The Prevalence and Characteristics of Difficult Patient Encounters: A Systematic Review and Meta-analysis, 2025, Jackson et al

[rvallee]

The Prevalence and Characteristics of Difficult Patient Encounters: A Systematic Review and Meta-analysis
Annals of Internal Medicine: https://doi.org/10.7326/ANNALS-25-01882
Paywalled: https://www.acpjournals.org/doi/10.7326/ANNALS-25-01882

Abstract​

Background:​

Patients are sometimes experienced as difficult by their providers.

Purpose:​

To estimate the prevalence of difficult patient encounters among adults being seen in nonpsychiatric settings. Secondary goals were to assess patient and provider characteristics associated with difficulty as well as patient outcomes.

Data Sources:​

MEDLINE, Web of Science, SciELO, ProQuest, Theses, Scopus, PsychInfo, Cochrane Central Register of Controlled Trials, Global Index Medicus, and EMBASE (inception through 7 July 2025).

Study Selection:​

In duplicate and independently.

Data Extraction:​

Prevalence, patient characteristics (sex, mental health diagnosis, somatization, personality disorders, and chronic pain), provider characteristics (type of provider, encounter setting, burnout, years of experience, and sex), and encounter outcomes (patient unmet expectations and satisfaction) were extracted in duplicate.

Data Synthesis:​

The prevalence of difficult encounters among clinic patients was 0.17 (95% CI, 0.15 to 0.19). Patient characteristics that increased difficulty included personality disorders (relative risk [RR], 2.2 [CI, 1.5 to 3.1]), depression (RR, 1.9 [CI, 1.7 to 2.2]), anxiety (RR, 2.1 [CI, 1.7 to 2.6]), and chronic pain (RR, 1.9 [CI, 1.5 to 2.4]). Providers with less experience (weighted mean difference, −3.5 years [CI, −5.0 to −1.9 years]) rated more encounters as difficult. Patients perceived as difficult were more likely to have unmet visit expectations (RR, 1.9 [CI, 1.4 to 2.5]) and lower satisfaction (RR, 0.76 [CI, 0.65 to 0.88]).

Limitation:​

Limited data and heterogeneity for many secondary analyses.

Conclusion:​

Providers perceived 17% of clinic patients as difficult. Patients perceived as difficult were more likely to have depression, anxiety, a greater number of symptoms, personality disorders, or chronic pain. Less experienced providers were more likely to judge patients as difficult. Patients from difficult encounters had more unmet visit expectations and less satisfaction.

 

[rvallee]

Hard to confirm since it's paywalled, but from abstract it seems to follow the pattern we are used to, and is directly related to outcomes. Patients want good outcomes. Physicians want good outcomes. Both patients and physicians are satisfied with good outcomes, and dissatisfied with bad outcomes. This is about bad outcomes where medicine is ineffectual.

The standard response to bad outcomes on the part of medicine seems to be all about making those outcomes worse, by shunning the patients, relying on failing psychosomatic models that make it impossible to improve those outcomes because they provide false claims that it's the patients' fault, hence the framing of 'difficult patients'. It's not the patients who are difficult, it's the problems that face us and medicine's ineptitude at producing better outcomes.

This ultimately seems to be about 99% of the problem with us, it's a reaction to failure and uncertainty, throwing out all the babies that are left in the dirty bathwater. It's so obvious and blatant for anyone looking at it soberly, without ideological beer goggles.

Psychosomatic ideology only worsens those outcomes, but it's the preferred way of dealing with them. Everyone is unhappy, but it's impossible to change anything because the solution from those who control the system is always more of the failure. This has been ongoing for decades, and seems unlikely to be fixed any time soon.

 

[SNT Gatchaman]

Primary care patients with mental health disorders, such as depression, anxiety, personality disorders, and substance use disorders, and patients with chronic pain were experienced as more difficult. Primary care patients report feeling inadequately trained to manage these problems.

That error is inadvertently accurate. The patient does indeed have to do a lot of the training the HCP hasn't/can't/won't in order to manage their own condition.

