A cohort study assessing difficult patient encounters in a walk-in primary care clinic, predictors and outcomes

Taking the next step: How student reflective essays about difficult clinical encounters demonstrate professional identity formation

BACKGROUND

Difficult clinical encounters pose emotional and behavioural challenges for medical students. Unless resolved, they threaten students' professional competence and well-being. Learning how to humanistically interact with patients perceived as "difficult" is an important component of the developmental process that underlies professional identity formation (PIF).

METHODS

This study used thematic analysis to examine reflective essay data from the same set of students (N = 69), first in their third year and then in their fourth year of training at a US public medical school. Analysis focused on how student perceptions of patients', preceptors', and their own behaviour, attitudes, and emotions in difficult patient care situations evolved over time, and how such evolution contributed to their professional growth.

FINDINGS

Students identified clinical predicaments influenced by their own emotions and behaviour, as well as those of patients and preceptors. In response to patients perceived as angry, rude, and uncooperative, students described themselves and their preceptors primarily as engaging in routine medical behaviours, followed by expressions of empathy. These encounters resulted in residual emotions as well as lessons learned. Fourth-year students reported more empathy, patient-centeredness, and patient ownership than third-year students. While student-physicians grew in professionalism and compassion, they also noted unresolved distressing emotions post-encounter.

CONCLUSIONS

From third to fourth year, medical students undergo a process of professional growth that can be documented at a granular level through their perceptions of themselves, their patients, and their preceptors. Despite positive professional growth, students' lingering negative affect merits attention and support from clinical teachers.

The "Difficult" Inpatient, a Qualitative Study of Physician Perspectives

BACKGROUND

Previous studies exploring difficult inpatients have mostly focused on psychiatric inpatients.

OBJECTIVE

To explore the characteristics of difficult medicine inpatients.

DESIGN

Qualitative study using focus groups and semi-structured interviews. Transcripts were recorded, transcribed, and coded (MAXQDA) using thematic content analysis.

PARTICIPANTS

Medicine inpatient providers at a tertiary care facility.

KEY RESULTS

Our sample consisted of 28 providers (6 hospitalists, 10 medicine attendings, 6 medicine residents, and 6 interns). Theme 1: Provider experience: Difficult inpatients were time-consuming and evoked emotional responses including frustration and dysphoria. Theme 2: Patient characteristics: Included having personality disorders or mental health issues, being uncooperative, manipulative, angry, demanding, threatening, or distrustful. Difficult patients also had challenging social situations and inadequate support, unrealistic care expectations, were self-destructive, tended to split care-team messages, and had unclear diagnoses. Theme 3: Difficult families: Shared many characteristics of difficult patients including being distrustful, demanding, manipulative, threatening, or angry. Difficult families were barriers to care, disagreed with the treatment plan and each other, did not act in the patient's best interest, suggested inappropriate treatment, or had unrealistic expectations.

STRATEGIES

Approaches to dealing with difficult patients or families included building trust, being calm, and having a consistent message. Communication approaches included naming the emotion, empathetic listening, identifying patient priorities and barriers, and partnering.

CONCLUSIONS

Difficult patients induced emotional responses, dysphoria, and self-doubt among providers. Underlying personality disorders were often mentioned. Difficult patients and families shared many characteristics. Communication and training were highlighted as key strategies.

Barriers to healthcare and a 'triple empathy problem' may lead to adverse outcomes for autistic adults: A qualitative study

LAY ABSTRACT

Autistic people live with more mental and physical health conditions and, on average, die younger than non-autistic people. Despite widespread commitments to tackling these issues, autistic people still report various barriers to accessing healthcare. This article aims to explore the area in depth, from the perspective of autistic people. This research benefits from being led by autistic people, for autistic people - all of the researchers are autistic, and most of us are also medical doctors. Data, in the form of written comments and stories, were collected as part of a large survey. Here, we explored these for common themes and possible deeper meaning within the experiences. People who took part reported a variety of barriers. Here, our article gives voice to their stories, in their own words. Themes included: early barriers; communication mismatch; doubt - in oneself and from doctors; helplessness and fear; and healthcare avoidance and adverse health outcomes. Our findings allowed us to create a model that aimed to understand and explain the reported barriers in the context of the previously known consequences. We also built on wider autism theories to explain our findings in more depth.

Applying a Trauma-Informed Lens to Challenging Adolescent Encounters: A Faculty Development Session for Pediatricians

Introduction

Patient encounters perceived to be challenging are common and contribute to both suboptimal patient health outcomes and provider burnout. A trauma-informed care (TIC) approach to these encounters is critical, as many of the characteristics associated with challenging patient encounters can be linked to a history of trauma exposure.

Methods

Our team created and delivered a 1-hour synchronous virtual session intended to bolster provider knowledge of TIC principles and their application to challenging adolescent encounters. Participants were all faculty and staff engaged in pediatric primary care at an urban academic center, including physicians, nurse practitioners, psychologists, and social workers. The content was rooted in adult learning principles and included didactic components anchored to case-based learning with facilitated group discussions and opportunities for reflection. We used paired pre- and postsession self-assessments of provider knowledge, confidence, and practice related to TIC using Likert-scale and free-text questions. Descriptive statistics and a paired t test were used to determine the impact of the session on these metrics.

Results

In 24 paired surveys, there were statistically significant increases (p ≤ .001) in participant perceived knowledge, confidence, and practice, with 100% of participants having a statistically significant improvement in one or more of these domains. There were also strongly positive Likert-scale and free-text responses regarding content relevance and delivery.

Discussion

We demonstrate that a brief session can create improvement in pediatric providers' perceived knowledge about the application of TIC principles to challenging adolescent encounters as well as confidence in their ability to put these into practice.

Difficult medical encounters in oncology: What physicians need. An exploratory study

Objective

The objective of this study was to assess how often-medical oncology professionals encounter difficult consultations and if they desire support in the form of training.

Methods

In February 2022, a survey on difficult medical encounters in oncology, training and demographics was set up. The survey was sent to 390 medical oncology professionals part of the OncoZON network of the Southeast region of the Netherlands.

Results

Medical oncology professionals perceive a medical encounter as difficult when there is a dominant family member (n = 27), insufficient time (n = 24), or no agreement between medical professional and patient (n = 22). Patients involved in these encounters are most often characterized with low health literacy (n = 12) or aggressive behavior (n = 10). The inability to comprehend difficult medical information or perceived difficult behavior complicates encounters. Of the medical oncology professionals, 27-44% preferred a training as a physical group meeting (24%) or an individual virtual meeting (19%).

Conclusion

Medical oncology professionals consider dominant or aggressive behavior and the inability to comprehend medical information by patients during consultations as difficult encounters for which they would appreciate support.

Innovation

Our results highlight concrete medical encounters in need of specific education programs within daily oncology practice.

Association Between Physician Empathy and Difficult Patient Encounters: a Cross-Sectional Study

BACKGROUND

Physicians frequently experience patients as difficult. Our study explores whether more empathetic physicians experience fewer patient encounters as difficult.

OBJECTIVE

To investigate the association between physician empathy and difficult patient encounters (DPEs).

DESIGN

Cross-sectional study.

PARTICIPANTS

Participants were 18 generalist physicians with 3-8 years of experience. The investigation was conducted from August-September 2018 and April-May 2019 at six healthcare facilities.

