Physical Symptoms and Physician-Experienced Difficulty in the PhysicianPatient Relationship

All physicianpatient relationships are vulnerable to communication problems, many medical problems are hard to solve, and medical care often engages physicians and their patients in emotionally painful and challenging situations. These situations are all difficult and yet fall within the range of the expected and accepted challenges of practicing medicine. By contrast, 10% to 20% of patients provoke a level of physician distress that transcends the expected and accepted level of difficulty (1, 2). These patients have been variously labeled as hateful, heartsink, problem, or difficult patients. They are frustrating, time consuming, and manipulative, and half of their physicians admit to secretly hoping that they will not return (2). Patients whom physicians find to be difficult are also high utilizers of health care services, and they are as dissatisfied with the care they receive as their physicians are upset to give it (2, 3). It is now clear that a syndrome of three patient characteristics is associated with this kind of difficulty. First, compared with not-difficult patients, difficult patients have twice the prevalence of significant psychopathologic disorders (67% vs. 35%). Second, 90% of difficult patients have an abrasive personality style or a pathologic personality disorder. And finally, most difficult patients have multiple physical symptoms (1, 2). In contrast to these three characteristics, which are strongly associated with physician-experienced difficulty, demographic characteristics and physical illnesses do not distinguish patients who are experienced as difficult (1, 2). The relationship among the three characteristics associated with physician-experienced difficulty is complex. Both physical symptoms and mental disorders are associated with difficulty, but physical symptoms and mental disorders are also closely associated with one another (4, 5). Nonetheless, previous analyses have confirmed that physical symptoms contribute significantly to physician-experienced difficulty independent of their association with mental disorders (2). However, questions remain about the relative contributions of mental disorders, physical and somatoform symptoms in general, and specific physical symptoms to physician-experienced difficulty. The term difficult patient legitimates the subjective experience of physicians who care for patients with these characteristics; it is also recognizable and intuitively understood. However, the difficulty experienced is the physician's, and some evidence indicates that physician characteristics influence difficulty (2, 6, 7). Therefore, the somewhat cumbersome phrases patients experienced as difficult and physician-experienced difficulty honestly locate the difficulty in the relationship between the physician and the patient. In this paper, I occasionally use the phrase difficult patient in addition to the phrases patients experienced as difficult and physician-experienced difficulty for three reasons. First, patient characteristics do largely determine which patients are experienced as difficult and which are not. Second, the term difficult patient is commonly used and immediately recognized, and thus deserves exploration. Finally, legitimating the physician's experience of difficulty is a first step in facilitating appropriate and therapeutic responses to that difficulty and patients' difficult behavior. Until recently, our understanding of patients experienced as difficult was based primarily on thoughtful descriptive work. A few empirical studies (3, 8-10) have used standardized approaches to identify difficult patients. These approaches and other standardized but psychometrically untested methods have shown associations between difficulty and psychopathology (3, 11-13), physical symptoms (3, 8, 9, 14), and personality styles (9) in various clinical populations. However, the lack of a reliable and independently validated method for identifying patients experienced as difficult has hampered empirical study of these patients, and it spurred development of the Difficult Doctor Patient Relationship Questionnaire (DDPRQ). Methods Participants The analysis of the relationship between patients' symptoms and physician-experienced difficulty reported here is based on data from the Primary Care Evaluation of Mental Disorders (PRIME-MD) 1000 Study (15), a mental health survey of 1000 patients in four primary care sites: University of South Alabama Medical School, Mobile, Alabama; New England Medical Center, Boston, Massachusetts; Uniformed Services University Health Services, Bethesda, Maryland; and Jacobi Medical Center, Bronx, New York. Details of the study are described elsewhere (2, 15). Complete data were obtained on the 10-item version of the DDPRQ (DDPRQ-10) (2) and the PRIME-MD for 627 persons enrolled during the last 8 months of the study (820 persons were approached; 632 agreed to participate). The first 96 patients were