AMA Journal of Ethics®

Illuminating the art of medicine

Journal of Ethics Header

AMA Journal of Ethics®

Illuminating the art of medicine

AMA Journal of Ethics. April 2017, Volume 19, Number 4: 381-390.
doi: 10.1001/journalofethics.2017.19.04.pfor1-1704.

Policy Forum

  • Print
  • |
  • View PDF

Roles of Physicians and Health Care Systems in “Difficult” Clinical Encounters

Physicians’ perceptions of “difficult” encounters are related to perceived workload, job satisfaction, and communication training, similar to burnout.

Elizabeth S. Goldsmith, MD, MS, and Erin E. Krebs, MD, MPH

Abstract

Physicians are, by definition, contributing partners in “difficult” patient-physician encounters. Although research on relevant physician qualities is limited, common themes mirror the more extensive literature on physician burnout. Focusing on primary care, we discuss physician-level factors in difficult encounters related to psychosocial attitudes and self-awareness, communication skills, and practice environments. Potential approaches to mitigating these factors include changes to medical training, such as structured peer case discussion groups and communication skills development, and changes to workplace environments, such as integrated mental health. Modifying physician-level factors in difficult encounters could ease perceived difficulties and improve outcomes for both physicians and patients.

Introduction

The “difficult patient” is a long-standing focus of medical scholarship and a common topic of discussion among physicians. “Difficult patients” have been defined primarily from the perspective of physicians, with most studies conducted in primary care settings. These studies are fairly consistent in their characterization of “difficult patients” as more likely to have multiple physical symptoms, high health care utilization, or functional impairment related to mental health diagnoses or substance dependence [1-3].

Of course, it takes two to tango, so what about “difficult doctors”? Here, we do not focus on physicians who commit malpractice or patient abuse but on the broad category of physicians most likely to be involved in subjectively difficult physician-patient encounters. We are not aware of studies that have identified such “difficult physicians” from a patient or third-party perspective. Instead, research on the physician side of difficult interactions has focused on physicians who report more “difficult patients” or difficult encounters than their colleagues do [1, 4-13]. Such “difficult doctors” might be more accurately described as physicians with a lower difficulty perception threshold. Regardless of what we call them, physicians who see relatively more encounters as difficult or frustrating have been the focus of a small number of studies from which a preliminary profile has emerged.

Research on the “Difficult Physician”

Physicians who perceive more encounters as difficult report having more negative attitudes about psychosocial aspects of medicine, less experience or training, and more work-related stress or dissatisfaction than their colleagues who report fewer difficult encounters. In the national Physicians Worklife Survey, physicians who considered high proportions of patients “generally frustrating to deal with” were more likely than their less-frustrated colleagues to be under 40 years of age, work more hours, have higher stress, and report caring for more patients with complex psychosocial and substance abuse problems [4]. In the Minimizing Error, Maximizing Outcomes Study, physicians who considered more encounters difficult were younger, more likely to report burnout, and less likely to report high job satisfaction than those who considered fewer encounters difficult [5]. A study of British general practitioners found that those reporting more “heartsink” patients had greater perceived workload, lower job satisfaction, and less training in counseling and communication skills than those reporting fewer heartsink patients [6]. Two studies examining physicians’ perceptions of walk-in visits found that physicians who considered more encounters to be difficult were more likely to have negative attitudes about psychosocial aspects of care [1, 7]. Qualitative research also has identified clinician traits that may contribute to clinicians’ tendency to perceive more encounters as difficult, many of which mirror the above findings: limited training in psychosocial care, difficulty setting boundaries, poor communication skills, emotional burnout, exhaustion, and perceived time pressure [8-13].