MAIN MEASURES

Based on the Jefferson Scale of Empathy (JSE) scores, we classified physicians into low and high empathy groups. The physicians completed the Difficult Doctor-Patient Relationship Questionnaire-10 (DDPRQ-10) after each patient visit. Scores ≥ 31 on the DDPRQ-10 indicated DPEs. We implemented multilevel mixed-effects logistic regression models to examine the association between physicians' empathy and DPE, adjusting for patient-level covariates (age, sex, history of mental disorders) and with physician-level clustering.

KEY RESULTS

The median JSE score was 114 (range: 96-126), and physicians with JSE scores 96-113 and 114-126 were assigned to low and high empathy groups, respectively (n = 8 and 10 each); 240 and 344 patients were examined by physicians in the low and high empathy groups, respectively. Among low empathy physicians, 23% of encounters were considered difficulty, compared to 11% among high empathy groups (OR: 0.37; 95% CI = 0.19-0.72, p = 0.004). JSE scores and DDPRQ-10 scores were negatively correlated (r = -0.22, p < 0.01).

CONCLUSION

Empathetic physicians were less likely to experience encounters as difficult. Empathy appears to be an important component of physician perception of encounter difficulty.

Frequency of Difficult Patient Encounters in a Japanese University Hospital and Community Hospitals: A Cross-sectional Study

Objective Difficult patient encounters (DPEs) are defined as encounters with patients causing strong negative feelings in physicians. In primary care settings, DPEs account for approximately 15% of visits among outpatients. To our knowledge, this is the first epidemiological study of DPEs in Japan. Methods We conducted a survey of 8 physicians (5.0±2 years of clinical experience) who examined first-visit patients ≥15 years old with clinical symptoms at the Department of General Medicine in Chiba University Hospital and 4 community hospitals over a 2-month period since December 2015. Materials We evaluated 10-Item Difficult Doctor-Patient Relationship Questionnaire (DDPRQ-10) scores (DPE ≥31 points; non-DPE ≤30 points) and patient age, sex, and presence of psychological or social problems. Results The valid response rate was 98.9% (94/95) and 98.4% (189/192) in the university and community hospitals, respectively. The percentage of DPEs was 39.8% (37/93) and 15.0% (26/173) in the university and community hospitals, respectively; the percentage of DPEs was significantly higher at the university hospital than at the community hospitals (p<0.001). The proportion of patients with psychosocial problems was significantly higher in the DPE group than in the non-DPE group (93.7% vs. 40.4%, p<0.001). Conclusion Our findings were similar to those reported in primary care settings in other countries in community hospital outpatient and general internal medicine departments, where patients are mostly non-referrals, although the values were higher in university hospital general medicine departments, where patients were mostly referrals. Patients involved in DPEs have a high rate of psychological and social problems.

When Should Providers Defer versus Impose Their Views?

AbstractThis piece discusses perhaps the most agonizing ethical decision ethics consultants and other providers encounter. This is the extent to which providers should defer decisions to patients or to their proxy decision makers as opposed to imposing their own views as to what they think is ethically right. It discusses the most difficult issues these providers may encounter, especially when they wish to depart from authoritative bodies' standards or guidelines, and it presents initial steps providers may take to help patients and their families work together to resolve these dilemmas more harmoniously. It highlights how providers may inadvertently impose flawed biases on patients and families. Finally, it discusses how providers should take initiative with both parties to offer to help appeal when these avenues already exist and seek to establish the appellate procedures when they are absent.

Which patient and surgeon characteristics are associated with surgeon experience of stress during an office visit?

Objective

To determine clinician and patient factors associated with the surgeon feelings of stress, futility, inadequacy, and frustration during an office visit.

Methods

A survey-based experiment presented clinical vignettes with randomized patient factors (such as symptom intensity, the number of prior consultations, and involvement in a legal dispute) and feeling behind schedule in order to determine which are most related to surgeon ratings of stress, futility, inadequacy, and frustration on 11-point Likert scales.

Results

Higher surgeon stress levels were independently associated with women patients, multiple prior consultations, a legal dispute, disproportionate symptom intensity, and being an hour behind in the office. The findings were similar for feelings of futility, inadequacy, and frustration.

Conclusion

Patient factors potentially indicative of mental and social health opportunities are associated with greater surgeon-rated stress and frustration.

Innovation

Trainings for surgeon self-awareness and effective communication can transform stressful or adversarial interactions into an effective part of helping patients get and stay healthy by diagnosing and addressing psychosocial aspects of the illness.

Level of evidence

N/a.

Development and Testing of a Communication Intervention to Improve Chronic Pain Management in Primary Care: A Pilot Randomized Clinical Trial

OBJECTIVES

Effective communication skills are essential for optimally managing chronic pain and opioids. This exploratory, sequential mixed methods study tested the effect of a novel framework designed to improve pain-related communication and outcomes.

METHODS

Study 1 developed a novel 5-step framework for helping primary care clinicians discuss chronic pain and opioids with patients. Study 2 pilot tested an intervention for teaching this framework using standardized patient instructors-actors trained to portray patients and provide immediate clinician feedback-deployed during regular clinic hours. Primary care physicians were randomized to receive either the intervention or pain management recommendations from the Centers for Disease Control and Prevention. Primary outcomes were pain-related interference at 2 months and clinician use of targeted communication skills (coded from transcripts of audio-recorded visits); secondary outcomes were pain intensity at 2 months, clinician self-efficacy for communicating about chronic pain, patient experience, and clinician-reported visit difficulty.

RESULTS

We enrolled 47 primary care physicians from 2 academic teaching clinics and recorded visits with 48 patients taking opioids for chronic pain who had an appointment scheduled with an enrolled physician. The intervention was not associated with significant changes in primary or secondary outcomes other than clinician self-efficacy, which was significantly greater in the intervention group.

DISCUSSION

This study developed a novel framework and intervention for teaching clinician pain-related communications skills. Although the intervention showed promise, more intensive or multicomponent interventions may be needed to have a significant impact on clinicians' pain-related communication and pain outcomes.

Residents' Experiences of Negative Emotions toward Patients: Challenges to their Identities

PhenomenonMedical learners are more likely than practicing physicians to experience negative emotions toward some patients whom they find challenging, and medical students experience such emotions related to their identity as learners. Little is known about experiences of residents, who are further along in their physician identity formation and have greater autonomy and competence. We explored and characterized how residents understand their experiences of the phenomenon of feeling negative emotions toward patients in relation to their identities as residents. Approach: In 2018, 305 final-year obstetrics and gynecology residents were invited to participate in interviews, which we conducted until reaching theoretical sufficiency. In semi-structured interviews conducted by phone, we probed interactions when residents felt negative emotions toward patients, including reasons for their feelings related to their professional identities, strategies, and curricular desires. The authors coded data and identified patterns using thematic analysis. Findings: Nineteen residents were interviewed by phone. Residents experienced negative emotions toward patients because of challenges to their identities as: physicians - wanting respect and specific unexpected patient behaviors; learners - desiring complete autonomy and experiencing challenges with attending physicians; teachers - wanting to be a role model and protect junior learners; and workers - trying to complete tasks. Among the strategies used to manage feelings toward patients, they struggled with "venting", or complaining about patients, which was not always helpful and residents recognized as perceived negatively by students. They desired curricular support for these interactions such as debriefs and other supported reflection, faculty modeling, and communication skills training. Insights: Like medical students and physicians in practice, residents experience negative emotions toward patients, often because of and made more difficult by their identities as physicians, learners, teachers, and workers. Educators should support residents' reflections about these interactions, model compassionate behavior when feeling challenged by patients, and address unhealthy coping strategies.

