["Difficult encounters" in primary care clinic: a patient and doctor perspective]

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.

The stories they tell: How third year medical students portray patients, family members, physicians, and themselves in difficult encounters

BACKGROUND

Physicians have long had patients whom they have labeled "difficult", but little is known about how medical students perceive difficult encounters with patients.

METHODS

In this study, we analyzed 134 third year medical students' reflective essays written over an 18-month period about difficult student-patient encounters. We used a qualitative computerized software program, Atlas.ti to analyze students' observations and reflections.

RESULTS

Main findings include that students described patients who were angry and upset; noncompliant with treatment plans; discussed "nonmedical" problems; fearful, worried, withdrawn, or "disinterested" in their health. Students often described themselves as anxious, uncertain, confused, and frustrated. Nevertheless, they saw themselves behaving in empathic and patient-centered ways while also taking refuge in "standard" behaviors not necessarily appropriate to the circumstances. Students rarely mentioned receiving guidance from attendings regarding how to manage these challenging interactions.

CONCLUSIONS

These third-year medical students recognized the importance of behaving empathically in difficult situations and often did so. However, they often felt overwhelmed and frustrated, resorting to more reductive behaviors that did not match the needs of the patient. Students need more guidance from attending physicians in order to approach difficult interactions with specific problem-solving skills while maintaining an empathic, patient-centered context.

[Clinical relationships and ethical problems in primary care, Sao Paulo, SP, Brazil]

OBJECTIVES

MAIN OBJECTIVE

to identify ethical problems in primary care according to nurses' and doctors' perceptions.

SECONDARY OBJECTIVE

to know ethical issues of patient-professional relationships in primary care.

DESIGN

Synthesis to integrate and reinterpret primary results of qualitative studies.

SETTING

Primary healthcare centers, Sao Paulo, SP, Brazil. PARTICIPANTS AND/OR CONTEXT: Incidental sample of 34 nurses and 36 medical doctors working in primary healthcare centers selected by convenience.

METHODS

Individual, semi-structured interviews to identity situations considered as sources of ethical problems. The sample is socially representative of primary care health centers and professionals. Data collection assured discourse saturation. Hermeneutic-dialectical discourse analysis was used to study the results.

RESULTS

Patient-professional relationships and team work were the main sources of ethical problems. The most important problems were patient information, privacy, confidentiality, interpersonal relationship, linkage and patient autonomy. These issues reflect the recent changes in clinical relation ships and show the peculiarities of primary care with its continuous care which lasts a long time. Healthcare involves multiprofessional team work in the midst of the patient claims for autonomy. Good care of patients needs requires a relationship based on communication and cooperation, and includes feelings and values, with communication skills.

CONCLUSIONS

Ethical problems in primary care are common situations. For quality and humane primary care the relationship should consist of dialogue, trust and cooperation.