DEFINITION

• Patients who might be described as "difficult" have mostly been defined by the negative emotional response that they trigger in clinical staff.
• These patients have been described as those who:
  • “Exasperate,” “overwhelm,” or “distress” their physicians[2]
  • Cause a clinician’s “heart to sink”[2]
  • Inspire feelings of “dread” in physicians[3]
• Others have advocated for alternative understandings of the "difficult patient" label.
  • “…someone who perceives himself as wronged in the medical encounter—perceives being treated unfairly, disrespectfully, dismissively, condescendingly, or offensively…”[4]
  • Some think of the relationship as difficult, rather than the patient[5]
  • Patients and families who do not passively agree with the physician or do not let the clinical team entirely dictate “what happens and when”[6]

EPIDEMIOLOGY

• Several studies have found the prevalence of "difficult encounters" or "difficult patients" to be in the range of 10-20%.[7][8][9]
• A variety of associations have been noted that give rise to labeling patients as "difficult."
  • Patient characteristics:
    • Psychiatric disorders[7][9][10][11][12][13][14]
    • More frequent use of health care services[7][9][10]
    • Substance abuse[15]
    • Decreased satisfaction with healthcare services[7][9]
    • Ambiguous or unclear diagnosis[14]
  • Physician characteristics:
    • Overworked/working more hours per week[12][14][15]
    • Poor communication skills[12]
    • Less experience/being younger[13][15]
  • Health care systems factors:
    • The pressure on clinical staff to meet productivity benchmarks[12]
    • Financial concerns[12]
    • Fragmented visits[12]
    • Patients’ increasing access to their medical records or internet-derived information that can lead them to challenge physician’s opinions[12][16]
• Prevalence in various hospital settings
  • This group of patients have been described mostly in the context of general practice,[2][8][9] psychiatry,[1][17] and pain.[11][18][19]
  • The increased comorbidity of psychiatric conditions among patients categorized as "difficult" by their physicians (see the bullet Patient Characteristics above) can give a "difficult patient" stigma to patients who have a psychiatric diagnosis in their one-liner when they are encountered in other healthcare contexts.
• The evidence is not conclusive whether patients viewed as "difficult" receive worse care.
  • Some suggest that these patients receive worse care.[20][21][22]
  • Others did not find an association between being viewed as "difficult" and management decisions.[23]
  • Even if clinical outcomes are not directly affected, the emotional responses that some patients engender can contribute to division among staff.[24]
• Negative impact on physicians and practitioners
  • Physicians who report difficulty with patient relationships also have lower job satisfaction and higher burnout than their peers.[25]