Discovering strengths in patients with medically unexplained symptoms - a focus group study with general practitioners

BACKGROUND

When patients suffer medically unexplained symptoms, consultations can be difficult and frustrating for both patient and GP. Acknowledging the patient as a co-subject can be particularly important when the symptoms remain unexplained. One way of seeing the patient as a co-subject is by recognizing any among their strong sides.

OBJECTIVES

To explore GPs' experiences with discovering strengths in their patients with medically unexplained symptoms and elicit GPs' reflections on how this might be useful.

METHODS

Four focus-groups with 17 GPs in Norway. Verbatim transcripts from the interviews were analyzed by systematic text condensation.

RESULTS

Recollecting patients' strengths was quiet challenging to the GPs. Gradually they nevertheless shared a range of examples, and many participants had experienced that knowing patients' strong sides could make consultations less demanding, and sometimes enable the GP to provide better help. Identifying strengths in patients with unexplained symptoms required a deliberate effort on the GPs' behalf, and this seemed to be a result of a strong focus on biomedical disease and loss of function.

CONCLUSIONS

Acknowledging patients' strong sides can bolster GPs' ability to help patients with medically unexplained symptoms. However, the epistemic disadvantage of generalist expertise makes this hard to achieve. It is difficult for GPs to integrate person-centered perspectives with biomedical knowledge due to the privileged position of the latter. This seems to indicate a need for system-level innovations to increase the status of person-centered clinical work. Key pointsMUS is challenging for both patients and GPs mainly because of the incongruence between symptoms and the dominating biomedical model.GPs' focus on pathology and loss of function can prevent them from discovering patients' strengths.Awareness of patients' strengths can make consultations less demanding for GPs and enable them to provide better help.A conscious effort is needed to discover patients' strengths.

Challenging encounters in clinical dentistry: a qualitative study investigating online reviews of patient satisfaction with Norwegian dentists

OBJECTIVE

Mapping key themes that characterize challenging and positive encounters in dental practice using online reviews of patient satisfaction.

MATERIALS AND METHODS

11,764 online patient reviews of dental encounters, consisting of an overall satisfaction rating (1-5 stars) and a free-text response, were collected from the web-site Legelisten.no. The reviews were split into two sets: reviews from patients with low satisfaction (1-2 stars) representing challenging encounters vs. patients with high satisfaction (4-5 stars) representing positive encounters. A qualitative thematic analysis was used to analyse the text materials in the datasets.

RESULTS

Five key themes to both challenging and positive patient encounters were identified: (1) Interpersonal factors, (2) Patient factors, (3) Dentist factors, (4) Situational factors, and (5) Consequences. These themes are discussed in light of their role in challenging and positive patient encounters, as well as previous studies of online reviews and patient satisfaction.

CONCLUSIONS

Based on the patients' experiences with dental encounters, challenging encounters seem to arise when dentists' personality traits and communication skills fail to match the patients' expectations or preferences. It appears central to patient satisfaction that dentists are able to shift between different communication styles in order to adapt to the personality and preferences of the patients.

Hospitalists' perspectives on challenging patient encounters and physician well-being: A qualitative study

OBJECTIVE

Challenging patient encounters contribute to physician burnout, though little is known about how these impact hospitalists specifically. This study explores how hospitalists characterize challenging patient encounters and their impact on hospitalist well-being to inform organizational efforts.

METHODS

We conducted a qualitative, descriptive study with 15 physician hospitalist faculty at two locations, a tertiary academic and safety-net hospital, utilizing a conceptual framework based on the Stanford Wellness Framework for physician resilience around challenging patient encounters.

RESULTS

Two themes emerged: feelings of helplessness and time-consuming encounters. Helplessness was associated with systems issues, misaligned patient/provider goals, and violence. Time-consuming encounters were due to systems issues, misaligned goals requiring prolonged conversations, and patient factors. These factors were found to negatively impact hospitalist well-being. Resilience strategies included developing and teaching empathy and seeking expert/colleague opinion through debriefing, peer-to-peer interactions, and external resources.

CONCLUSIONS

Organizational strategies to support hospitalists in the context of challenging patient encounters require a multifaceted approach: improved system processes, fostering a local culture of empathy-building, and supporting peer-to-peer relationships and debriefing mechanisms.

PRACTICE IMPLICATIONS

Enhanced communication around system process improvements and culture of wellness, in addition to communication skills and mindfulness, could improve hospitalist well-being.

Negative Patient Descriptors: Documenting Racial Bias In The Electronic Health Record

Little is known about how racism and bias may be communicated in the medical record. This study used machine learning to analyze electronic health records (EHRs) from an urban academic medical center and to investigate whether providers' use of negative patient descriptors varied by patient race or ethnicity. We analyzed a sample of 40,113 history and physical notes (January 2019-October 2020) from 18,459 patients for sentences containing a negative descriptor (for example, resistant or noncompliant) of the patient or the patient's behavior. We used mixed effects logistic regression to determine the odds of finding at least one negative descriptor as a function of the patient's race or ethnicity, controlling for sociodemographic and health characteristics. Compared with White patients, Black patients had 2.54 times the odds of having at least one negative descriptor in the history and physical notes. Our findings raise concerns about stigmatizing language in the EHR and its potential to exacerbate racial and ethnic health care disparities.

Professionalism in Family Planning Care Workshop

INTRODUCTION

When clinicians feel negative emotions toward patients, providinge patient-centered care can be difficult. This can occur in family planning scenarios, such as when a provider is uncomfortable with a patient choosing abortion. The Professionalism in Family Planning Care Workshop (PFPCW), framed around professionalism values, used guided reflection to foster self-awareness and empathy in order to teach future providers to provide patient-centered care.

METHODS

In the PFPCW, learners discussed challenging patient interactions and family planning scenarios to develop self-awareness and identify strategies for maintaining therapeutic relationships with patients when they experience negative feelings toward them. We implemented the workshop across the United States and Canada and collected pre- and postsurvey data to evaluate program outcomes at Kirkpatrick evaluation levels of participant reaction and effects on learners' attitudes.

RESULTS

A total of 403 participants participated in 27 workshops in which pre- and postworkshop surveys (70% and 46% response rates, respectively) were administered. Sixty-five percent of the participants were residents, and 36% had previously participated in a similar workshop. The majority (92%) rated the PFPCWs as worthwhile. Participants valued the discussion and self-reflection components. Afterward, 23% reported that their attitudes toward caring for people with unintended pregnancy changed to feeling more comfortable. Participants said they would employ self-reflection and empathy in future challenging interactions.

DISCUSSION

In this pilot implementation study, our workshop provided learners with strategies for patient-centered care in challenging family planning patient interactions. We are currently modifying the workshop and evaluation program based on feedback.

Visit Linearity in Primary Care Visits for Patients with Chronic Pain on Long-term Opioid Therapy

BACKGROUND

Physicians and patients report frustration after primary care visits for chronic pain. The need to shift between multiple clinical topics to address competing demands during visits may contribute to this frustration.

OBJECTIVE

This study creates a novel measure, "visit linearity," to assess visit organization and examines whether visits that require less shifting back and forth between topics are associated with better patient and physician visit experiences. It also explores whether visit linearity differs depending on the following: (1) whether or not pain is a major topic of the visit and (2) whether or not pain is the first topic raised.

