Exploring the Patient Perspective Caitlin Regner BS student researcher Jennifer Edgoose MDMPH Principal Investigator Jenniferedgoosefammedwiscedu Wisconsin Research amp Education Network ID: 536099
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Slide1
Difficult Patients: Exploring the Patient Perspective
Caitlin Regner, BS, student researcherJennifer Edgoose, MD/MPH, Principal Investigator (Jennifer.edgoose@fammed.wisc.edu)
Wisconsin Research & Education Network
September 21, 2012Slide2
Who are “difficult” patients?
What characteristics make a patient “difficult”?Mental health disorders Multiple symptomsChronic painFunctional impairmentUnmet expectationsLower satisfaction with careHigh users of health care services
Dr. Tom O’Dowd coined the term “
heartsink
patient
”
BMJ, 1988Slide3
Who defines them?
Providers with:Greater perceived workloadLower job satisfactionPoorer psychosocial scoresLess experience 9 versus 12 years (p=0.0002)Slide4
Why not just ignore them?
Photo by Chat-Lunatique
Because we can’t.
At least 1 in 6 patients are “difficult” and so we see them every day.Slide5
Research Question
If physicians find their relationships with difficult patients to be frustrating, if not overwhelming, ……do difficult patients also find these relationships to be
equally challenging
?Slide6
Study Design
Prospective cohort studyPatient inclusion criteria:Patients of 12 family medicine residents18 years or olderPatients were assigned coded numbers.Patients were notified of study at clinic check-in.Residents indicated difficult patients for that dayOnly coded numbers were submitted to maintain patient confidentialitySlide7
Study Design
Survey completed throughOption 1: interview by medical studentOption 2: written self completionBasic Demographic Data collected:GenderEnglish speaking or non-English speakingEthnicity/RaceEducation
Level
6
Questions developed
Graded on a
Likert
Scale from 1-7
Comments optional for each questionSlide8
Patient Questionnaire
In general, how easy is it for you to talk with your doctor?How easy do you think your medical problems are for your doctor to deal with? How much control do you feel you have over your health care decisions?How often do you feel your doctor addresses your concerns during your appointments? Slide9
Patient Questionnaire
How often does your doctor ask you non-medical questions to help understand your concerns during your appointments? (e.g. What is your occupation or job?; Where are you from?; Who do you live with?; Do you have access to a car?; Do you have problems paying for your medicines?) What can we change to do a better job of taking care of you at our clinic? Slide10
Results: Study enrollment profile
EligibleParticipated
Response
Rate
Total
267
161
60%
Non Difficult
220
129
59%
Difficult
47
32
68%
Total Difficult Patients: 19%Slide11
Results: Comparison of survey responses based on difficulty status
QuestionDifficult
Mean (95% CI)
N=32
Non-Difficult, Mean (95% CI)
N=129
P-
Value
a
1.
Ease of communication with provider
1.39 (1.11-1.68)
1.88 (1.65-2.11)
0.043*
2. Self-perception of medical
difficulty
2.63 (2.00-3.25)
2.60 (2.34-2.87)
0.95
3. Agency
in decision-making
3.08 (2.37-3.79)
2.48 (2.22-2.73)
0.057
4. Frequency
of medical concerns being addressed
1.48 (1.16-1.81)
1.71 (1.48-1.95)
0.35
5. Frequency of social concerns being addressed2.80 (2.11-3.48)2.73 (2.41-3.05)0.85
a
Two sample t-test comparison of means; *p < 0.05Slide12
“I do whatever she tells me. There’s no point in coming in if you don’t listen to your doctor.”“She is very worried about my health.”
“Is very willing to take time. I never feel rushed.”“I LOVE DR. X!”Results: Difficult Patient CommentsSlide13
“Dr. X asks excellent questions and is open to your questions.”
“My mom is 95 and speaks Spanish only, so there are some communication issues.”“Take care of the problems that I tell you are wrong, not what you think is wrong.” “Fewer questionnaires. This one wasn’t too bad.”Results: Non-Difficult Patient CommentsSlide14
Results: Gender profile of the study participants
MaleN=56
Female
N=
105
P-
value
a
Non-Difficult
49
80
Difficult
7
25
Difficult (%)
12.5%
23.8%
X=2.93; p=0.087
a
Chi-square statisticsSlide15
Results: Comparison of survey responses based on gender
QuestionMale,Mean (95% CI)N=56
Female,
Mean (95% CI)
N=105
P-
Value
a
1.