Physician Burnout and Physician-Perceived Difficulty

Findings from literature on physician-related factors in difficult encounters have intriguing parallels with research on physician burnout. Reported job dissatisfaction and burnout are themselves characteristics of physicians who perceive more encounters as difficult [4-6, 8-10, 13], and physician burnout and difficult physician-patient encounters might have similar causes and consequences. Physician burnout is a complex construct that incorporates dimensions of practice environment, social and cultural influences, and personal qualities [14, 15]. Although age, gender, and specialty do not consistently predict burnout [16, 17], limited self-awareness and inability to set professional and personal boundaries do [18]. These self-awareness and boundary challenges are also noted in physicians who perceive more encounters as difficult [8, 10-12]. Similarly, both physicians who report high burnout levels and physicians who report more difficult encounters describe their workplaces as characterized by limited control over scheduling and by high workload and time pressure [4-6, 17-20]. Improvement in factors common to physician burnout and physician-perceived difficult encounters may mitigate both of these pressing problems. In what follows, we focus on three key categories of physician-related qualities—psychosocial attitudes and self-awareness, communication skills, and practice environments—that contribute to difficult patient-physician encounters and on the teaching of skills that might reduce such encounters.

Psychosocial Attitudes and Self-Awareness

Negative attitudes toward psychosocial care, a common theme in existing research on difficult physicians, develop under mixed influences of medical training and individual physicians’ personal backgrounds [21, 22]. Medical training’s focus on pathophysiology has important implications for our approach to biopsychosocial problems: disproportionate attention to the biological aspects of these problems implies psychosocial aspects are secondary or separate—beyond our scope of practice [23]. Physicians’ own psychosocial attributes and self-awareness also matter for patient care [21, 22]. Some physicians are well aware of the cultural influences of race, ethnicity, gender, or sexual orientation on their own identities and might easily recognize tensions related to such influences within medical encounters [24]. Other physicians may have a hard time seeing their personal background as culturally relevant and recognizing how their backgrounds can influence patient interactions. In addition, some attributes of physicians who perceive more encounters as difficult, such as discomfort with uncertainty and inability to set boundaries [8, 10], are personal qualities that people can have difficulty identifying and modifying in themselves [22]—and that can worsen physician burnout if unaddressed [18]. Mentored development of self-awareness skills might help to reduce both physician burnout and perceived difficulty of encounters.

Several approaches have been developed to support clinicians in psychosocial insight and self-reflection in both educational and practice settings, including structured peer-case discussions such as modified Balint groups and Schwartz RoundsTM. Introduced by Michael and Enid Balint in the 1950s and grounded in psychoanalysis, Balint groups are small clinician groups that meet regularly to discuss patient interactions that participants have found difficult [25, 26]. Such groups aim to help physicians gain perspective on the role their own traits, attitudes, and behaviors play in difficult encounters and develop skills they can apply in future practice [25, 26]. Schwartz Rounds build similar principles into interactive case discussions in the larger, familiar grand rounds format, again focused on improving psychosocial and personal awareness for the sake of improved patient communication and care as well as physician support [27]. Interestingly, this emphasis on physician self-awareness and on completing the “emotional work” of difficult patient interactions [28] was fundamental to the concept of patient-centered care as described by Balint in 1969 [25]. Although evidence suggests structured group discussions may help build practical self-reflection habits into medical training and can ultimately improve job satisfaction [13, 27], approaches to improving physician self-awareness have remained on the margins of undergraduate and postgraduate medical training [29]. Further research is needed to determine whether their broad implementation could lead to substantial improvements in patient care and physician well-being [26]. More educational grounding in the biopsychosocial model of health, with structured training in self-awareness and communication skills, could produce physicians who find—and make—care less “difficult” for all involved.

Communication Skills

Success in a healing role—an important source of personal meaning and professional satisfaction for many doctors [8, 10, 18]—requires high-level communication skills. Physicians must convey nonjudgmental interest, empathy, and respect to build the therapeutic alliance while efficiently accomplishing clinical tasks [8, 10, 30, 31]. Insufficient communication and patient management skills can impede clinical care, compound physicians’ emotional work, and predispose physicians to burnout [11, 13, 14, 30].