DESIGN

This study analyzed 41 video-recorded visits using inductive, qualitative analysis informed by conversation analysis. We used linear regression to evaluate associations between visit organization and post-visit measures of participant experience.

PARTICIPANTS

Patients were established adult patients planning to discuss pain management during routine primary care. Physicians were internal or family medicine residents.

MAIN MEASURES

Visit linearity, total topics, return topics, topic shifts, time per topic, visit duration, pain main topic, pain first topic, patient experience, and physician difficulty.

KEY RESULTS

Visits had a mean of 8.1 total topics (standard deviation (SD)=3.46), 14.5 topic shifts (SD=6.28), and 1.9 topic shifts per topic (SD=0.62). Less linear visits (higher topic shifts to topic ratio) were associated with greater physician visit difficulty (β=7.28, p<0.001) and worse patient experience (β= -0.62, p=0.03). Visit linearity was not significantly impacted by pain as a major or first topic raised.

CONCLUSIONS

In primary care visits for patients with chronic pain taking opioids, more linear visits were associated with better physician and patient experience. Frequent topic shifts may be disruptive. If confirmed in future research, this finding implies that reducing shifts between topics could help decrease mutual frustration related to discussions about pain.

Patient perspectives on health care provider practices leading to an axial spondyloarthritis diagnosis: an exploratory qualitative research study

BACKGROUND

The average time to a diagnosis for people with axial spondyloarthritis (axSpA) is 7-10 years. Delayed diagnosis may result in increased structural damage, worse physical function, and worse quality of life relative to patients with a timely axSpA diagnosis. Understanding patient experiences may provide insights for how to reduce diagnostic delays.

OBJECTIVE

To provide foundational knowledge about patient experiences with healthcare providers leading to an axSpA diagnosis.

METHODS

We conducted an exploratory qualitative research study with six focus groups interviews with participants recruited from three rheumatology clinics within the United States (MA (n = 3); CO (n = 2); PA (n = 1)) that included a total of 26 adults (10 females, 16 males) with rheumatologist confirmed diagnosis of axSpA in 2019. Focus groups were ~ 2 h, audio recorded, transcribed, and subject to dual coding. The codes reviewed were in relation to the patients' diagnostic experiences.

RESULTS

Patients described frustrating and lengthy diagnostic journeys. They recognized that the causes of diagnostic delays in axSpA are multifactorial (e.g., no definitive diagnostic test, disease characteristics, lack of primary care provider's awareness about axSpA, trust). Patients described how doctors minimized or dismissed complaints about symptoms or told them that their issues were psychosomatic. Patients believed the healthcare system contributed to diagnostic delays (e.g., lack of time in clinical visits, difficulty accessing rheumatologists, health insurance challenges). Advice to physicians to reduce the diagnostic delay included allowing time for patients to give a complete picture of their illness experience, listening to, and believing patients, earlier referral to rheumatology, provision of HLA-B27 gene testing, and that physicians need to partner with their patients.

CONCLUSIONS

Patients desire a definitive test that could be administered earlier in the course of axSpA. Until such a test is available, patients want clinicians who listen to, believe, and partner with them, and who will follow them until a diagnosis is reached. Educating primary care clinicians about guidelines and referral for diagnosis of axSpA could reduce diagnostic delay.

Recognising autism in healthcare

Recognition of autism and the associated co-occurring physical and mental health issues has increased over recent years. However, undergraduate and postgraduate curricula take time to adapt and to impact on what is delivered in training so healthcare professionals, including doctors, report little training on these topics. Doctors need to know when someone might be autistic in order to respond to them appropriately. This article sets out the reasons why recognition of autism is important and the positive impacts of recognising and understanding autism on health outcomes, service delivery and patient experience. The negative consequences of not recognising autism or understanding the impact of autistic traits on the person are also explored. A companion article then covers how practice can be made more appropriate for autistic people to improve outcomes.

Patients with Ehlers-Danlos syndrome on the diagnostic odyssey: Rethinking complexity and difficulty as a hero's journey

Patients with hypermobile Ehlers-Danlos syndrome, an hereditary disorder of the connective tissue, often face a long and difficult diagnostic odyssey in pursuit of a name for their condition. Clinicians may dismiss subjective symptoms of chronic pain, thus prolonging patients' odysseys and worsening their care and satisfaction and creating antagonisms in the patient-provider relationship. A greater understanding of patient experiences is necessary in order to decrease burdens of this relationship and to improve care. To that end, we conducted 22 in-depth, semistructured interviews with individuals who had undergone this diagnostic odyssey. We focused on the impact that the odyssey had on their lives, both inside and outside the clinic. Through narrative analysis, we found a sort of "hero's journey" in the description of their cases, highlighting issues of uncertainty and integration as well as honoring their struggles. Interviewees had encountered difficulties in working with clinicians, in multiplying symptoms, and in negative psychosocial consequences. Attention to patients' lived experience may help to build empathy and understanding for the difficult and complex clinical situation presented by Ehlers-Danlos syndrome. Using the hero's journey as a lens onto this experience allows for a more patient-centered approach to this understanding and has potential value for comprehension of other complex diseases and invisible illnesses.

Personal Experiences with Diagnostic Delay Among Axial Spondyloarthritis Patients: A Qualitative Study

INTRODUCTION

On average, patients with axial spondyloarthritis (axSpA) suffer from symptoms up to 13 or more years before diagnosis, contributing to psychological distress and healthcare burden METHODS: We conducted six semi-structured focus groups with 26 axSpA patients (from 3 rheumatology practices located in the states of Massachusetts, Colorado, and Pensylvania, USA) exploring early disease and diagnostic experiences. Verbatim transcripts were coded using a start list with emerging thematic codes added. A qualitative thematic analysis was performed RESULTS: Many participants described meandering and frustrating diagnostic journeys. Participants reported that intermittent axSpA symptoms and idiopathic pain contributed to physician confusion and delay in patients seeking care. Participants were sometimes perceived as somaticizing, drug-seeking, or "crazy." Diagnostic delay led to frustration and mental suffering. Doctors "giving up" was considered profoundly negative. Stories of symptoms fell into five areas: (1) pain; (2) stiffness; (3) impact on sleep; (4) impact on daily activities; and (5) changes with weather. Self-advocacy and family advocacy were considered essential. Participants suggested wider use of HLA-B27 testing and development of a definitive diagnostic test CONCLUSION: Most participants described significant suffering prior to axSpA diagnosis which could have been avoided with earlier intervention. Further research on the early disease experiences of axSpA patients is needed.

Agenda setting and visit openings in primary care visits involving patients taking opioids for chronic pain

Background

Agenda setting is associated with more efficient care and better patient experience. This study develops a taxonomy of visit opening styles to assess use of agenda and non-agenda setting visit openings and their effects on participant experience.

Methods

This observational study analyzed 83 video recorded US primary care visits at a single academic medical center in California involving family medicine and internal medicine resident physicians (n = 49) and patients (n = 83) with chronic pain on opioids. Using conversation analysis, we developed a coding scheme that assessed the presence of agenda setting, distinct visit opening styles, and the number of total topics, major topics, surprise patient topics, and returns to prior topics discussed. Exploratory quantitative analyses were conducted to assess the relationship of agenda setting and visit opening styles with post-visit measures of both patient experience and physician perception of visit difficulty.