Patients with medically unexplained symptoms have been reported to be a common source of frustration for their providers. These patients commonly report poor functional status, higher symptom burden, and higher health care use. Primary consultative services focused on managing patients with medically unexplained symptoms had a higher prevalence of difficult patients. All included studies suggest that patients with somatization, poor functional status, or high health care use were more likely to be experienced as difficult, but the results were too heterogeneous to pool. Many provider interventions, focused on improving patient–provider communication, have been found to reduce provider frustration among patients with medically unexplained symptoms.

In conclusion, we found that physicians rate 1 in 6 of the patients they treat as difficult but not because they have more medical problems. Rather, patients considered difficult were more likely to have chronic pain, personality disorders, and mental health disorders - chronic problems for which nonpsychiatric physicians often have limited training and few efficacious treatments. Although it is reassuring that these patients have not reported worse outcomes, it is important to provide physicians with skills to address their needs. We suspect the ability to successfully treat these patients might change physician’s perception of them from “difficult” to “rewarding.”

As @rvallee has frequently noted, the patients would like treatments and the HCPs would like to successfully treat their patients. But none of that can happen unless the work is done.

 

[Sean]

Well imagine how sick patients feel when endlessly confronted with doctors with this kind of attitude, who simply cannot say 'we don't know what is wrong or how to treat it', and instead insist on imposing non-diagnoses and non-treatments, and blaming it all on the patient when it inevitably doesn't work.

Do these clowns ever look in a mirror?

 

[BrightCandle]

So this is an admission the are failing 1 in every 6 patients with this ideology and once again it's the patients that are difficult not the healthcare system that is failing them?!

 

[Utsikt]

Many provider interventions, focused on improving patient–provider communication, have been found to reduce provider frustration among patients with medically unexplained symptoms.

If they looked a bit closer at those interventions they would have seen that most of them are about how to more effectively gaslight the patients.

We need to teach the providers to say «I don’t know» and «I’m not able to treat your symptoms, but I will help you get the help you need to manage as best as possible».

 

[rvallee]

If they looked a bit closer at those interventions they would have seen that most of them are about how to more effectively gaslight the patients.

We need to teach the providers to say «I don’t know» and «I’m not able to treat your symptoms, but I will help you get the help you need to manage as best as possible».

I'd say the problem is far bigger than this. It's not about what individual physicians can do, this is simply not how huge systems like health care are supposed to work. It's that nothing happens past that, and physicians know this. There is no plan B, no pathway to handle those cases, more often than not not even disability support. Everything just stops if they don't know what's wrong, and that's usually when no one does. This is one reason psychosomatic ideology is so obsessively propped, it keeps the complete lie that it doesn't matter, those "worried well" will be fine, nothing wrong with them, onto the next patient in line.

If at the very least there was a comprehensive process that handled this, recorded, catalogued, kept track, helped those patients along, worked with researchers to do some second-line work, trying things, literally anything competent and scientific that kept careful track of things, giving a solid picture of how much unmet need there is.

But there is no such thing. Physicians are expected to handle this all on their own, knowing that there is nothing they can do, and that nothing exists to handle it. This is what's wrong, it's a system failure. They fail the patients far worse but those systems also fail clinicians, but since those systems are all built and run by physicians it's the same failure, just at a different level. Which negates the whole "we just don't have time" because none of those decisions are actually made with any pressure.

All of this mainly because of the rotten psychosomatic ideology that encourages not knowing, that promises that ignoring those problems, not recording them, not giving those patients any recognition, they will all simply cease to exist as a problem. Which is delusional, the problem just keeps growing because as medicine gets better and better at keeping people alive from what used to be certain death it's naturally growing the set of chronic problems they can't handle.

But there is zero leadership when it comes to this, no one even seems to be thinking about things this way. "I don't know" is never enough, because it's supposed to be followed by "but someone might, they're working on it". Except they're not working on it. No one really is, not in a way that has any chance of achieving anything. This problem is so obvious but so enormous that it seems impossible to even voice, let alone lead to anything.

I'm still pretty certain that if psychosomatic ideology were rooted out entirely, burned like the mad ideology it's always been, it would clear the path to improving all of this. But psychosomatic is the giant pile of cocaine that has always been there, and it's irresistible. Also there are zero consequences to this massive failure and no incentives to improve anything. So on and on the wheel of failure keeps spinning.

 

[ScoutB]

Maybe you've already seen it, but this article seems like an example of thing you were getting at in the other thread, @hotblack.