Patient-centered communication and shared decision-making involve skills that have become increasingly well-defined through research [32, 33]. In many common symptomatic conditions, physician communication is the core intervention. For example, acute back pain guidelines recommend self-care advice and education but no diagnostic tests or specific treatments for most patients [34]. Training primary care physicians to effectively communicate this advice improves patient distress and reduces additional care seeking [35]. In many chronic conditions, such as diabetes and longitudinal HIV care, effective communication and perceived patient-centered care can promote adherence to prescribed treatments and behavior change recommendations [30, 36-41]. Furthermore, physicians who use communication skills effectively report more positive experiences of patient care, particularly with psychosocially challenging diagnoses [42, 43].

Communication skills can be taught effectively in medical training environments, both to medical trainees and to their teachers [33, 44]. Nevertheless, most medical schools and residency training programs do not have structured or specific approaches to improving communication skills or ensuring communication competency [32, 33]. More widespread training in techniques such as motivational interviewing, an interactive approach that elicits and engages patients’ intrinsic motivation to make personal changes, could improve physicians’ effectiveness in the management of a wide range of complex conditions requiring behavior change [45]. Outlining specific communication skills and tactics in policy documents, such as the residency program requirements issued by the Accreditation Council for Graduate Medical Education (ACGME), and building specific communication skills assessments into testing environments such as the objective structured clinical examination (OSCE), could motivate medical schools and residency programs to build up such training. Medical education developers seeking guidance can look to the training programs of our colleagues in clinical psychology and other mental health professions, which have prioritized communication skills development for some time.

Finally, it is a long-standing reality that medical training often occurs in low-resource environments—problematic for patients for many reasons and also for trainees and early-career physicians who might feel least equipped to handle complexities of care. The challenges of care in low-resource settings make it all the more important for training environments to impart communication and personal awareness skills that can have short- and long-term benefits to both physicians and patients [33].

Practice Environments

We must acknowledge the role of practice structure and resource limitations in generating both difficult encounters and physician burnout in primary care settings. Organizational interventions addressing workplace factors might be an effective means of reducing both physician burnout and difficult encounters, although research to date comprises a limited number of studies and a wide variety of approaches, ranging from simple scheduling changes to intensive multifaceted interventions [46].

Perceived time pressure is a common problem cited by both physicians who perceive more encounters as difficult and physicians with high burnout levels [6, 8, 10, 16, 17]. Assessment and management of complex biopsychosocial problems requires time that physicians often don’t have or cannot be paid for and can require skills beyond even optimally trained physicians’ scope. Even sophisticated interventions targeting psychosocial care are more likely to fail when time, reimbursement, and resources are lacking. For example, a recent trial of a structured behavioral/mental health risk assessment intervention in primary care clinics was successful in its goals of identifying many clinically relevant problems and triaging care but was ultimately found to be too time-consuming to be sustainable in real-world practice [47, 48].

Team-based approaches have the potential to achieve what individual physicians cannot. For example, integration of mental health professionals into primary care settings improves both quality of medical care and patient outcomes [49]. Although this might be a particularly promising approach to addressing psychosocial challenges in primary care, effects on physician outcomes such as burnout are in need of research. A more transformational approach to primary care, the patient-centered medical home model, is a complex organizational intervention intended to make care more team-based, coordinated, and accessible. The patient-centered medical home approach has demonstrated ability to improve patient experiences and delivery of preventive care services [50], but evidence on physician outcomes is somewhat conflicting. A 2013 systematic review found low-strength evidence of beneficial effects on primary care staff satisfaction [50]. More recently, however, one study found that the Veterans Health Administration’s patient-centered medical home transformation was associated with a modest increase in primary care physician turnover [51], and another study found no relationship between the level of medical home implementation and burnout prevalence among primary care employees [52]. More research is needed on physician outcomes of such organizational interventions and on the mechanisms by which these outcomes are achieved.

Conclusion

“Difficult doctors”—or, more accurately, physicians who often report frustration or difficulty with patient encounters—might have more negative attitudes about psychosocial aspects of medicine, less experience or training in relevant skills, and more work-related stress or dissatisfaction. These qualities mirror those found among physicians experiencing burnout and suggest opportunities for improvement in both training and practice organization. Graduate and postgraduate medical education present particularly important opportunities—too often missed—to ensure competency in self-reflection and critical communication skills; it is time to leverage training to teach these skills more pragmatically and effectively. Primary care practice changes, such as integrated mental health, the patient-centered medical home, and other organizational approaches might deliver better patient care and have the potential to improve physician well-being; more research is needed to determine when, where, and how such organizational changes can live up to this potential. Such training and practice changes merit further investigation to determine whether and how they might ease perceived difficulties for both physicians and patients, in line with the fundamental principles of patient-centered care.



