; civilian, 15%; p = 0.99). The correlates of difficulty in both groups were similar, with mental disorders and multiple symptoms increasing the likelihood of a difficult encounter. The psychometric properties of patient care in military and civilian internal medicine ambulatory settings are remarkably similar. These data support mutual generalizability of primary care research findings with respect to psychometric properties between military and civilian populations.

Attribution-related causes of a difficult doctor-patient relationship

Network-wide traffic control strategies (e.g. perimeter control and route guidance) in urban networks have recently been mainly studied to relieve or postpone congestion based on the theory of macroscopic fundamental diagram (MFD). Nevertheless, these studies are mostly applied to the statically partitioned networks or the dynamic networks that fail to fully consider traffic state prediction, conflicting with strongly spatiotemporal variability of traffic congestion or objective of active traffic management (ATM). This paper proposes a methodology to dynamically identify critical congestion warning areas from heterogeneous urban road networks, which aids to design efficient perimeter control approaches. In the methodology, a dynamic directed weighted network is built on the base of the link connectivity and the real-time traffic loads, and a link travel time prediction method based on Kalman filter is developed to calibrate directed weight values and undirected input values for links. With the undirected link input information, a dynamic congestion warning community detection method which consists of three consecutive steps is developed. Firstly, it could capture emergence of new congestion areas based on the definition of congestion seed intersection. Secondly, expansion and regression of each congested area could be achieved with the objectives of spatial compactness and traffic condition homogeneity. Thirdly, a two-level merging algorithm of adjacent different congestion areas is designed utilizing modularity model in community detection of complex networks. The proposed methodology is validated using ground truth data from downtown network of Jinan City in China. The results show that the proposed algorithms can efficiently track congestion evolutionary processes and effectively detect congestion warning areas from the test real network.

Use of the Label “Litigation Neurosis” in Patients with Somatoform Pain Disorder

The use of the term “litigation neurosis”—a condition with controversial clinical significance—might correspond to the expression for a difficult physician-patient relationship. The characteristics of patients with a DSM-III-R diagnosis of somatoform pain disorder who had been labeled “litigation neurosis” by their physicians were explored. Among 74 patients referred to a pain clinic, 30% had been labeled litigation neurosis, and among 81 patients referred while claiming disability benefits, 19% had been thus categorized. The attribution of this label was neither correlated to actually being involved in a claim for disability benefits nor to involvement in legal action. Patients who had been designated with litigation neurosis were characterized by a lower educational level, a higher rate of DSM-III-R major depression, and a much higher frequency of personality disorders than patients who were not thus labeled. We postulate that the communication style of patients with this constellation of characteristics, in particular the presence of psychiatric comorbidity, may have engendered a difficult doctor-patient relationship, leading physicians to use the label in the absence of objective evidence of litigation or involvement in legal action. We agree that the inappropriate use of labels such as “litigation neurosis” should be questioned.

Predictors of physician frustration in the care of patients with rheumatological complaints

Recent studies of the doctor-patient relationship have shown that certain patients are perceived as frustrating or difficult by their doctors; however, little is known about the characteristics of these patients that elicit this dissatisfaction. As part of a larger study of rheumatology clinic patients with fibromyalgia or rheumatoid arthritis ( N = 68) we used stepwise multiple regression to select the factors most associated with physician frustration while controlling for the effects of other variables. Variable domains included demographics, psychiatric diagnoses, personality factors, functional disability, disease state, and trauma history. These domains as well as individual variables within these domains were systematically evaluated for their unique contribution to the prediction of physician frustration as measured by the Difficult Doctor-Patient Relationship Questionnaire (DDPRQ). Initial bivariate correlates of physician frustration included marital status, current dysthymia and agoraphobia, lifetime panic disorder and obsessive-compulsive disorder, adult rape and physical abuse, somatization disorder, physical and social disability, the presence of fibromyalgia, as well as neuroticism, illness impact, and perceived loss of control. The best multivariable model for estimating frustration magnitude included somatization disorder, perception of lack of control over illness, and a lifetime history of obsessive-compulsive disorder. These factors explained 48% of the variance in DDPRQ score. Physicians in this study were most frustrated with patients who had ongoing preoccupation with multiple medically unexplained physical symptoms as well as the perception of greater impact and lack of control over their illness. These findings suggest that treatment of somatization in patients with chronic symptoms may decrease physician frustration.

The difficult patient

To determine the proportion of primary care patients who are experienced by their physicians as "difficult," and to assess the association of difficulty with physical and mental disorders, functional impairment, health care utilization, and satisfaction with medical care. Survey. Four primary care clinics. Six-hundred twenty-seven adult patients. Physician perception of difficulty (Difficult Doctor-Patient Relationship Questionnaire), mental disorders and symptoms (Primary Care Evaluation of Mental Disorders, [PRIME-MDI]), functional status (Medical Outcomes Study Short-Form Health Survey [SF-20]), utilization of and satisfaction with medical care by patient self-report. Physicians rated 96 (15%) of their 627 patients as difficult (site range 11-20%). Difficult patients were much more likely than not-difficult patients to have a mental disorder (67% vs 35% [corrected], p < .0001). Six psychiatric disorders had particularly strong associations with difficulty: multisomatoform disorder (odds ratio [OR] = 12.3. 95% confidence interval [CI] = 5.9-26.8), panic disorder (OR = 6.9, 95% CI = 2.6-18.1), dysthymia (OR = 4.2, 95% CI = 2.0-8.7), generalized anxiety (OR = 3.4, 95% CI = 1.7-7.1), major depressive disorder (OR = 3.0, 95% CI = 1.8-5.3), and probable alcohol abuse or dependence (OR = 2.6, 95% CI = 1.01-6.7). Compared with not-difficult patients, difficult patients had more functional impairment, higher health care utilization, and lower satisfaction with care, whereas demographic characteristics and physical illnesses were not associated with difficulty. The presence of mental disorders accounted for a substantial proportion of the excess functional impairment and dissatisfaction in difficult patients. Difficult patients are prevalent in primary care settings and have more psychiatric disorders, functional impairment, health care utilization, and dissatisfaction with care. Future studies are needed to determine whether improved diagnosis and management of mental disorders in difficult patients could diminish their excess disability, health care costs, and dissatisfaction with medical care, as well as the physicians experience of difficulty.

The difficult doctor-patient relationship: Somatization, personality and psychopathology

The difficult doctor-patient relationship and “difficult patients” have been the subject of considerable anecdotal study. Reliable methods for identification of difficult patients have not been available for the empirical study of their prevalence and characteristics. We developed the Difficult Doctor-Patient Relationship Questionnaire (DDPRQ), composed of 30 Likert items, completed by physicians after encounters with patients. Adult patients and their providers in an academic, municipal hospital clinic participated in the instrument development ( n = 92), reliability ( n = 224), and assessment of patient characteristics phases ( n = 113) of the study. The DDPRQ was shown to be a reliable, practical instrument. Factor analysis revealed 5 dimensions with face validity. The DDPRQ classified 10.3–20.6% of patient encounters as “difficult” depending on the sample. Demographic characteristics, provider characteristics and most medical diagnoses were not associated with DDPRQ score. In contrast, difficult patients were characterized by psychosomatic symptoms, at least mild personality disorder, and Axis I (major) psychopathology, and most had more than one of these characteristics. The need to identify and understand these components of difficult patient behavior and to include the doctor-patient relationship in strategies for managing the difficult patient is discussed.