Results

We identified 2 visit opening styles representing agenda setting (agenda eliciting, agenda reframing) and 3 non-agenda setting opening styles (open-ended question, patient launch, physician launch). Agenda setting was only performed in 11% of visits and was associated with fewer surprise patient topics than visits without agenda setting (mean (SD) 2.67 (1.66) versus 4.28 (3.23), p = 0.03).

Conclusions

In this study of patients with chronic pain, resident physicians rarely performed agenda setting, whether defined in terms of “agenda eliciting” or “agenda re-framing.” Agenda setting was associated with fewer surprise topics. Understanding the communication context and outcomes of agenda setting may inform better use of this communication tool in primary care  practice.

Development of Grip self-help: An online patient-tailored self-help intervention for functional somatic symptoms in primary care

Functional Somatic Symptoms (FSS) are somatic symptoms for which no somatic cause can be identified despite adequate diagnostic testing. FSS are common, costly, and disabling, and treatment options are limited. Psychotherapy is one of few evidence-based treatments for FSS. Yet, this form of therapy is not widely used, since it is usually reserved for severe symptoms, requires a highly trained therapist, and is not well accepted by patients. The current paper describes the development of the online intervention 'Grip self-help' and provides a description of the intervention itself. Grip self-help is an early intervention for mild to moderate FSS in primary care, which aims to reduce somatic symptoms and improve quality of life. In the Grip self-help intervention, patients fill out a set of online questionnaires exploring unhelpful cognitions, emotions, behaviors, and social factors associated with the symptoms. Using this information, a personal profile is generated, identifying factors that might maintain FSS in that individual. As a next step, patients are offered online self-help exercises that are tailored to these factors. Guidance is offered by a primary care professional. The intervention will ultimately result in a personalized self-help guide, composed of texts that are extracted from the exercises patients found useful during the intervention. Grip self-help is the first intervention for FSS combining the concepts of e-health, self-help, and personalized medicine. Guided by a primary care professional, patients are offered an easily accessible, yet highly personalized treatment. Grip self-help thus has the potential to meet the needs of the large group of patients with mild to moderate FSS.

Practice Makes Perfect: Training Residents in Difficult Encounters

INTRODUCTION

A significant number of patient encounters are perceived to be difficult. Residents receive little training in managing difficult clinical encounters, and lectures or traditional simulated patient encounters may not provide the opportunity to practice learned skills. Deliberate practice has been shown to be effective in training clinical skills. We used simulation with deliberate practice and feedback to train residents in difficult patient encounters.

METHODS

Twelve second-year residents in the University of Missouri Family and Community Medicine residency program participated in simulated patient encounters with difficult patients. The patients represented challenging personalities identified in a resident focus group. Resident performance was scored by the standardized patient, resident observers, and faculty instructor. Following debriefing with feedback, the residents repeated the clinical encounter incorporating the feedback. The sessions were scored again by the same individuals.

RESULTS

All scores improved from the first to second clinical encounter, except those that were at 100% for both encounters. The most improvement seen was in standardized patient scores. The smallest improvement was in provider self-scores.

CONCLUSION

Resident performance improved according to all observers and their own self-assessments. These results are consistent with other studies that have demonstrated the effectiveness of deliberate practice in improving skills in other areas of medical education. Simulation-based learning with deliberate practice has the potential to improve resident management of difficult patient encounters.

Characterizations of motivation and identity in medical students' reflections about challenging patient interactions

Purpose: Students' negative emotions in patient interactions can relate to their learning motivation and identity. Educators can support learning from these interactions by advocating for reflection. We explored how students, in reflection essays about emotionally difficult patient interactions that challenged their notions of professionalism, described aspects of motivation and identity. Materials and Methods: All third-year medical students on the ob-gyn clerkship complete written reflections about a "clinical situation that challenged or affirmed your professionalism." We conducted directed content analysis of essays (academic years 2014-2017) using relevant theories (self-determination, goal orientation and identity formation) based on previous work and organized the data into categories. Results: In 265 essays (of 396, 67%), students described patient interactions that challenged their notions of professionalism, of which 90% included descriptions of their emotions. When reflecting on these interactions, students described psychological needs acknowledged in self-determination theory, competence, autonomy in patient care and connection to the team. Students indicated challenges in identity when advocating for patients due to team hierarchy and evaluation concerns. Conclusions: Reflection essays about difficult patient interactions allow students to explore emotions, motivation and identity. They help educators understand whether the clinical learning environment is meeting students' needs to support learning in challenging interactions.

Fifteen-minute consultation: Attachment as a model to understand and manage difficult doctor-parent relationships

Paediatricians are often faced with managing the child who is unwell, and parents, who may present in ways that are difficult to manage. Difficult behaviours can range from those who disregard their child's needs, to those who overstate their child's minor symptoms, to those who ask for help but then refuse to accept it. This paper gives a framework using attachment theory to help paediatricians recognise, understand and deal with difficult doctor-parent interactions in a way that is appropriate and sensitive. Making changes to the way we communicate with parents can improve outcomes for the child, the family and the doctor's own well-being.

Behaviours of healthcare professionals towards difficult patients: A structural equation modelling study

BACKGROUND

Some patients are stigmatised as difficult patients by healthcare professionals. This phenomenon has great many negative consequences. The behaviours of healthcare professionals towards difficult patients are important.

OBJECTIVE

To explore the behaviours of all healthcare professionals towards difficult patients.

RESEARCH DESIGN

This study was based on a cross-sectional research design using structural equation modelling.

PARTICIPANTS AND RESEARCH CONTEXT

Two hundred and fifty-four healthcare professionals were involved in the study in Turkey. 'Participant Information Form' and the 'Healthcare Professionals Behaviour Assessment Questionnaire For Difficult Patient' were used to collect data from participants.

ETHICAL CONSIDERATION

Ethical approval was obtained from Gazi University Ethics Committee for the study. Informed consent of the participants in the study was taken and the confidentiality of the participants was ensured.

FINDINGS

It was explored that the behaviours of healthcare professionals towards difficult patients were categorised into ethical, supportive and negative. The highest mean score was supportive behaviour and the least mean score was negative. According to structural equation modelling, the most important predictor of difficult encounters was an ethical dimension. One-unit increase in ethical behaviour contributed to 0.92 unit increase in positive patient behaviour.

DISCUSSION

Patients generally are perceived as 'difficult patient' by the healthcare professionals, so the patients' treatment and care services are affected negatively due to healthcare professionals' negative beliefs and attitudes. The healthcare professionals should behave supportively towards difficult patients.

CONCLUSION

Healthcare professionals should be aware of management strategies in dealing with difficult encounters. The behaviours of healthcare professionals should be improved in a positive way and awareness of ethical dimension of difficult encounters should be increased.

Usefulness of a short training seminar on how to handle difficult patients in simulated education

OBJECTIVE

To evaluate a short-time simulation training seminar on how to handle difficult patients using professional simulated patients (SPs) such as actors.

PARTICIPANTS

Sixty-three second-year residents at Chiba University Hospital between 2015 and 2017 who only attended the seminar once.

INTERVENTION

The participants were divided into small groups, each of which was assigned a supervisory doctor as facilitator. Those who were playing the doctor's role enacted a medical interview with an SP. After the interview, the facilitator, the SP, and the observing residents participated in a debriefing while watching a recorded video of the interview.