References

  1. Hinchey SA, Jackson JL. A cohort study assessing difficult patient encounters in a walk-in primary care clinic, predictors and outcomes. J Gen Intern Med. 2011;26(6):588-594.
  2. Lin EH, Katon W, Von Korff M, et al. Frustrating patients: physician and patient perspectives among distressed high users of medical services. J Gen Intern Med. 1991;6(3):241-246.
  3. Hahn SR, Kroenke K, Spitzer RL, et al. The difficult patient: prevalence, psychopathology, and functional impairment. J Gen Intern Med. 1996;11(1):1-8.
  4. Krebs EE, Garrett JM, Konrad TR. The difficult doctor? Characteristics of physicians who report frustration with patients: an analysis of survey data. BMC Health Serv Res. 2006;6:128. http://bmchealthservres.biomedcentral.com/articles/10.1186/1472-6963-6-128. Accessed February 26, 2017.
  5. An PG, Rabatin JS, Manwell LB, Linzer M, Brown RL, Schwartz MD; MEMO Investigators. Burden of difficult encounters in primary care: data from the Minimizing Error, Maximizing Outcomes study. Arch Intern Med. 2009;169(4):410-414.
  6. Mathers N, Jones N, Hannay D. Heartsink patients: a study of their general practitioners. Br J Gen Pract. 1995;45(395):293-296.
  7. Jackson JL, Kroenke K. Difficult patient encounters in the ambulatory clinic. Arch Intern Med. 1999;159(10):1069-1075.
  8. Cannarella Lorenzetti R, Jacques CH, Donovan C, Cottrell S, Buck J. Managing difficult encounters: understanding physician, patient, and situational factors. Am Fam Physician. 2013;87(6):419-425.
  9. Haas LJ, Leiser JP, Magill MK, Sanyer ON. Management of the difficult patient. Am Fam Physician. 2005;72(10):2063-2068.
  10. Steinmetz D, Tabenkin H. The “difficult patient” as perceived by family physicians. Fam Pract. 2001;18(5):495-500.
  11. Levinson W, Roter D. Physicians’ psychosocial beliefs correlate with their patient communication skills. J Gen Intern Med. 1995;10(7):375-379.
  12. Elder N, Ricer R, Tobias B. How respected family physicians manage difficult patient encounters. J Am Board Fam Med. 2006;19(6):533-541.
  13. Kjeldmand D, Holmström I. Balint groups as a means to increase job satisfaction and prevent burnout among general practitioners. Ann Fam Med. 2008;6(2):138-145.
  14. Robertson HD, Elliott AM, Burton C, et al. Resilience of primary healthcare professionals: a systematic review. Br J Gen Pract. 2016;66(647):e423-e433.
  15. Matheson C, Robertson HD, Elliott AM, et al. Resilience of primary healthcare professionals working in challenging environments: a focus group study. Br J Gen Pract. 2016;66(648):e507-e515.
  16. Keeton K, Fenner DE, Johnson TR, Hayward RA. Predictors of physician career satisfaction, work-life balance, and burnout. Obstet Gynecol. 2007;109(4):949-955.
  17. Thomas NK. Resident burnout. JAMA Intern Med. 2004;292(23):2880-2889.
  18. Zwack J, Schweitzer J. If every fifth physician is affected by burnout, what about the other four? Resilience strategies of experienced physicians. Acad Med. 2013;88(3):382-389.
  19. Stevenson AD, Phillips CB, Anderson KJ. Resilience among doctors who work in challenging areas: a qualitative study. Br J Gen Pract. 2011;61(588):e404-e410.
  20. Jensen PM, Trollope-Kumar K, Waters H, Everson J. Building physician resilience. Can Fam Physician. 2008;54(5):722-729.
  21. Novack DH, Suchman AL, Clark W, Epstein RM, Najberg E, Kaplan C. Calibrating the physician. Personal awareness and effective patient care. JAMA. 1997;278(6):502-509.
  22. Breen KJ, Greenberg PB. Difficult physician-patient encounters. Intern Med J. 2010;40(10):682-688.
  23. Crowley-Matoka M, Saha S, Dobscha SK, Burgess DJ. Problems of quality and equity in pain management: exploring the role of biomedical culture. Pain Med. 2009;10(7):1312-1324.
  24. Frost HD, Regehr G. “I am a doctor”: negotiating the discourses of standardization and diversity in professional identity construction. Acad Med. 2013;88(10):1570-1577.
  25. Balint E. The possibilities of patient-centered medicine. J R Coll Gen Pract. 1969;17(82):269-276.
  26. Van Roy K, Vanheule S, Inslegers R. Research on Balint groups: a literature review. Patient Educ Couns. 2015;98(6):685-694.
  27. Lown BA, Manning CF. The Schwartz Center Rounds: evaluation of an interdisciplinary approach to enhancing patient-centered communication, teamwork, and provider support. Acad Med. 2010;85(6):1073-1081.
  28. Sinclair A, Nease D. The emotional work of dealing with patients. Health Aff (Millwood). 2010;29(10):1972-1973.
  29. Association of American Medical Colleges. Recommendations for clinical skills curricula for undergraduate medical education.
