Medical practice

Pushy or rude patients 'more likely' to be misdiagnosed

"'Difficult' patients are more likely to get the wrong diagnosis," The Daily Telegraph reports.

A Dutch study suggests that patients who are aggressive or argumentative may lead doctors to lose focus when trying to come to a diagnosis.

The study included more than 60 young doctors. They didn't see actual patients, but they reviewed six different consultation scenarios as laid out in a booklet. The scenarios were written to reflect certain "difficult patient archetypes", such as patients who demand more treatment, are aggressive, or who question their doctor’s competence.

They were asked to make the diagnosis and rate the patient's likeability. The researchers found that when faced with the more "difficult" patients, a mistake in diagnosis was significantly more likely.

The main limitation is that we cannot be sure whether this study design reflects real clinical practice. The use of scenarios in booklets can’t really be compared to the effect of a real patient who the doctor can speak to themselves.

The results shouldn't suggest that we all return to the paternalistic "doctor knows best" deferential attitude common in previous generations. There is nothing wrong with expressing concerns or asking about alternative treatment or diagnostic options.

There is an important difference between being assertive and being rude – doctors have feelings too. 

Where did the story come from?

The study was carried out by researchers from Erasmus University, Erasumus Medical Center, and Admiraal de Ruyter Hospital, all in The Netherlands. No funding was provided for this study and no competing interests have been declared. 

The study was published in the peer-reviewed medical journal BMJ Quality and Safety.

The findings of this study have been reported accurately in the UK media. However, it should have been made clearer that these results are based on booklets containing scenarios and not real doctor-patient interaction.

What kind of research was this?

This experimental study aimed to study the effects of difficult patient behaviour on diagnostic accuracy in the general practice consulting room. 

However, it is difficult to model the real repercussions of a "pushy" patient in the consulting room and the effect this may have on the doctor. This study assessed this by asking doctors to review written patient scenarios in a booklet.

It could have been more useful to assess this more realistically by using live patient actors for the doctors to consult with.

What did the research involve?

Researchers recruited doctors from family practices in Rotterdam.

Six clinical situations were prepared in booklets to model behaviours of hypothetical pushy patients in the consulting room. These were as follows:

  • frequent demander
  • aggressive patient
  • patient who questions his doctor's competence
  • a patient who ignores his doctor's advice
  • a patient who has low expectations of his doctor's support
  • a patient who presents herself as utterly helpless

Doctors were required to diagnose simple and complex conditions. These were:

The first three of this list were considered simple cases and the last three complex.

Doctors each received a booklet containing the six clinical situations: three presented as difficult and three as neutral. Different versions of the booklets were prepared with a different order and version of cases, then distributed at random. Doctors were asked to carry out the following three tasks:

  • Reading the case, then writing down the most likely diagnosis as fast as possible while maintaining accuracy.
  • Reflecting on the cases, writing down the diagnosis previously given and listing the findings in the description that support the diagnosis, those that do not, and the findings they would expect in a true diagnosis.
  • The patient was then rated on a likability scale.

Diagnostic accuracy was evaluated by considering the confirmed diagnosis, which was scored (by a diagnostic accuracy score) as correct, partially correct or incorrect (scored as 1, 0.5 or 0 points, respectively). If the core diagnosis was mentioned, this was considered a correct diagnosis, and partially correct when the core diagnosis was not given, but an element of the condition was mentioned.

What were the basic results?

A total of 63 doctors were assessed in this study. The findings of this research were that the accuracy of diagnosis was significantly lower for difficult patients than neutral patients (diagnostic accuracy score 0.54 versus 0.64).

Simple cases were more accurately diagnosed than complex ones. All diagnostic accuracy scores increased after reflection, regardless of case complexity and of patient behaviours (Overall difficult versus neutral, 0.60 vs 0.68). Amount of time needed to diagnose the case was similar across all situations and, as might be expected, the average likability ratings were lower for difficult than for neutral patient cases.

How did the researchers interpret the results?

The researchers conclude that, "Disruptive behaviours displayed by patients seem to induce doctors to make diagnostic errors. Interestingly, the confrontation with difficult patients does however not cause the doctor to spend less time on such case. Time can therefore not be considered an intermediary between the way the patient is perceived, his or her likability and diagnostic performance."


This study aimed to investigate the effect of difficult patient behaviour on diagnostic accuracy in the general practice consulting room. 

The findings suggested that when faced with difficult patients, a doctor is more likely to make a mistake in diagnosis; however, with a little time to reflect, more accurate diagnoses are made.

The main limitation is that we cannot be sure whether this study reflects real clinical practice. The use of text-based situations can’t really be compared to the effect of a real patient in the consulting room, who the doctor can speak to themselves. In reality, what may seem to be more challenging consultations may be resolved by finding out the patient's concerns and discussing them, for example. Patients will always have valid health concerns or anxieties underlying any behaviour that may be perceived as "difficult" or "pushy". What may have been more useful is to use a study design where the GP actually consults with a live patient actor.

The research included a small number of doctors who were nearing the end of their GP training, but may not have the same level of experience at diagnosing or managing more challenging patients or consultations, compared with someone who has been practicing for some time.

That being said, the findings are in agreement with other research which suggests that "disruptive" or "difficult" patients fuel negative emotions in the consulting room.

Media reports suggest that more research is on the way, looking at further scenarios. This will be valuable, as it is important that all doctors are aware of their emotional responses to different patient presentations. This may further our understanding of the effect this might have on the accuracy of their diagnosis, with a knock-on effect on patient safety.

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