• Sherri A Hinchey and Jeffrey L Jackson.
• General Medicine Division, Tripler Army Medical Center, Honolulu, HI, USA.
• J Gen Intern Med. 2011 Jun 1; 26 (6): 588594588-94.

BackgroundPrevious studies have found that up to 15% of clinical encounters are experienced as difficult by clinicians.ObjectivesExplore patient and physician characteristics associated with being considered "difficult" and assess the impact on patient outcomes.DesignProspective cohort study.ParticipantsSeven hundred fifty adults presenting to a primary care walk-in clinic with a physical symptom.Main MeasuresPre-visit surveys assessed symptom characteristics, expectations, functional status (Medical Outcome Study SF-6) and the presence of mental disorders [Primary Care Evaluation of Mental Disorders, (PRIME-MD)]. Post-visit surveys assessed satisfaction (Rand-9), unmet expectations and trust. Two-week assessment included symptom outcome (gone, better, same, worse), functional status and satisfaction. After each visit, clinicians rated encounter difficulty using the Difficult Doctor-Patient Relationship Questionnaire (DDPRQ). Clinicians also completed the Physician's Belief Scale, a measure of psychosocial orientation.Key ResultsAmong the 750 subjects, 133 (17.8%) were perceived as difficult. "Difficult" patients were less likely to fully trust (RR = 0.88, 95% CI: 0.77-0.99) or be fully satisfied (RR = 0.78, 95% CI: 0.62-0.98) with their clinician, and were more likely to have worsening of symptoms at 2 weeks (RR = 0.75, 95% CI: 0.57-0.97). Patients involved in "difficult encounters" had more than five symptoms (RR = 1.8, 95% CI: 1.3-2.3), endorsed recent stress (RR = 1.9, 95% CI: 1.4-3.2) and had a depressive or anxiety disorder (RR = 2.3, 95% CI: 1.3-4.2). Physicians involved in difficult encounters were less experienced (12 years vs. 9 years, p = 0.0002) and had worse psychosocial orientation scores (77 vs. 67, p < 0.005).ConclusionBoth patient and physician characteristics are associated with "difficult" encounters, and patients involved in such encounters have worse short-term outcomes.

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