    https://members.aamc.org/eweb/upload/Recommendations%20for
    %20Clinical%20Skills%20Curricula%202005.pdf. Published 2005. Accessed February 26, 2017.
  30. Nicolaidis C. Police officer, deal-maker, or health care provider? Moving to a patient-centered framework for chronic opioid management. Pain Med. 2011;12(6):890-897.
  31. Boudreau JD, Cruess SR, Cruess RL. Physicianship: educating for professionalism in the post-Flexnarian era. Perspect Biol Med. 2011;54(1):89-105.
  32. Levinson W, Lesser CS, Epstein RM. Developing physician communication skills for patient-centered care. Health Aff (Millwood). 2010;29(7):1310-1318.
  33. Sibille K, Greene A, Bush JP. Preparing physicians for the 21st century: targeting communication skills and the promotion of health behavior change. Ann Behav Sci Med Educ. 2010;16(1):7-13.
  34. Chou R, Qaseem A, Snow V, et al; Clinical Efficacy Assessment Subcommittee of the American College of Physicians; American College of Physicians/American Pain Society Low Back Pain Guidelines Panel. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147(7):478-491.
  35. Traeger AC, Hübscher M, Henschke N, Moseley GL, Lee H, McAuley JH. Effect of primary care-based education on reassurance in patients with acute low back pain: systematic review and meta-analysis. JAMA Intern Med. 2015;175(5):733-743.
  36. Kaplan SH, Greenfield S, Ware JE Jr. Assessing the effects of physician-patient interactions on the outcomes of chronic disease. Med Care. 1989;27(suppl 3):S110-S127.
  37. Sherbourne CD, Hays RD, Ordway L, DiMatteo MR, Kravitz RL. Antecedents of adherence to medical recommendations: results from the Medical Outcomes Study. J Behav Med. 1992;15(5):447-468.
  38. Van Korff M, Gruman J, Schaefer J, Curry SJ, Wagner EH. Collaborative management of chronic illness. Ann Intern Med. 1997;127(12):1097-1102.
  39. Stewart M, Brown JB, Donner A, et al. The impact of patient-centered care on outcomes. J Fam Pract. 2000;49(9):796-804.
  40. Ciechanowski PS, Katon WJ, Russo JE, Walker EA. The patient-provider relationship: attachment theory and adherence to treatment in diabetes. Am J Psychiatry. 2001;158(1):29-35.
  41. Beach M, Keruly J, Moore R. Is the quality of the patient-provider relationship associated with better adherence and health outcomes for patients with HIV? J Gen Intern Med. 2006;21(6):661-665.
  42. Sullivan MD, Leigh J, Gaster B. Brief report: training internists in shared decision making about chronic opioid treatment for noncancer pain. J Gen Intern Med. 2006;21(4):360-362.
  43. Krebs EE, Bergman AA, Coffing JM, Campbell SR, Frankel RM, Matthias MS. Barriers to guideline-concordant opioid management in primary care—a qualitative study. J Pain. 2014;15(11):1148-1155.
  44. Branch WT Jr, Frankel R, Gracey CF, et al. A good clinician and a caring person: longitudinal faculty development and the enhancement of the human dimensions of care. Acad Med. 2009;84(1):117-125.
  45. VanBuskirk KA, Wetherell JL. Motivational interviewing with primary care populations: a systematic review and meta-analysis. J Behav Med. 2014;37(4):768-780.
  46. Panagioti M, Panagopoulou E, Bower P, et al. Controlled interventions to reduce burnout in physicians: a systematic review and meta-analysis. JAMA Intern Med. 2017;177(2):195-205.
  47. Krist AH, Phillips SM, Sabo RT, et al; MOHR Study Group. Adoption, reach, implementation, and maintenance of a behavioral and mental health assessment in primary care. Ann Fam Med. 2014;12(6):525-533.
  48. Phillips SM, Glasgow RE, Bello G, et al; MOHR Study Group. Frequency and prioritization of patient health risks from a structured health risk assessment. Ann Fam Med. 2014;12(6):505-513.
  49. Butler M, Kane RL, McAlpine D, et al. Integration of Mental Health/Substance Abuse and Primary Care. Rockville, MD: Agency for Healthcare Research and Quality; 2008. AHRQ publication 09-E003. https://www.ahrq.gov/downloads/pub/evidence/pdf/mhsapc/mhsapc.pdf. Accessed November 8, 2016.
  50. Jackson GL, Powers BJ, Chatterjee R, et al. The patient-centered medical home: a systematic review. Ann Intern Med. 2013;158(3):169-178.
  51. Sylling PW, Wong ES, Liu CF, et al. Patient-centered medical home implementation and primary care provider turnover. Med Care. 2014;52(12):1017-1022.
  52. Simonetti JA, Sylling PW, Nelson K, et al. Patient-centered medical home implementation and burnout among VA primary care employees [published online ahead of print November 23, 2016]. J Ambul Care Manage.