OUTCOME MEASURES

Pre- and post-seminar questionnaires using a 7-point Likert scale (from 1: strongly disagree to 7: strongly agree) were used to examine the differences in "confidence in ability to handle difficult patients" and "learning motivation to handle difficult patients". The two items examined by both pre- and post-seminar questionnaires, were analyzed by a paired t-test. The residents were also surveyed on their satisfaction with the seminar, acquisition of new knowledge, and impressions and comments (free-text answers).

RESULTS

The findings of the questionnaire showed a significant post-seminar increase in confidence (3.1±1.6 to 4.0±1.5 [p<0.01]) and learning motivation (5.3±1.8 to 5.8±1.5 [p<0.01]) as well as high levels of satisfaction (5.8±1.1) with the seminar and acquisition of knowledge (5.7±1.3). Some residents further reported that the seminar led to self-review and was valuable for their future clinical practice.

CONCLUSION

Our seminar on how to handle difficult patients was perceived as effective, as evaluated by the questionnaire, despite the short duration of the session. Factors potentially contributing to this effectiveness include the use of actors as SPs and the post-interview debriefing with feedback from the SP, colleagues, and facilitator.

Patient-physician relationship and use of gut feeling in cancer diagnosis in primary care: a cross-sectional survey of patients and their general practitioners

OBJECTIVES

To examine whether the quality of the patient-physician relationship, assessed by the general practitioner (GP) and the patient, associates with GPs' use of gut feeling (GF) in cancer diagnosis.

DESIGN

Cross-sectional questionnaire survey of cancer patients and their GPs.

SETTING

Danish primary care.

PARTICIPANTS

Newly diagnosed cancer patients and their GPs. Patients completed a questionnaire and provided the name of the GP to whom they have presented their symptoms. The named GP subsequently received a questionnaire.

PRIMARY AND SECONDARY OUTCOME MEASURES

GPs' use of GF in the diagnostic process for the particular patient. GPs who answered that they used their GF 'to a high degree' or 'to a very high degree' were categorised as 'used their GF to a great extent'. GPs who answered that they used their GF 'to some degree', 'to a limited degree' or 'not at all' were categorised as 'limited or no use of GF'.

RESULTS

GPs were less likely to use GF when they assessed relational aspects of the patient encounter as difficult compared with less difficult (OR=0.67; 95% CI 0.46 to 0.97). The physician-reported level of empathy was positively associated with use of GF (OR=2.60; 95% CI 1.60 to 4.22). The lower use of GF in difficult encounters was not modified by level of empathy.

CONCLUSIONS

Experiencing relational aspects of patient encounter as difficult acted as a barrier for the use of GF in cancer diagnosis. Although physician-rated empathy increased use of GF, high empathy did not dissolve the low use of GF in difficult encounters. As diagnosis of cancer is a key challenge in primary care, it is important that GPs are aware that the sensitivity of cancer-related GF is compromised by a difficult patient-physician relationship.

Are we preparing future doctors to deal with emotionally challenging situations? Analysis of a medical curriculum

OBJECTIVE

Skilful communication by doctors is necessary for healthcare delivery during emotionally challenging situations. This study analyses a medical curriculum for the frequency and intensity of teaching content on communication in emotionally challenging situations.

METHODS

A questionnaire with 31 questions ("EmotCog31") was used to evaluate teaching sessions at 17 departments of a medical school for one semester.

RESULTS

Teaching content on communication in emotionally challenging situations was observed in 62 of 724 (∼nine percent) teaching sessions. Fifty-six percent of these sessions were within psychosocial specialisations. Lecturers used mental diseases as teaching topics four times more than somatic diseases. Forty-two percent of the 62 sessions were large-group while fifty-eight percent were small-group, interactive sessions. Clinical examples were used in sixty-nine percent of these sessions. Eighty-one percent of the handouts provided and sixty-six percent of simulated patient scenarios used were rated as helpful. Two-thirds of teaching sessions were rated positively when they included practical context.

CONCLUSION

There was a considerable lack of teaching on communication skills in an emotional context. Teaching was limited to psychosocial specialties, reducing the impact of available knowledge for other medical specialties.

PRACTICE IMPLICATIONS

More interactive, practically oriented teaching methods are useful for teaching emotional communication skills.

Challenges to patient centredness - a comparison of patient and doctor experiences from primary care

Background

We designed this observational study to investigate the level of patients’ and doctors’ ratings of patient-centred aspects of the primary care consultation.

Methods

Questionnaire study with patients and doctors. Consecutive patients in a primary care setting and 16 doctors responding post visit. Results are presented as proportions with 95% confidence intervals.

Results

411 questionnaires, 223 from patients and 188 from doctors, covered 251 consultations. Both patients and doctors gave the highest possible estimations on the aspects of patient-centred communication and satisfaction less frequently when the patient had other reasons for visit than purely somatic. Unlike the doctors’ estimations, the frequency of highest possible estimations in patient responses dropped if the patients had two to six reasons for visit rather than one. Among the six patient-centred aspects, both patients and doctors gave the highest possible estimation least frequently on the aspect of shared decision-making.

Conclusion

The results suggest that the nature of the reason, as well as the number of reasons for visit, interferes with the doctors’ level of patient-centred communication. Our results furthermore confirm the findings of previous studies that doctors insufficiently involve patients in their care.

Electronic supplementary material

The online version of this article (10.1186/s12875-019-0959-y) contains supplementary material, which is available to authorized users.

What Do Medical Students Do and Want When Caring for "Difficult Patients"?

Phenomenon: Medical students, like physicians, experience negative emotions such as frustration when interacting with some patients, and many of these interactions occur for the first time during clinical clerkships. Students receive preclinical training in the social and behavioral sciences, often including learning about "difficult patient" interactions, yet little is known about their desire for training during clinical education. We explored students' strategies in these difficult clinical interactions, whether they felt prepared by the curriculum, and what support they would have liked. These data inform proposed strategies for supporting clinical learning. Approach: We interviewed 4th-year students about interactions with patients toward whom they felt negative emotions and sought to identify strategies and supports needed in these interactions. Interviews ended when theoretical sufficiency was achieved. We used qualitative content analysis to organize strategies into themes about areas benefiting from curricular supports. We mapped students' desired curricular support examples to cognitive apprenticeship teaching methods-modeling, coaching, reflection, scaffolding, exploration, and articulation-and aligned them with traditional pedagogical techniques. Findings: We interviewed 26 medical students (44 volunteered/180 invited). Their strategies formed five themes: finding empathy (with a subtheme of focusing on social determinants of health), using learned communication approaches, anticipating challenging interactions, seeking support, and considering it an opportunity for more responsibility. Students described ideal clinical teaching, including postinteraction debriefs with an emphasis on validating their emotional reactions and challenges. Students mentioned all cognitive apprenticeship teaching methods, most prominently modeling (observing supervisors in such interactions) and supported oral reflection. They also identified a need for faculty and resident development to enact these teaching methods. Insights: Although students use some learned strategies in interactions in which they feel negative emotions toward patients, they desire more preparation and support during their clinical rotations. Their desires map to traditional pedagogical techniques and to methods of cognitive apprenticeship. Our findings point to the need to use these techniques to enhance clinical learning for students who experience emotionally challenging patient interactions.

Family physicians' views on participating in prevention of major depression. The predictD-EVAL qualitative study

BACKGROUND

The predictD intervention, a multicomponent intervention delivered by family physicians (FPs), reduced the incidence of major depression by 21% versus the control group and was cost-effective. A qualitative methodology was proposed to identify the mechanisms of action of these complex interventions.

