Can docs can handle irritable patients without it altering their clinical decisions?

A patient challenges the doctor's experience, raises their voice, or lashes out at the nurse. The exchange becomes tense. Does clinical reasoning then follow the same path? In 2020, in the BMJ Quality & Safety, psychologist Linda Isbell's team surveyed American emergency physicians and nurses about this type of encounter. The results found, "63% reported that their emotions had influenced their clinical assessment, decisions, or care. Among them, the effect was considered detrimental in 92% of cases." These findings, however, were based on the healthcare professionals' retrospective accounts. Isbell and her colleagues therefore wanted to observe what changes when only the patient's behaviour varies. Their new experiment has just been published in the same journal.Staged emergency consultationsConducted online from June to August 2022, this experiment brought together 134 emergency physicians from 46 U.S. states and the District of Columbia, who had an average of 14.2 years of experience after residency. Each participant assessed four simulated patients presenting complex cases: myocardial infarction, malaria, venous thrombosis and adrenal insufficiency.For each scenario, participants consulted the patient's electronic medical record (EMR), watched a three-to-four-minute video depicting the patient's condition, and then received the results of the physical examination and any additional tests ordered. The patient appeared either calm or irritable—with an annoyed tone, questioning the physician's competence, or lashing out at the nurse—but the clinical data remained the same. The researchers also varied the presence of a history of psychiatric illness. Each emergency physician encountered each of the four scenarios once, presented in a randomized order.Finally, the team measured stress related to uncertainty, specifically the tendency to experience anxiety in the face of an uncertain diagnosis or to fear the consequences of a poor outcome.A profoundly altered perspectiveThe study revealed significant variations in physicians' perceptions. Patients described as difficult received an average irritability score of 80.85 out of 100, compared to 30.83 for calm patients (p < 0.001). They were also judged to be less peaceful, with a score of 24.23 versus 55.23 (p < 0.001).Their attitude influenced both the physician's emotions and their perception: Anger increased by 31.61 points, anxiety by 15.25, and fatigue by 14.47 (p < 0.001 for each difference). Empathy decreased by 20.84 points, engagement by 14.98, and positive feelings by 11.88 (p < 0.001).These patients were judged to be less sympathetic (-36.79 points), less cooperative (-34.31), and less reliable in their clinical narrative (-14.11), with p < 0.001. Physicians considered them less likely to adhere to their treatment (-17.48 points) or return to work quickly (-7.80). They also believed them to be more prone to exaggerating their pain (p < 0.001).These differences appeared despite identical clinical information. The stress associated with uncertainty exacerbated certain reactions. For each additional point on this stress scale, the gap between the two conditions increased by 4.36 points for anger (p = 0.01) and by 4.31 for fatigue (p = 0.02). Anticipated adherence to treatment decreased by an additional 4.93 points (p < 0.01).“Physicians’ emotional reactions to patients—and their assessment of those patients—were not immune to the effects of the patients’ irritable behaviour,” the authors summarized. The impermeability of clinical decisions was confirmed; the way patients were perceived, much less so.Clinical decision-making remains consistentDespite these discrepancies, no statistically significant difference was detected in physicians' decisions. Patient behaviour did not alter the priority level, the number of tests requested, or the likelihood of consultation or hospitalization. Participants requested an average of 0.24 more tests when faced with difficult patients (p = 0.52); the probability of consultation increased by 4.95 percentage points (p = 0.32), and the probability of hospitalization by 3.15 percentage points (p = 0.52).Overall, the correct diagnosis was among the differential diagnoses in 37.1% of cases and constituted the final diagnosis in 53.2% of cases, with no significant variation based on patient behavior. This does not prove that decisions were immune to irritation, only that no effect was observed under the conditions of this simulation.Experience as a safeguard?Why didn't the decisions follow the same pattern? The authors suggest two possible explanations. First, the complexity of the cases