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'Difficult' patients more likely to cause GP misdiagnosis

Patients displaying ‘difficult’ behaviour increase GPs’ risk of getting a diagnosis wrong, according to a study published today.

The study by researchers from the Erasmus University in Rotterdam, Netherlands and published in BMJ Quality & Safety concluded that GPs devote so much mental resources to their patients’ emotional behaviour that their decision-making becomes impaired.

But the researchers concluded that the patients’ difficult behaviour did not lead the GPs to spend less time with them.

The study cited previous research that found that around 15% of patients were ‘hard to see’, displaying argumentative or aggressive behaviour.

The GPC said that the study showed the need to work on reducing stress for GPs.

The study, on whether patients’ disruptive behaviours influence the accuracy of a doctor’s diagnosis, presented 63 GPs in their last year of medical training with six ‘vignettes’.

The vignettes depicted three diagnostically simple cases, and three diagnostically complex cases. The patients were a mix of ‘difficult’ – displaying distressing behaviours - and ‘neutral’.

The GPs were asked to evaluate the vignettes and make each patient’s diagnosis quickly, and then through deliberate reflection.

It found that doctors were 42% more likely to misdiagnose a ‘difficult’ patient than a ‘neutral’ one in a complex case and were 6% more likely to do so in a simple one.

The study concluded: ‘Disruptive behaviours displayed by patients seem to induce doctors to make diagnostic errors.

‘The emotion-triggering patient’s behaviours may capture so many of the doctors’ mental resources that fewer resources are left to deal with the clinical findings of the case, thereby impairing decision-making.’

It added: ‘Interestingly, the confrontation with difficult patients does however not cause the doctor to spend less time on such case.’

GPC clinical and prescribing chair Dr Andrew Green said: ‘One of the hardest skills GPs need to learn is the ability to put aside our personal feelings about patients and provide them all with the same level of service. This is not an easy thing to do, and we don’t always succeed, but it remains at the heart of our professionalism.

‘Bad things tend to happen when doctors are hungry, angry, late or tired, so it is sad that many GPs are forced to be in these states for much of their working day. Those with the power to change things need to place reducing these adverse factors at the centre of their policies.’


Readers' comments (23)

  • Vinci Ho

    Interesting Dutch report .
    Here, we also have 'difficult' health secretary more likely to cause GP ...........

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  • Although Hunt is displaying the most difficult behaviour possible, no doctor will misdiagnose his malign intentions.

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  • Did it really need studies to prove what everyone already knows?

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  • Difficult patients should just be kicked off the list. No messing about.

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  • Mr Mephisto

    In sporting terms difficult patients put you on "the back foot" - no wonder you end up slicing or miss-hitting your shots.

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  • |Anonymous | Medical student|15 Mar 2016 9:13am
    Define a difficult patient... A more complex patient with challenging behaviour, due to their medical condition, say dementia, autism? Is that how you would want a distressed member of your family treated? "You're just too difficult to deal with! Off the list you go!"

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  • The differential diagnosis of a patient with difficult behavioural changes might be more successfully addressed by a brief review of prescription drug history.
    There have been three recent television documentaries showing apparently conscientious doctors, seemingly unaware of, or uncertain about behavioural changes and extreme distress in the patient in front of them.
    One, a G.P. - commented to the patient, concern about obvious "restlessness".
    The clinical picture in each "cameo" was highly suggestive of SSRI, SNRI or "antipsychotic" induced severe ADR - movement disorder i.e. akathisia.
    Two cases were consulting with "expert psychiatrists"!
    All three patients were taking psycholeptic "medication.
    These highly probable movement disorders, which would be due to extra-pyramidal drug injuries, were apparently completely ignored by the "experts" - if indeed these, viewer - observed phenomena are akathisia.
    The G.P. showed a greater level of concerned observation.
    In view of the fact that searching the "yellow-card database", (13/03/2016) produces no result for "akathisia" identifies two major risks to patient safety and survival.
    Firstly, this "much more common than appreciated", life threatening, prescription ADR is often undiagnosed.
    Secondly, and as a sequel, it is under-reported.
    Far from "precipitate removal from the list" -(above) - why not apply the principles of good medical practice and a knowledge based approach to this vital differential diagnosis?
    How many times are the bizarre behaviour changes induced by SSRI's "managed" by increasing the dose, or changing to an alternative SSRI in an attempt to terminate an understandably difficult and frustrating consultation?
    The increasing toxicity is then mis-diagnosed as "psychotic depression" or other SMI.

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  • Very interesting research. I think we all knew this anyway but its surprising how much dealing with challenging complex patients reduces our ability to make accurate diagnoses.
    We always knew that some complex challenging patients were their own worst enemies.

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  • NHS Manager 9.54AM- Define a difficult patient- what he means is the one who wants MRI for Headache of 1 day, Antibiotic for sore throat of 1 day or referral to specialist for a minor ankle sprain

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