PURPOSE

To seek the opinions of these FPs on the potential successful components of the predictD intervention for the primary prevention of depression in primary care and to identify areas for improvement.

METHOD

Qualitative study with FPs who delivered the predictD intervention at 35 urban primary care centres in seven Spanish cities. Face-to-face semi-structured interviews adopting a phenomenological approach. The data was triangulated by three investigators using thematic analysis and respondent validation was carried out.

RESULTS

Sixty-seven FPs were interviewed and they indicated strategies used to perform the predictD intervention, including specific communication skills such as empathy and the activation of patient resources. They perceived barriers such as lack of time and facilitators such as prior acquaintance with patients. FPs recognized the positive consequences of the intervention for FPs, patients and the doctor-patient relationship. They also identified strategies for future versions and implementations of the predictD intervention.

CONCLUSIONS

The FPs who carried out the predictD intervention identified factors potentially associated with successful prevention using this program and others that could be improved. Their opinions about the predictD intervention will enable development of a more effective and acceptable version and its implementation in different primary health care settings.

Communication about chronic pain and opioids in primary care: impact on patient and physician visit experience

Patients and physicians report that communication about chronic pain and opioids is often challenging, but there is little empirical research on whether patient-physician communication about pain affects patient and physician visit experience. This study video recorded 86 primary care visits involving 49 physicians and 86 patients taking long-term opioids for chronic musculoskeletal pain, systematically coded all pain-related utterances during these visits using a custom-designed coding system, and administered previsit and postvisit questionnaires. Multiple regression was used to identify communication behaviors and patient characteristics associated with patients' ratings of their visit experience, physicians' ratings of visit difficulty, or both. After adjusting for covariates, 2 communication variables-patient-physician disagreement and patient requests for opioid dose increases-were each significantly associated with both worse ratings of patient experience and greater physician-reported visit difficulty. Patient desire for increased pain medicine was also significantly positively associated with both worse ratings of patient experience and greater physician-reported visit difficulty. Greater pain severity and more patient questions were each significantly associated with greater physician-reported visit difficulty, but not with patient experience. The association between patient requests for opioids and patient experience ratings was wholly driven by 2 visits involving intense conflict with patients demanding opioids. Patient-physician communication during visits is associated with patient and physician ratings of visit experience. Training programs focused on imparting communication skills that assist physicians in negotiating disagreements about pain management, including responding to patient requests for more opioids, likely have potential to improve visit experience ratings for both patients and physicians.

Difficult patient-doctor encounters in a Swiss university outpatient clinic: cross-sectional study

INTRODUCTION

Previous research has shown that multiple factors contribute to healthcare providers perceiving encounters as difficult, and are related to both medical and non-medical demands.

AIM

To measure the prevalence and to identify predictors of encounters perceived as difficult by medical residents.

DESIGN AND SETTING

Cross-sectional study at the Department of Ambulatory Care and Community Medicine (DACCM), a university outpatient clinic with a long tradition of caring for vulnerable patients.

METHOD

We identified difficult doctor-patient encounters using the validated Difficult Doctor-Patient Relationship Questionnaire (DDPRQ-10), and characterised patients using the patient's vulnerability grid, a validated questionnaire measuring five domains of vulnerability, both completed by medical residents after each encounter. We used a multiple linear regression model with the outcome variable as the DDPRQ-10 score, controlling for resident characteristics.

PARTICIPANTS

We analysed 527 patient encounters performed by all 27 DACCM residents (17 women and 10 men). We asked each medical resident to evaluate 20 consecutive consultations starting on the same date.

OUTCOME

One hundred and fifty-seven encounters (29.8%) were perceived as difficult.

RESULTS

After adjusting for differences among residents, all five domains of the patient vulnerability grid were independently associated with a difficult encounter: frequent healthcare user; psychological comorbidity; health comorbidity; risky behaviours and a precarious social situation.

CONCLUSION

Nearly a third of encounters were perceived as difficult by medical residents in our university outpatient clinic that cares for a high proportion of vulnerable patients. This represents twice the average ratio of difficult encounters in general practice. All five domains of patient vulnerability appear to have partial explanatory power on medical residents' perception of difficult patient encounters.

Helpful ways providers can communicate about persistent medically unexplained physical symptoms

BACKGROUND

Communication between patients and providers about persistent "medically unexplained" physical symptoms (MUS) is characterized by discordance. While the difficulties are well documented, few studies have examined effective communication. We sought to determine what veterans with Gulf War Illness (GWI) perceive as the most helpful communication from their providers. Veterans with GWI, a type of MUS, have historically had complex relationships with medical providers. Determining effective communication for patients with particularly complex relationships may help identify the most critical communication elements for all patients with MUS.

METHODS

Two hundred and-ten veterans with GWI were asked, in a written questionnaire, what was the most useful thing a medical provider had told them about their GWI. Responses were coded into three categories with 10 codes.

RESULTS

The most prevalent helpful communication reported by patients was when the provider offered acknowledgement and validation (N = 70). Specific recommendations for managing GWI or its symptoms (N = 48) were also commonly reported to be helpful. In contrast, about a third of the responses indicated that nothing about the communication was helpful (N = 63). There were not differences in severity of symptoms, disability or healthcare utilization between patients who found acknowledgement and validation, specific recommendations or nothing helpful.

CONCLUSIONS

Previous research has documented the discord between patients and providers regarding MUS. This study suggests that most patients are able to identify something helpful a provider has said, particularly acknowledgement and validation and specific treatment recommendations. The findings also highlight missed communication opportunities with a third of patients not finding anything helpful.

Using the common-sense model to understand health outcomes for medically unexplained symptoms: a meta-analysis

Consistent with the common-sense model of self-regulation, illness representations are considered the key to improving health outcomes for medically unexplained symptoms and illnesses (MUS). Which illness representations are related to outcomes and how they are related is not well understood. In response, we conducted a meta-analysis of the relationship between illness representations, self-management/coping, and health outcomes (perceived disease state, psychological distress, and quality of life) for patients with MUS. We reviewed 23 studies and found that threat-related illness representations and emotional representations were related to worse health outcomes and more negative coping (moderate to large effect). Generally, increases in negative coping mediated (with a moderate to large effect) the relationship of threat/emotional illness representations and health outcomes. Protective illness representations were related to better health outcomes, less use of negative coping and greater use of positive coping (small to moderate effect). The relationship of protective illness representations to better health outcomes was mediated by decreases in negative coping (moderate to large effect) and increases in positive coping (moderate effect). Perceiving a psychological cause to the MUS was related to more negative health outcomes (moderate to large effect) and more negative emotional coping (small effect). The relationship of perceiving a psychological cause and more negative health outcomes was mediated by increases in negative emotional coping. Improving our understanding of how illness representations impact health outcomes can inform efforts to improve treatments for MUS. Our results suggest behavioural treatments should focus on reducing threat-related illness representations and negative coping.

Difficult Patient Encounters: Assessing Pediatric Residents' Communication Skills Training Needs

Introduction

Difficult patient encounters (DPEs) are common and can lead to frustration and dissatisfaction among healthcare providers. Pediatric resident physician experiences with DPEs and curricula for enhancing necessary communication skills have not been well described.