Elizabeth S. Goldsmith, MD, MS, is a physician fellow in clinical and health services research at the US Department of Veterans Affairs (VA) Center for Chronic Disease Outcomes Research and an epidemiology PhD student at the University of Minnesota School of Public Health in Minneapolis. She is interested in primary care and health disparities research, particularly concerning the effects of people’s life experiences and identities on chronic disease prevention, diagnosis, and management.

Erin E. Krebs, MD, MPH, is a core investigator at the US Department of Veterans Affairs (VA) Center for Chronic Disease Outcomes Research and an associate professor of medicine at the University of Minnesota in Minneapolis. A general internist with an active primary care practice, she also serves as the women’s health medical director for the Minneapolis VA Health Care System. Her research focuses on chronic pain management in primary care and benefits and harms of opioid analgesics.

Acknowledgements

This article is the result of work supported with resources and the use of facilities at the Minneapolis Veterans Administration Health Care System.

Courage and Compassion: Virtues in Caring for So-Called “Difficult” Patients, April 2017

Difficult Patient-Physician Relationships and the Risk of Medical Malpractice Litigation, March 2009

Do Physicians Have an Ethical Duty to Repair Relationships with So-Called “Difficult” Patients?, April 2017

Forty Years since “Taking Care of the Hateful Patient”, April 2017

Investing in Each Other—Balint Groups and the Patient-Doctor Relationship, July 2012

Lessons About So-Called “Difficult” Patients from the UK Controversy over Patient Access to Electronic Health Records, April 2017

Repairing “Difficult” Patient-Clinician Relationships, April 2017


Disclaimer

The contents of this article do not represent the views of the US Department of Veterans Affairs or the United States Government.

The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect the views and policies of the AMA.