might have led emergency physicians to slow down and engage in more careful reasoning, less susceptible to their immediate reactions. Their experience—more than 14 years of practice on average—may also have helped them mitigate this effect. However, these mechanisms remain hypothetical. The study neither measured the type of reasoning used nor compared experienced physicians with novices.The researchers also caution against overly reassuring interpretations. "Poor quality care can manifest itself in many ways, beyond reduced diagnostic accuracy," they write. A colder tone, less attentive listening, or signs of irritation can erode trust and, ultimately, hinder patient adherence or follow-up.Residents make more errorsWhile these results are reassuring regarding the robustness of reasoning among experienced emergency physicians (average of 14 years of practice), other studies suggest that this defense may be weaker among physicians at the beginning of their careers. In 2017, at Erasmus University Hospital in Rotterdam, Netherlands, 63 family medicine residents diagnosed six fictitional clinical cases in which the patient was presented as either difficult or neutral. Their average accuracy score reached 0.54 in the first case, compared to 0.64 in the second (p = 0.017). Deliberate reasoning improved overall performance, from 0.60 to 0.68 (p = 0.002), without eliminating the gap between the two groups.The same team replicated the experiment with 74 internal medicine residents from the same institution. Their score dropped from 0.51 to 0.41 when faced with difficult patients (p < 0.01). They retained fewer clinical details (29.82% vs. 32.52%; p < 0.001), but more details about the patient's behaviour (25.51% vs. 17.89%; p < 0.001). A portion of their cognitive resources seemed to be consumed by this behaviour.The effect extends beyond diagnosis. In a simulation conducted with 130 emergency room nurses in the U.S., 56.5% of handovers concerning an irritable patient contained a negative description, compared to 7.3% for a calm patient (p < 0.001). The tests or treatments to be planned were also mentioned less frequently, at 48.5% compared to 58.5% (p = 0.022).Effects that may be underestimatedThe lack of detected effect on decisions must be considered within a more comfortable context than real emergencies. Participants had unlimited time, without interruptions or overload, when faced with simulated patients. Some measures were new and self-reported; all four participants were white, and the sample was limited to experienced American emergency physicians. "Our results may therefore underestimate the influence of irritable patient behaviour and physician stress in the face of uncertainty in real clinical practice," acknowledged Isbell and colleagues.The experiment did not reveal any different diagnoses or decisions. However, it shows how quickly irritation transforms the relationship: less empathy and engagement and more suspicion about the reliability of the patient's account. The rationality of the decisions prevailed. The therapeutic bond, however, was already beginning to crack.This article has been translated from its original French and first appeared on our sister site Profession Santé. References: Isbell LM, Tager J, Beals K, Liu G. Emotionally evocative patients in the emergency department: a mixed methods investigation of providers’ reported emotions and implications for patient safety. BMJ Qual Saf. 2020;29(10):803-814. doi: 10.1136/bmjqs-2019-010110Isbell LM, Huff NR, Liu G, et coll. When emergency physicians meet patients displaying irritable behaviours: a randomised vignette-based experiment investigating physicians’ emotions and clinical reasoning. BMJ Qual Saf: 12 juillet 2026. doi: 10.1136/bmjqs-2025-019061Schmidt HG, van Gog T, Schuit SCE, van den Berge K, van Daele PLA, Bueving H, et coll. Do patients’ disruptive behaviours influence the accuracy of a doctor’s diagnosis? A randomised experiment. BMJ Qual Saf. 2017;26(1):19-23. doi:10.1136/bmjqs-2015-004109Mamede S, van Gog T, Schuit SCE, van den Berge K, van Daele PLA, Bueving H, et coll. Why patients’ disruptive behaviours impair diagnostic reasoning: a randomised experiment. BMJ Qual Saf. 2017;26(1):13-18. doi:10.1136/bmjqs-2015-005065Huff NR, Chimowitz H, DelPico MA, Gleason KT, Nanavati JD, Smulowitz P, et coll. The consequences of emotionally evocative patient behaviors on emergency nurses’ patient assessments and handoffs: an experimental study using simulated patient cases. Int J Nurs Stud. 2023;143:104507. doi:110.1016/j.ijnurstu.2023.104507

Can docs can handle irritable patients without it altering their clinical decisions?

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