Materials and methods

We used a cross-sectional survey research design for our needs assessment on resident experiences with DPEs. Thirty-three pediatric residents completed this anonymous survey. The survey assessed residents’ experiences with and self-efficacy regarding DPEs. Descriptive statistics were used to analyze the quantitative data. Additionally, two authors independently coded free response data to include in the narrative description of the survey results.

Results

These survey results include the views of 92% of the residents in the program (33/36). Residents reported a greater frequency of difficult encounters in the inpatient setting than the outpatient setting. The majority of residents rated their communication skills during DPEs as “fair” or “good” (70%, 23/33). Residents tended to have lower confidence when discussing chronic pain, managing parental insistence on a plan, and breaking bad news. They generally reported higher levels of anxiety for scenarios involving angry patients and families, families insisting on a plan, and when breaking bad news. Residents cited many challenges, including working with angry and demanding families. Additionally, residents described difficulty with managing discordant opinions between the family and the healthcare team regarding the care plan. Residents expressed a preference for learning how to manage challenging patient encounters using clinical experiences. Simulation, discussion, and observation of role models also rated highly as educational methods for increasing skills, while most residents rated lectures as the least important means of training skills for these difficult encounters.

Discussion

We found that pediatric residents experience difficult encounters frequently, especially in the inpatient setting. Individual residents vary in their confidence and anxiety levels with different types of difficult encounters and may benefit from not only general communication skills training, but also from targeted training to equip them for the particular contexts they find most challenging. Residents value interactive structured learning activities, including discussion and simulation. Residents most consistently value the opportunity to lead challenging conversations in the clinical setting, especially when followed by effective debriefing and feedback by trained faculty preceptors.

Conclusions

Next steps include creating a “Difficult Encounters” communication skills curriculum informed by this needs assessment, which aim to enhance patient care as well as increase resident self-efficacy. In addition to the curriculum development for residents, it may be helpful to initiate faculty development on how to supervise resident-led difficult conversations and provide effective debriefing and feedback to promote resident growth.

What Makes "Difficult Patients" Difficult for Medical Students?

PURPOSE

Physicians can find it challenging to provide high-quality care to "difficult patients." While studies support that medical students also find some patients "difficult," little is known about why they do or how being a student affects their perceptions. The authors conducted this study to gain a deeper understanding of students' experiences with "difficult patients" to inform clinical teaching about effective patient communication and patient-centered care.

METHOD

In 2016, the authors conducted interviews with fourth-year medical students, who were asked to describe patient interactions in which they felt negative emotions toward the patient, as well as describe the clinical setting and their feelings. The authors audiorecorded and transcribed the interviews. Then, using a constructivist grounded theory approach, they reviewed the transcripts, coded the data using a codebook they had developed, and grouped the codes into themes.

RESULTS

Twenty-six students (of 44 volunteers and 180 students invited) were interviewed. Students described negative feelings toward patients and patients' behaviors, which were exacerbated by three situations related to their role and expectations as learners: (1) patients' interference with students' ability to "shine"; (2) patients' interference with students' expectations of patient-centered care; and (3) students' lack of the tools or authority to improve patients' health.

CONCLUSIONS

Educators should consider these findings, which can be explained by the professional identity formation and goal orientation theory frameworks, as they teach medical students to provide high-quality care for patients they find "difficult."

Internists' dilemmas in their interactions with chronically ill patients; A comparison of their interaction strategies and dilemmas in two different medical contexts

Background

Internists appear to define productive interactions, key concept of the Chronic Care Model, as goal-directed, catalyzed by achieving rapport, and depending on the medical context: i.e. medically explained symptoms (MES) or medically unexplained symptoms (MUS).

Objective

To explore internists’ interaction strategy discourses in the context of MES and MUS.

Methods

We interviewed twenty internists working in a Dutch academic hospital, identified relevant text fragments in the interview transcripts and analyzed the data based on a discourse analysis approach.

Results

We identified four interaction strategy discourses: relating, structuring, exploring, and influencing. Each was characterized by a dilemma: relating by ‘creating nearness versus keeping distance’; structuring by ‘giving space versus taking control’; exploring by ‘asking for physical versus psychosocial causes’; and influencing by ‘taking responsibility versus accepting a patient’s choice. The balance sought in these dilemmas depended on whether the patient’s symptoms were medically explained or unexplained (MES or MUS). Towards MUS the internists tended to maintain greater distance, take more control, ask more cautiously questions related to psychosocial causes, and take less responsibility for shared decision making.

Discussion and conclusions

Adopting a basic distinction between MES and MUS, the internists in our study appeared to seek a different balance in each of four rather fundamental clinical dilemmas. Balancing these dilemmas seemed more difficult regarding MUS where the internists seemed more distancing and controlling, and tended to draw on their medical expertise. Moving in this direction is counterproductive and in contradiction to guidelines which emphasize that MUS patients warrant emotional support requiring a shift towards interpersonal, empathic communication.

Difficult medical encounters and job satisfaction - results of a cross sectional study with general practitioners in Germany

Background

In primary care 15% of patient encounters are perceived as challenging by general practitioners (GP). However it is unknown what impact these encounters have regarding job satisfaction. The aim of this study was to evaluate which encounters are perceived as challenging by German GPs and whether they were associated with job satisfaction.

Methods

A total of 1538 questionnaires were sent to GPs in the federal state of Schleswig-Holstein, Germany. GPs should rate 14 medical conditions and 8 traits of patients on the perceived challenge using a Likert scale (1: ‘not challenging at all’ to 10: ‘extremely challenging’). Job satisfaction was measured with the Warr–Cook–Wall job satisfaction scale. A linear regression analyses were used to explore potential associations between for the primary outcome variable ‘overall job satisfaction’.

Results

Total response was 578 (38%). GPs perceived 16% of their patients as challenging. Psychiatric disorders such as somatization disorder (mean = 7.42), schizophrenia (mean = 6.83) and anxiety disorder (mean = 6.57) were ranked as high challenging while diabetes mellitus type 2 (mean = 4.87) and high blood pressure (mean = 3.22) were ranked as a rather low challenging condition. GPs were mostly satisfied with ‘colleagues’ (mean = 5.80) and mostly dissatisfied with their ‘hours of work’ (mean = 4.20). The linear regression analysis showed no association with challenging medical conditions and traits of patients but only with different aspects of job satisfaction concerning the outcome variable ‘overall job satisfaction’.

Conclusions

Especially psychiatric conditions are perceived as challenging the question arises, in what amount psychiatric competences are gained during the postgraduate specialty training in general practice and if GPs with a mandatory rotation in psychiatry perceive these conditions as less challenging. Interestingly this study indicates that challenging encounter in terms of challenging medical conditions and traits of patients do not affect GP’s job satisfaction.

Electronic supplementary material

The online version of this article (10.1186/s12875-018-0747-0) contains supplementary material, which is available to authorized users.

A Qualitative Study of Difficult Nurse-Patient Encounters in Home Health Care

The purpose of this study was to explore nurse-patient encounters from the perspective of the home health care registered nurse. A qualitative descriptive design was used to collect data from a purposive sample of 20 nurses from Connecticut, Massachusetts, and Rhode Island currently or previously employed as a home health care nurse. Four themes and 1 interconnecting theme emerged from the data: objective language; navigating the unknown; mitigating risk; looking for reciprocality in the encounter; and the interconnecting theme of acknowledging not all nurse-patient encounters go well. Three types of encounters-constructive, nonconstructive, and destructive-were defined.