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Difficult Patient Encounters in the Ambulatory Clinic
Clinical Predictors and Outcomes
Jeffrey L. Jackson, MD, MPH;
Kurt Kroenke, MD
Arch Intern Med. 1999;159:1069-1075.
Background One sixth of patient encounters are perceived as difficult by clinicians. Our goal was to assess clinical predictors and outcomes from such encounters.
Methods Five hundred adults presenting to a primary care walk-in clinic with a physical symptom completed surveys before the visit, immediately after the visit, at 2 weeks, and at 3 months. Patient measurements included mental disorders (PRIME-MD), functional status (Medical Outcomes Study Short-Form Health Survey [SF-6]), satisfaction (RAND 9-item survey), symptom resolution, visit costs, previsit and residual expectations of care, and health services utilization. Measurements from the 38 participating clinicians included the Physician's Belief Scale and physician perception of encounter difficulty (Difficult Doctor-Patient Relationship Questionnaire).
Results Seventy-four patient encounters (15%) were rated as difficult. Patients in such encounters were more likely to have a mental disorder (odds ratio, 2.4; 95% confidence interval, 1.3-4.4), more than 5 somatic symptoms (odds ratio, 1.4; 95% confidence interval, 1.1-1.8), and more severe symptoms (odds ratio, 1.6; 95% confidence interval, 1.04-2.3). Difficult-encounter patients had poorer functional status, more unmet expectations (P=.005), less satisfaction with care (P=.03), and higher use of health services (P<.001). Clinicians with poorer psychosocial attitudes as reflected by higher scores on the Physician's Belief Scale experienced more encounters as being difficult (23% vs 8%; P<.001).
Conclusions Patients presenting with physical symptoms who are perceived as difficult are more likely to have a depressive or anxiety disorder, poorer functional status, unmet expectations, reduced satisfaction, and greater use of health care services. Physicians with poorer psychosocial attitudes are more likely to experience encounters as difficult.
From the Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Md, and Walter Reed Army Medical Center, Washington, DC (Dr Jackson); and Department of Medicine, Regenstrief Institute for Health Care, Indianapolis University School of Medicine, Indianapolis, Ind (Dr Kroenke).
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