Does a higher frequency of difficult patient encounters lead to lower quality care?

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Original Research

Does a higher frequency of difficult patient encounters lead to lower quality care?

J Fam Pract. 2013 January;62(1):24-29

By

Perry G. An, MD

Linda Baier Manwell, MS

Eric S. Williams, PhD

Neda Laiteerapong, MD

Roger L. Brown, PhD

Joseph S. Rabatin, MD

Mark D. Schwartz, MD

P.J. Lally, MD

This study would suggest it does not. Despite physician burnout, dissatisfaction, and related stresses associated with challenging practices, investigators found that quality of care was unaffected.

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References

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ABSTRACT

Background Difficult patient encounters in the primary care office are frequent and are associated with physician burnout. However, their relationship to patient care outcomes is not known.

Objective To determine the effect of difficult encounters on patient health outcomes and the role of physician dissatisfaction and burnout as mediators of this effect.

Design A total of 422 physicians were sorted into 3 clusters based on perceived frequency of difficult patient encounters in their practices. Patient charts were audited to assess the quality of hypertension and diabetes management and preventive care based on national guidelines. Summary measures of quality and errors were compared among the 3 physician clusters.

Results Of the 1384 patients, 359 were cared for by high-cluster physicians (those who had a high frequency of difficult encounters), 871 by medium-cluster physicians, and 154 by low-cluster physicians. Dissatisfaction and burnout were higher among physicians reporting higher frequencies of difficult encounters. However, quality of patient care and management errors were similar across all 3 groups.

Conclusions Physician perception of frequent difficult encounters was not associated with worse patient care quality or more medical errors. Future studies should investigate whether other patient outcomes, including acute care and patient satisfaction, are affected by difficult encounters.

Physicians who have high numbers of difficult patient encounters are more likely to report burnout and related stressor effects than are colleagues with fewer difficult encounters.¹ More of them also perceive that they provide suboptimal care than do colleagues who report fewer difficult patients.¹ These were some of the findings taken from the Minimizing Error, Maximizing Outcome (MEMO) Study that we conducted from 2001 to 2005.¹ But these findings prompted us to wonder: Is that perception accurate?

Whether physicians reporting high numbers of difficult patient encounters actually provide poorer care is unknown. In a recent study of physicians from one large primary care system, patient panels that were more challenging—as determined by higher rates of underinsured, minority, and non-English-speaking patients—were associated with lower quality care.² Hinchey and Jackson found that 2 weeks after initial presentation, patients involved in difficult encounters at a walk-in clinic experienced worsening physical symptoms.³ However, this study did not address whether difficult patient encounters affected the care rendered by providers to patients in general.

A detailed, rigorous model describing the interplay and relationships among difficult encounters, adverse physician outcomes (eg, burnout, dissatisfaction), and patient health outcomes has yet to be developed. To better understand the effects of these interactions, we revisited data from the MEMO study.

The findings that prompted another look at the data
When we conducted the MEMO study, we surveyed 422 physicians working in 119 primary care clinics in the upper Midwest and New York City.⁴ Almost half (49%) of the physicians reported moderately or highly stressful jobs; 27% reported burnout; and 30% were at least moderately likely to leave their practices within 2 years. Of these physicians, 113 (27%) reported high numbers of difficult encounters, which corresponds with other reports of 10% to 37% in primary care settings.^5-7 These 113 physicians were 12.2 times more likely to report burnout compared with colleagues with fewer difficult encounters.¹ They also reported lower job satisfaction, increased stress, more time pressure, and greater intent to leave practice, which are also echoed in other studies.^8-10

FAST TRACK

The perception of frequent difficult encounters is associated with increased physician burnout and dissatisfaction, but not with suboptimal care or higher rates of errors.

We found in our study (and at least one other) that physicians experiencing burnout are often younger and female, work long hours, and practice in a medicine subspecialty.^1,11 Many physicians who care for difficult patients report that they secretly hope these patients will not return.⁶

Our hypothesis
We hypothesized that frequent difficult encounters may amplify an adverse work environment, and that physicians facing time pressure and a lack of work control brought on by these encounters might be unable to sustain a high standard of care for their overall patient load.

METHODS

Participants
Physician and patient participants and design of the MEMO study are described in detail elsewhere.¹² The following, though, is a recap:

We recruited 422 general internists and family physicians from 119 ambulatory care clinics in New York City and the upper Midwest. These regions offered a diverse patient and payer mix. Physicians were asked via on-site presentations and mailed invitations to complete a survey derived from focus groups and the Physician Worklife Survey.^13,14

We also recruited up to 8 patients per participating physician via mailed invitations. Inclusion criteria were a minimum age of 18; a diagnosis of at least one target condition (hypertension, diabetes, congestive heart failure); ability to read in English, Spanish, or Chinese; and at least 2 visits with their primary physician in the previous year.