A randomized simulation study reveals that challenging patient behaviors can shape physicians’ emotions and perceptions, but that experienced emergency physicians maintained the quality of their clinical decision-making despite these pressures.
Study: When emergency physicians encounter patients exhibiting frustrating behaviors: A randomized vignette-based experiment investigating physicians’ emotions and clinical reasoning. Image credit: PeopleImages/Shutterstock.com
recent BMJ quality and safety This study investigated whether patients’ irritable behavior influences emergency physicians’ emotions, clinical assessment, and clinical judgment.
Why encounters with difficult patients affect doctors’ responses
In the emergency department, encounters with patients exhibiting uncivil or provocative behavior are becoming increasingly common, correlating with an increased risk of compromised care. Previous studies have shown that such behaviors reduce clinicians’ diagnostic accuracy and impede engagement and decision-making.
Although these behaviors are thought to evoke negative emotions in clinicians, direct empirical research remains lacking. Qualitative evidence links clinician anger, frustration, and irritation to decreased engagement, poor judgment, and poor quality of care, but the mechanisms underlying these effects are still poorly understood.
Uncertainty is inherent in medical practice and directly impacts clinical reasoning and decision-making, especially when dealing with complex or ambiguous patients. The degree of uncertainty experienced by clinicians varies depending on patient characteristics and situational factors, and difficult patient behavior is known to amplify uncertainty.
The interaction between clinician characteristics, such as intolerance of uncertainty, and situational factors, such as patient behavior, remains unclear. Emotional components of uncertainty intolerance (e.g., stress from uncertainty) may enhance negative clinical and emotional reactions, but systematic investigation is lacking. These research gaps highlight the need for controlled experimental studies to uncover how patient behavior and clinician intolerance of uncertainty shape clinical decisions and outcomes.
Testing physician decision-making in simulated emergencies
The randomized vignette-based online experiment was conducted from June to August 2022 using Qualtrics survey software. Attending emergency physicians evaluated four simulated emergency department (ED) patient cases in a multimedia format. Patients’ behavior (angry or calm) and history of mental illness (present or absent) were varied systematically. For each case, participants reported their clinical assessments, judgments, behaviors, and emotional reactions.
The attending emergency physicians were selected from a randomly selected list from across the country. Four cases were developed based on specific clinical scenarios: fatigue (myocardial infarction), fever and sore throat (malaria), migraine (venous thrombosis), and abdominal pain (adrenal insufficiency).
Behavioral and psychiatric history was manipulated through written vignettes, electronic health records (EHRs), and 3- to 4-minute videos with standardized patient actors. Clinical information was consistent between versions. Mental illness is indicated only by medical history, not observed behavior.
Participants were randomly assigned to one of four case sets covering all experimental conditions in randomized patient order. For each encounter, participants reported their emotions, involvement, appraisals, and clinical decisions. Measures were developed through literature review, expert opinion, and pilot testing.
Manipulation checks included scores for irritability and assessment of perceptions of mental and physical illness. Additional measures included the 8-item Stress from Uncertainty Scale (SUS), an attitude measure toward people with mental illness, and demographic data.
Clinical judgment was stable despite emotional reactions
Researchers mailed invitations to 1,000 attending physicians, and 134 completed the study. Participants, representing 46 US states and the District of Columbia, had an average of 14.2 years of emergency medicine experience after training. Initial analyzes confirmed that the experimental manipulation worked as intended, with physicians consistently perceiving irritable patients as more irritable, less calm, and more anxious than calm patients. Patients who were easily irritable and those with a history of mental illness were both more likely to be perceived as mentally ill, but their perceptions of physical illness did not change.
The researchers found that most of the observed effects were driven by the patient’s behavior, rather than their history of mental illness. Compared to calm patients, irritable patients caused greater anger, anxiety, and fatigue in physicians, and decreased empathy, engagement, and well-being. They were also viewed more negatively, with doctors determining that they were more likely to exaggerate pain, be less cooperative, less likely to comply with treatment or return to work, and suffer from slightly more severe medical conditions despite being presented with identical clinical information. However, these changes in perception did not translate into differences in clinical decisions, diagnostic accuracy, or other aspects of patient management.
Physicians with high SUS scores were particularly susceptible to these effects. As the stress of uncertainty increased, frustrated patients elicited stronger negative emotional reactions, became less likable, and were seen as less likely to adhere to treatment. Despite this amplification of emotional and interpersonal responses, high SUS scores still had no measurable impact on clinical decision-making, behavior, or diagnosis.
A history of mental illness had a relatively small effect on physician response. No significant three-way interactions were observed, and history of mental illness did not have a consistent effect on the overall results. The main exception was that physicians with low SUS reported lower self-confidence and less understanding of cases involving patients with a history of mental illness, whereas physicians with high SUS reported similarly low confidence regardless of history of mental illness. Physicians also expected that patients with a history of mental illness would be less likely to adhere to treatment.
Overall, physicians considered all four cases to be difficult, regardless of experimental conditions, and frequently ordered diagnostic tests, consulted specialists, and hospitalized patients. The correct diagnosis was obtained in 37.1% of the differential diagnoses and was chosen as the final diagnosis in 53.2% of cases, but there were no significant differences between the groups. Participants also reported lower levels of prejudicial attitudes toward people with mental illness overall, suggesting that stigma is unlikely to explain the study results.
Simulated scenarios cannot fully recreate an emergency department
The findings should be interpreted in light of the limitations of the study. The experiment used a simulated patient encounter in which physicians were given unlimited time and was not exposed to the interruptions and pressures of a real emergency department, potentially reducing the influence of patient behavior on clinical decision-making.
Additionally, the study relied in part on a newly developed measure of self-report, included only standardized white patients, and included experienced U.S. emergency physicians, which may limit the generalizability of the findings to other medical settings and populations.
Training may help clinicians manage emotional problems
A physician’s emotional response to a patient’s frustrating behavior can threaten the quality of the physician-patient relationship and the physician’s well-being, especially for physicians who are vulnerable to the stress of uncertainty. However, this study found no evidence that these responses altered clinical decisions, order of testing, admission decisions, or diagnostic accuracy during the mock encounter.
The authors argue that strengthening medical education, training, and professional culture, along with broader healthcare reforms that address systemic stressors such as overcrowding, may help clinicians better manage their emotional reactions and uncertainty. Blanket solutions are best, but targeted interventions, even modest ones, have the potential to improve the quality of care and strengthen support for clinicians, especially as many people already suffer from burnout.
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