Correspondence |
Difficult patients or difficult encounters?
Sir,Dr Schattner1 stresses that research interest in the psychosocial and behavioural aspects of medical illness is rapidly growing, and extensive data have accumulated to support a bi-directional relationship of high clinical significance. In this field, communication studies on the doctor-patient relationship have been of interest to a growing number of researchers. Many studies investigate different aspects of communication. There are studies2 aimed at observing communication models (e.g. biomedical model, psychosocial or biopsychosocial model) or centeredness (e.g. patient-centered, doctor-centered or relation-centered models) and communications channels.
A topic receiving growing attention is a patient category associated with the distress they provoke in the professional, variously labelled3 ‘hateful patients’, ‘heartsink patients’, ‘frustrating patients’, ‘problem patients’ and ‘difficult patients’. ‘Difficult patients’ are those who provoke distress in their physician that exceeds the expected and accepted level of difficulty. Hahn3 estimated that 10% to 20% of consultations deal with such patients. Compared with ‘non-difficult’ patients, ‘difficult’ patients have twice the prevalence of significant psychopathological disorders (67% vs. 35%), an abrasive personality style or a pathological personality disorder (90%), and greater incidence of multiple physical symptoms.3
The ‘difficult patient’ category has been increasingly accepted in studies, but as this label has both practical and emotional implications, some researchers have preferred to focus on encounters and relationships, speaking of ‘difficult encounters’ or ‘difficult relations’.4 Even among studies that have used the ‘difficult patients’ category, many have emphasized how professionals may contribute themselves to the problems.4
Hall5 emphasizes the need of studies on concordance between the provider and patient on values and expectations associated with their respective roles. She underscores that providers' characteristics are studied much less than patient characteristics are, perhaps because of the relative difficulty of persuading the providers to be studied. She presents a paradox: it is often said that provider communication is studied more than patient communication. However, provider characteristics are studied much less than patient characteristics. There are several reasons for this. Providers probably are not eager to be personally studied and to spend time filling in questionnaires about themselves. Furthermore, an assumption sometimes seems to be made that only patients have emotions, attitudes, and characteristics (such as social class) that might influence the nature of communication. The ‘difficult patient’ category exacerbates this distortion, reinforcing only one side of a complex issue.
These considerations emphasize the importance of treating these studies as relational in nature, rather than looking at only one of the components. To apply this categorization to only patients or only doctors may provoke distortions, and the tendency to moral, rather than scientific, debate. To illustrate how this perspective arouses intense emotional reaction, it is only necessary to imagine the reaction to a symmetrically created ‘difficult doctor’ category.
Therefore, we consider it more appropriate to place the emphasis on difficult relationships and encounters, to investigate further the factors that contribute to these problems.
Department of Psychiatry Federal University of São Paulo São Paulo Brazil e-mail: mdemarco{at}psiquiatria.epm.br
References
1. Schattner A. The emotional dimension and the biological paradigm of illness: time for a change. Q J Med 2003; 96:617–21.
2. Roter DL. The enduring and evolving nature of the patient–physician relationship. Patient Educ Couns 2000; 39:5–15.[CrossRef][Web of Science][Medline]
3. Hahn SR. Physical Symptoms and Physician-Experienced Difficulty in the Physician–Patient Relationship. Ann Intern Med 2001; 134:897–904.
4. Steinmetz D, Tabenkin H. The ‘difficult patient’ as perceived by family physicians. Family Practice 2001; 18:495–500.
5. Hall JA. Some observations on provider–patient communication research. Patient Educ Couns 2003; 50:9–12.[Web of Science][Medline]
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