Subject: Friend, how to protect yourself during "difficult" patient interviews?

Hello Friend,

Diagnostic accuracy declines significantly when physicians are faced with "difficult patients," regardless of amount of time spent or case complexity, new research shows.

Two studies conducted by researchers from Erasmus Medical Center, in Rotterdam, the Netherlands, showed that physicians were much more likely to misdiagnose "difficult patients," defined as those who engage in disruptive behaviors, in comparison with patients who engage in neutral, or nondisrupitve, behaviors, regardless of case complexity.

The findings were published online March 2016,  in BMJ Quality and Safety.

Does Case Reflection Help?

In the first study, six different scenarios involving either difficult or neutral patients were presented. These included a "frequent demander," an aggressive patient, a patient who questioned the doctor's competence, a patient who ignored the doctor's advice, a patient with low expectations, and a patient who presented herself as completely helpless.

Patients' diagnoses were depicted as either simple or complex. Simple diagnoses included community-acquired pneumonia, pulmonary embolism, and meningoencephalitis. Complex diagnoses included hyperthyroidism, appendicitis, and acute alcoholic pancreatitis.

The study included 63 family practice medical residents. The participants were asked to quickly make their diagnosis for each patient and to later make a more reflective diagnosis.

The results showed that mean scores for diagnostic accuracy were significantly lower for the difficult vs neutral patients, regardless of case complexity (0.54 v 0.64; P = .017).

The physicians had a 42% greater chance of misdiagnosing a difficult patient compared with a neutral patient. As expected, overall diagnostic accuracy was higher for the simple diagnoses (P < .001).

Interestingly, the physicians spent as much time with the neutral patients as they did with the difficult ones.

Diagnostic accuracy improved somewhat when clinicians were asked to reflect on the cases, regardless of patient behaviors (P = .002). However, the accuracy was still greater for patients who were not considered difficult.

"It seems that deliberate reflection, unlike its role in previous studies involving other determinants of diagnostic error such as availability bias, was not able to overcome the adverse effect of difficult patient behaviours," the authors note.

Emotional Reactions

In the second study, the same team of researchers sought to better determine the mechanisms underlying the poorer diagnostic accuracy seen with difficult patients.

For this study, 74 first- and second-year internal medicine physician trainees were presented with similar scenarios. However, two additional types of difficult patients were included ― those who threatened the doctor, and those who accused the doctor of discrimination.

As with the first study, the results showed a 20% reduction in diagnostic accuracy for difficult patients (P< .01). The time spent on diagnoses was similar.

The physicians, who were later asked to recall clinical findings and patient behaviors, recalled fewer clinical findings for the difficult patients; however, they did recall more behaviors involving the difficult patients (for both, P < .001).

The results support the hypothesis that a "resource depletion" accounts for the increased diagnostic errors seen with more difficult patients ― the mental energy spent dealing with difficult behaviors disrupts the correct processing of important clinical information, the authors conclude.

"The findings suggest that disruptive behaviors 'capture' the doctor's attention at the expense of attention for the clinically relevant information," first author Silvia Mamede, MD, of Erasmus Medical Center, told Medscape Medical News.

"When asked to recall the information from a case afterwards, doctors who were confronted with a difficult patient remember more information about the patient's behaviors and less information of the clinically relevant symptoms than doctors confronted with the natural version of the same patient," she said.

"Recall of information is considered a measure of the amount of attention given to such information."

Importantly, it is uncertain whether the results would remain consistent for experienced physicians in comparison with the medical residents used in the studies, Dr Mamede noted.

"As physicians gain experience, they will tend to encounter difficult patients more frequently, [and] this may lead to more negative evaluations stored in memory, which might make emotional reactions more likely to occur," she said.

"It remains to be investigated whether more experienced physicians are better able to counteract the effect of these reactions ― because they learn how to deal with them ― or would be even more harmed by them."

In general, the findings suggest a need for increased awareness of the potential for judgments of patients to influence diagnoses.

"Physicians should be aware that, as anybody else, they have emotional reactions that can interfere with their reasoning," Dr Mamede said.

Offsetting the Effect

In an accompanying editorial, Donald A Redelmeier, MD, and Edward Etchells, MD, of the Division of General Internal Medicine, Sunnybrook Health Sciences Centre, in Toronto, Canada, suggest several strategies to help offset the potential negative effects of encounters with difficult patients, including "harnessing metacognitive debiasing skills."

1- "One approach, for example, is for physicians to reframe the situation as a counterfactual by imagining the patient as easy instead of difficult," Dr Redelmeier writes.

"Doing so demands mental discipline, of course, but might potentially enhance deliberation and decrease the time wasted by distracting emotions."

2- Clinicians may also benefit from more structured diagnostic checklists or computer-assisted diagnoses when evaluating a difficult patient, and simply making the effort to perform a more diligent follow-up with such cases can also help, he said.