Ease of communication with provider
2.15 (1.74-2.57)
1.59
(1.40-1.77)
0.005**
2. Self-perception of medical
difficulty
2.98
(2.57-3.39)
2.41 (2.12-2.70)
0.024*
3. Agency
in decision-making
2.86 (2.43-3.30)
2.46 (2.15-2.76)
0.130
4. Frequency
of medical concerns being addressed
1.97 (1.55-2.39)
1.51 (1.31-1.71)
0.028*
5. Frequency of social concerns being addressed
2.72 (2.23-3.22)
2.76 (2.40-3.11)
0.910
a
Two
sample t-test comparison of means; *p < 0.05; **p < 0.01Slide16
Results: Racial profile for study participants
a
White
N=110
Black
N=31
Asian
N=10
American
Indian
N=3
P-
value
b
Non-Difficult
89
23
9
2
Difficult
21
8
1
1
Difficult (%)
19.1%
25.8%
10.0%
33.3%
X=1.66; p=0.65a 7 subjects did not select a race categoryb Chi-square statisticsSlide17
Results: Comparison of survey responses
based on raceQuestion
White,
Mean
(SD)
N=110
Black
Mean
(SD)
N=31
Asian,
Mean
(SD)
N=10
Am.Indian
,
Mean
(SD)
N=3
P-
Value
a
3. Agency
in decision-making
2.47
(
1.50 )
2.61
(1.67)
2.90 (1.73)5.50(2.12)0.049*4. Frequency of medical concerns being addressed 1.58 (1.05)
1.45
(1.18)
3.20 (2.30)
2.33
(1.15)
<0.001***
a
One-way Analysis of Variance (ANOVA)
* p < 0.05; *** p < 0.001Slide18
Results: Multivariate Analysis of Gender, Race, Education and Difficulty
Gender is a significant predictor for questions 1, 2 and 3 (p = 0.008; 0.015 and 0.046 respectively). Thus males report a harder time talking with their doctor; think they are more difficult for their doctor; and feel less in control of their health care decisions.Difficulty is NOT a predictor for these questions surrounding patient-doctor communication.Slide19
In summary
While providers of difficult patients are frustrated, patients are not. This is inconsistent with a previous study showing difficult patients are “less satisfied” than non-difficult patients but this study by Hinchey and Jackson applied the RAND-9 survey which looks at satisfaction from a standpoint not specific to the doctor-patient relationship but includes satisfaction about wait times, clinic location, phone scheduling, and other more clinic-process oriented inquiries.
Our survey may therefore explains why these challenging patients are more likely to keep returning to their providers
.Slide20
What does this mean?
We speculate that provider frustration lies in the incongruity of patient and physician perspectives about their relationship. Is the world view of patient and provider discordant due to educational differences, language and/or personality disorders?Schafer and Nowlis found that when analyzing 21 difficult patients, 33% of difficult patients had at least one personality disorder, particularly dependent personality disorders.
Do providers feel guilt about their feelings toward their patients and (over) compensate with extra time and energy? Slide21
Limitations of the study
Underpowered to state definitively : Difficult versus non-difficult patients do not feel differently about their ability to communicate effectively with their doctors.Limited number of control variablesonly controls for demographicsno socioeconomic or health problem indicators
Single clinic surveyed which may not be
generalizable
to a broader populationSlide22
Future research
Ethnicity requires further exploration due to low sample size; only 6 Hispanic patients participated in this study.Education level is undergoing further analysisSlide23
Photo by
giveawayboyPhoto by Chat-Lunatique
A study is underway
exploring a tool to assist
providers in working with difficult patients.
US
THEMSlide24
Thank you!
Northeast Clinical Staff and ResidentsJon Temte – SSRCA DirectorMary Beth Plane – Director, DFM Research ServicesLarissa Zakletskaia – Data Base Administrator (DFM)Slide25
Bibliography
Hahn SR, Kroenke K, Spitzer RL, Brody D, Williams JB, Linzer M, de Gruy FV 3rd. The difficult patient: prevalence, psychopathology, and functional impariment. J Gen Internal Medicine. 1996 Jan; 11(1):1-8. Mathers N, Jones N, Hannay
D.
Heartsink
patients: a study of their general practitioners.
Br
J Gen Pract
. 1995;45(395):293-296.
Hahn SR. Physical Symptoms and Physician-Experienced Difficulty in the Physician-Patient Relationship.
Ann Internal Med.
2001 May 1; 129(9 pt. 2):897-904.
Jackson
JL,
Kroenke
K. Difficult patient encounters in the ambulatory clinic. Arch Intern Med.
1999;159:1069-1075.
Hahn
SR, Thompson KS, Wills TA
et al
. The difficult doctor-patient relationship: somatization, personality and psychopathology.
J
Clin
Epidemiol
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1994:47:647-657.
Hinchey, SA, Jackson AL. A cohort study assessing difficult patient encounters in a walk-in primary care clinic, predictors and outcomes. J Gen Intern Med. 2011 Jan 25.
Ashworth
CD, Williamson P, Montano D. A scale to measure physician beliefs about psychosocial aspects of patient care.
Soc Sci Med. 1984;19:1235-1238.An PG, Rabatin JS, Manwell LB, Linzer M, Brown RL, Schwartz MD Burden of difficult encounters in primary care: data from the minimizing error, maximizing outcomes studey. Arch Int Med. 169:410-414.Edgoose JYC. Finding the person behind the patient. Presentation given at the Wisconsin Psychological Association 2012 Annual Convention, April 2012. Schafer S, Nowlis DP. Personalisty disorders among difficult patients. Arch Fam Med. 1998;7:126-129.Slide26
Questions?
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