selected by convenience but independently of suspected psychopathology or difficulty. Subsequently, 536 patients were selected by using a site-specific procedure to avoid sampling bias (2, 15). The systematically selected sample and the convenience sample did not differ in demographic characteristics, physical illnesses, number of mental disorders, or DDPRQ-10 scores. Twenty-seven primary care physicians participated in the study; 19 (70%) were trained in internal medicine, and 8 were trained in family practice. Their mean age (SD) was 40 9.6 years; their mean post-residency experience was 10 years; and 67% of them were male. Eighty-one percent of the physicians judged their interest in mental disorders to be greater than that of their colleagues of similar age and training. Data Collection Physician-experienced difficulty was assessed by using the DDPRQ-10 (2) (Table 1 and Appendix Figure), which consists of 10 Likert items and uses a 6-point response scale. The DDPRQ-10 was derived from the original 30-item DDPRQ (1) by using a multiple regression analysis on a sample of 475 previously studied patients (1). The DDPRQ-10 requires less than 1 minute to complete, has an R 2 of 0.96 with the original instrument, and had an internal consistency reliability (Cronbach ) of 0.88 in the current study. It can be scored as a continuous variable or as a dichotomous variable using a cut-point that classifies 20% of the development sample as difficult (1). Table 1. Correlation between Item Score on Difficult Doctor Patient Relationship Questionnaire and Number of Somatoform and Physical Symptoms Appendix Figure. Difficult Doctor Patient Relationship Questionnaire, 10-Item Version. Five of the DDPRQ-10 items are about the physician's subjective experience (for example, Do you find yourself secretly hoping that this patient will not return? ). Four items are quasi-objective questions about the patient's behavior, such as How time consuming is caring for this patient? The one item that refers to symptomsTo what extent are you frustrated by this patient's vague complaints? combines elements of the patient's behavior and of the physician's subjective response. This item had a corrected item-total correlation of 0.68 with the other nine items. Physicians completed the DDPRQ-10 after administering the PRIME-MD, and thus they were aware of the presence or absence of mental disorders when they were assessing the difficulty of their patients. Mental disorders were assessed by using the PRIME-MD, a two-part case-finding and diagnostic tool designed for use by primary care physicians (15). The first part of the PRIME-MD, the Patient Questionnaire, is a one-page case-finding screen with 26 yes-or-no questions about physical and psychiatric symptoms experienced in the past month. The first 16 items of the Patient Questionnaire ask about the most common physical symptoms seen in the primary care setting (16). The second part of the PRIME-MD, the Clinician Evaluation Guide, is a branching-logic semistructured interview administered by the physician that contains five modules individually triggered by positive responses on the Patient Questionnaire. These five modules diagnose mood, anxiety, eating, alcohol, and somatoform disorders (15). The somatoform module of the Clinician Evaluation Guide was entered if three or more physical symptoms were endorsed on the Patient Questionnaire. In the somatoform module, physicians determined whether the endorsed symptoms had a physical source adequate to explain their severity and associated disability. The possible responses were yes, work up in progress, and no. Only symptoms lacking an adequate physical explanation were considered to be somatoform. In addition, in keeping with the algorithms of the Diagnostic and Statistical Manual of Mental Disorders (17), symptoms that were determined to be due to a mood or anxiety disorder or to occur exclusively during a panic attack were labeled as not somatoform. Patients completed the Patient Questionnaire and questions about demographic characteristics, health-related quality of life, and other psychiatric symptom scales before their visit. Physicians chose when to examine the Patient Questionnaire and when to administer the triggered components of the Clinician Evaluation Guide. The DDPRQ was completed after the Clinician Evaluation Guide, as was the physician's assessment of medical problems and current and planned treatment. Statistical Analysis Associations between the number of physical symptoms and somatoform symptoms and the total DDPRQ-10 score were assessed by using both bivariate correlation and partial correlations that controlled for the number of physical and mental illnesses. Univariate association between specific symptoms and the physician's experience of the patient as difficult or not difficult was assessed by using chi-square analyses. To isolate the contributions of demographic and clinical characteristics, physical and mental disorders, and physical or somatoform symptoms to physic