"For the present, we suggest ongoing consideration of strategies that might lessen the detrimental impact of negative emotions yet still preserve the positive emotions that inspire physicians to diagnose most patients accurately."

BMJ Qual Saf. Published March 14, 2016. Schmidt et al, 


Dealing with difficult patients' clinical interview and OSCE

Patients visit doctors complaining of a symptom, not a disease. It is all about the differential diagnosis of symptoms and signs. DDx is the main focus of physicians during patients’ interviews, right?

OSCE stations, similar to real life patients’ interviews, have limited time.  Physicians have no choice but to be focused and to organize the interview in a time efficient manner. The reality is that physicians have no time to listen to their patients. On the other hand, physicians have to be vigilant not to miss anything!

Obviously, there is a need for some sort of an approach that will fulfill both patients and physicians goals. An approach that will explore all the patients’ presenting issues in a limited time frame. An approach that will protect both the patients and physicians.


What do you think the solution is? ....

Since 2004, OSCEhome developed a Systematic Approach flowcharts that helps you master these two aspect specifically....

OSCEhome Systematic Approach

The solution is to memorize a set of history taking questions and to do physical list that will fully take off the burden of the differentials and clinical decision making off our minds removing stress and give physicians the time to incorporate communication skills and establish rapport with their patients.

How did we at OSCEhome formulated the OSCEhome Systematic Approach ?

We started by preparing a list of all signs and symptoms a physician faces. We wrote one sign or symptom on a separate sheet of paper. Then for each symptom or sign we wrote all the possible differentials. Then, we draw a table, assigned a column for each differential and wrote that symptom/sign presentation details, quality, duration, relation to other symptoms/signs, and red flags.. Etc.. Then for every detail, we wrote questions to ask for or points to examine.

Obviously, there are now, many identical questions or points to examine concerning this symptom among all these differential diseases. We started to merge the diseases’ columns into one set of questions. When the same question is required for several diseases, we placed these diseases’ names between brackets after the question to help us later with the clinical decision making process. Then we arranged these questions and points to examine in a logical easy flowing flowchart.

We have noticed that there are some details that are not required if you are just screening for a symptom and not thoroughly gathering details about it. So, we divided the to ask/do list into two files, we placed the must ask/do important ones up in the list for screening, and the rest at the bottom for detailed data gathering sub-file, and just in case we run out of time.

What about communication skills? It a major issue to ensure an easygoing interview professional organized interview and to achieve a mutual understanding and respect. We rephrased the questions to meet communication skills guidelines. e.g. English language issues, open ended questions, non-leading questions, respective manner ..etc.

Now, we have all the needed questions to ask and points to examine concerning that symptom on a separate sheet of paper. We placed the sheet in a separate file, labelled it with the symptom/sign name. Then, we repeated the same process for all other signs and symptoms.  Again, there are now, many identical questions or points to examine among all these symptom/signs.

We started to gather identical questions or points to examine into a separate file box and crossed it out on that symptom/ sign sheet. e.g questions about medications, past illnesses, social, ..etc.

Now, we have three sets of box files;

  1. Chief complaint data gathering box file,

  2. Specific symptom/sign box files, and

  3. Standard questions box file.

Remember, in real practice, as well as during OSCE stations, our time is limited. So, we carefully went into each of these box files and rearranged the questions and points to examine for maximum time efficiency.

We came up with a tree of a step by step history taking and physical file boxes. During the patient interview, you go through the file boxes one by one. You only open the box files you need.



Let us take an example. A patient presented with cough.

  1. Introductions box: 5 sentences to say.

  2. Chief Complaint: 10 question to ask.

  3. HPI: 15 questions to ask.

  4. Respiratory question box: 10 questions to ask.

  5. Standard questions box: 14 questions to ask.

  6. Wrap up box: Sentences for 8 points to explain.


Most of the patients’ answers will be “NO”. How long then, will it take you to ask all these questions and wrap up the case?

FIVE minutes! And you have COVERED all the guidelines and checklists.

We created similar flowcharts for the physical examination, counselling, and ER stations that, with practice, will take you just 5 minutes to perform.

ONE flow chart of 7 steps with 23 history taking and 24 physical examinations boxes to choose one depending on the case !


Rest assured that all the guidelines are fulfilled, including communication skills.

You won’t forget anything to ask, examine, or explain. No need to be anxious and nervous.

You will be on a relaxed autopilot mode! Letting you focus on the clinical decision process and communication skills.

The systematic approach took three of us a full year to finalize and nine years so far to tweak.

Don’t you agree, it is worth a try? It is yours in just few minutes for the cost of a cup of coffee a day for a month!


Protect yourself, save your time and effort and get your OSCEhome ebook package now at:

     Have a nice day.