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Here’s a note in the British Medical Journal Quality & Safety On March 7th (LINK HERE).  At first link, it looks like a McPaper with minimal publishable findings.  However, it raises some interesting thoughts:

Clinical Context
Some patients display behaviors that increase the stress involved in the clinician-patient encounter, because they are perceived as avoiding care, demanding, argumentative, aggressive, lacking trust, and/or completely helpless. Previous research suggests that patients who exhibit disruptive behaviors or traits when seen by physicians induce negative emotions in these physicians.
Although these emotions could in theory cause diagnostic errors, to date there has been no evidence to support this hypothesis. The goal of the present vignette studies was to examine the effect of difficult patients’ behaviors on clinicians’ diagnostic performance.

Study Synopsis and Perspective
Diagnostic accuracy declines significantly when physicians face “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, compared with patients who engage in neutral, or nondisruptive, behaviors, regardless of case complexity.
The findings were published online March 7 in BMJ Quality and Safety.

Does Case Reflection Help?
…6 different scenarios involving either difficult or neutral patients were presented. These included a “frequent demander,” an aggressive patient, a patient who questioned the physician’s competence, a patient who ignored the physician’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 patients vs the neutral patients, regardless of case complexity (0.54 vs 0.64; P =.017).
The physicians had a 42% greater chance of misdiagnosing a difficult patient compared with a neutral patient. As expected, the overall diagnostic accuracy was higher for the simple diagnoses (P <.001).
It is interesting to note that 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.

 Do patients’ disruptive behaviours influence the accuracy of a doctor’s diagnosis? A randomised experiment, H G Schmidt, Tamara van Gog, Stephanie CE Schuit, Kees Van den Berge, Paul LA Van Daele, Herman Bueving, Tim Van der Zee, Walter W Van den Broek, Jan LCM Van Saase, Sílvia Mamede BMJ Qual Saf Published Online First: 7 March 2016

Things that perturb the clinical milieu make it more difficult to treat the patient, no surprise.  I suggest that as the setting becomes more chaotic and “empowering” of the difficult patient, the worse the diagnostic process gets.

There has been a strong movement towards patient empowerment and minimizing physician authority in the patient/provider relationship.  The model that has unconsciously become adopted is the Retail American Medicine, mall sales-floor interaction with the store clerk.  What is “disruptive behavior” in a clinic is familiar benefit on the mall sales floor in America.  The customer learns to engage sales staff with demanding, argumentative, aggressive (behavior), lacking trust…

There is a process and a flow to conducting a patient interview.  That’s why it’s a learning lesson in Medical School.  It’s one of the hardest processes to perfect.  Controlling and modulating the process is not designed to benefit a physician’s sense of superiority, or to belittle the patient; it’s to deliver the most effective care.

The measurement indicators are simple.  How has controlled substance prescribing changed in the United States?  What percentage of antibiotics are unnecessarily prescribed?  The answers are “Out of control.” and “80%

I saw a patient yesterday, and at the end of the day received a stern phone message to call the patient’s daughter to explain why I had not continued controlled substances for an acute self-limiting pain condition.  She was not at the patient’s visit, and there are no indications he is incompetent.  Rather than discussing the issue with me, he may well have run home and complained to his daughter that I was mean.  He was given every opportunity to discuss his pain management in the visit.  demanding, argumentative, aggressive (behavior), lacking trust… One can add on passive-aggressive behavior as well.

A patient’s care plan is a mutual discussion.  The elements are based on clinical judgment.  Nevertheless, patients often approach the topic of controlled substances as though the medications are open to negotiation.  They are not the objective points to be discussed.  All medical objects are instruments, to achieve a certain end.  If the patient controls the process, the patient should be allowed prescriptive authority.

Another message read, “Still have cough.  Need another Z-Pak.”

I suggest that most medications be de-labeled, and offered to patients over-the-counter.  That may lead to reckless use.  I’m not sure we have to protect foolish patients from foolish use.  The way it is now, is classic .  The physician is a puppet who will take the blame if the patient’s medical decisions go wrong.  Stevens-Johnson syndrome from antibiotics?  Sue the doctor.  Overdose on Percocet + Whiskey?  Sue the doctor.  Obamacare?  Blame the doctor.  Heath Ledger?  Blame the Doctor.

In economics, moral hazard occurs when one person takes more risks because someone else bears the cost of those risks. A moral hazard may occur where the actions of one party may change to the detriment of another after a financial transaction has taken place.

What is the impetus of a physician to bear the cost of a patient’s risky behavior?  Clearly, the Obama Administration is simultaneously turning up the price of risk-bearing on physicians, in the issue of controlled substances behavior – all the while, forcing the social demand up across the country by “patient empowerment” of insisting on controlled substance prescriptions.

It’s classic market Communism – if the cost of providing something rises above the financial yield of providing it, there will be a shortage, no matter how good the intentions are.  The cost of providing pain control – appropriately AND inappropriately – is out of proportion to its benefit.  People with GENUINE PAIN – as well as the shifty folks – will suffer.

The appropriate thing is, as in the late USSR, is to stir up the masses to make sacrifices, and the people at the top to stand back in their dachas and be safe.  It’s also been called “The Poor are a Gold Mine.”  Be brave, Comrade Doctor, and do your work, even if it costs you more than you benefit!  The people at the top thank you – or they would, if they allowed your type into their houses!

All the minarchists like Ayn Rand simply insist that there will be no enforced moral hazard.  If you want to take a risk, like promising to do a professional job such as doctors do, you should be compensated fairly – and the measure of fairness is done by the doctor first, and then in agreement with the patient.  In other words, DIRECT PRIMARY CARE.  If you are put at more risk than you are compensated for, you will dump patients.  That’s the Obamacare model, and it’s working like gangbusters.

Welcome your thoughts.