Patient and provider characteristics associated with difficult clinical encounters

1. In this systematic review, 17% of primary care patients were perceived as difficult by physicians, particularly those with depression, anxiety, personality disorders, or chronic pain.

2. Resident physicians, or those with less experience, higher burnout, or lower job satisfaction, were more likely to perceive patients as difficult.

Evidence Rating Level: 1 (Excellent)

Study Rundown: Some patients may be perceived as difficult by primary care providers. Although prior literature suggests that such perceptions may relate to patient factors (e.g., mental health disorders, female sex) and provider factors (e.g., limited clinical experience, burnout), findings have been inconsistent. This systematic review sought to estimate the prevalence of difficult encounters in non-psychiatric settings, identify associated patient and provider characteristics, and examine patient outcomes. The authors reported that seventeen percent of clinic patients were perceived as difficult by primary care physicians. Patients with medically unexplained symptoms, depression, anxiety, personality disorders, or chronic pain were more likely to be viewed as difficult. While initial analyses indicated a higher likelihood among women, this association disappeared after adjustment for depression and outcome reporting bias. Patients with substance use disorders were not more likely to be perceived as difficult. Similar prevalence estimates were observed across clinic, emergency, and inpatient settings. Patients perceived as difficult demonstrated higher symptom burden, poorer functional status, increased health care utilization, and lower satisfaction with care, and were more likely to report unmet needs. Provider characteristics associated with perceiving patients as difficult included being a resident, having less clinical experience, reduced empathy, higher burnout, and lower job satisfaction. Overall, the generalizability of these findings is constrained by the predominance of low-strength evidence and substantial heterogeneity in prevalence estimates. Nevertheless, this review identifies a set of patient and provider characteristics that may help inform strategies to better understand and manage challenging clinical encounters.

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Relevant Reading: A Cohort Study Assessing Difficult Patient Encounters in a Walk-In Primary Care Clinic, Predictors and Outcomes

In-Depth [systematic review]: This systematic review assessed patient and physician characteristics associated with difficult medical encounters, as well as outcomes of patients considered difficult. Articles were identified from MEDLINE, Web of Science, SciELO, ProQuest, Theses, Scopus, PsychInfo, Cochrane Central, Global Index Medicus, and EMBASE through June 7, 2025. Studies were included if they assessed adults (≥18 years) in non-psychiatric settings and reported prevalence, characteristics, or outcomes of patients perceived as difficult, or characteristics of physicians who perceived them as difficult. Qualitative studies and those reporting only intervention effectiveness were excluded. The primary outcome was prevalence of patients perceived as difficult; secondary outcomes included patient and provider characteristics and patient outcomes. Forty-three articles (45 studies) were included, most from the United States (n = 28). Most studies were conducted in primary care (n = 31), with others in emergency, multispecialty, rheumatology, or inpatient settings. Among primary care patients, 17% were considered difficult (95% confidence interval [CI], 0.15–0.19; 10 studies). Prevalence did not differ across settings (p = 0.83). Women were more likely to be perceived as difficult (relative risk [RR], 1.1; 95% CI, 1.0–1.3), but not after adjusting for depression (RR, 0.62; 95% CI, 0.19–2.1). Patients with depression (RR, 1.9; 95% CI, 1.7–2.2), anxiety (RR, 2.1; 95% CI, 1.7–2.6), personality disorders (RR, 2.2; 95% CI, 1.5–3.1), or chronic pain (RR, 1.9; 95% CI, 1.5–2.4) were more likely to be considered difficult; those with substance use disorders were not (RR, 1.5; 95% CI, 0.95–2.3). Difficult patients reported more symptoms, worse functional status, higher health care use, more unmet expectations (RR, 1.9; 95% CI, 1.4–2.5), and lower satisfaction (RR, 0.76; 0.65–0.88). Residents and less experienced physicians, or those with lower empathy, higher burnout, or lower job satisfaction, were more likely to perceive patients as difficult. Overall, over one in six patients are perceived as difficult, particularly those with mental health or chronic pain conditions, and by less experienced or less satisfied providers.

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