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The Physician-Patient Relationship |

Physical Symptoms and Physician-Experienced Difficulty in the Physician–Patient Relationship

Steven R. Hahn, MD
[+] Article and Author Information

Copyright ©2004 by the American College of Physicians

Grant Support: By an unrestricted educational grant from the Roerig-Pratt Division of Pfizer Pharmaceuticals.

Requests for Single Reprints: Steven R. Hahn, MD, Adult Primary Care Services, Ambulatory Care Pavilion 316E, Jacobi Medical Center, Bronx, NY 10461; e-mail, shahn@aecom.yu.edu.


Ann Intern Med. 2001;134(9_Part_2):897-904. doi:10.7326/0003-4819-134-9_Part_2-200105011-00014
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Background: The practice of medicine has many expected and accepted challenges, but all physicians experience some patients as difficult to a degree that transcends these expectations. Physician-experienced difficulty is associated with a syndrome of three characteristics: patient psychopathology, abrasive interpersonal styles, and multiple physical symptoms.

Objective: To assess the roles played by the number of physical symptoms and by specific symptoms in determining whether physician-experienced difficulty occurs.

Design: New analyses of epidemiologic survey data from the Primary Care Evaluation of Mental Disorders (PRIME-MD) 1000 Study.

Setting: Four primary care clinics.

Participants: 627 ambulatory patients seen by 27 physicians.

Measurements: Physician-experienced difficulty was measured by using the 10-item Difficult Doctor Patient Relationship Questionnaire (DDPRQ-10); patient-reported physical symptoms and physician-assessed psychopathology and somatoform symptoms were evaluated by using the PRIME-MD; and physical illnesses were measured by using a physician questionnaire.

Results: The number of physical symptoms and the number of somatoform symptoms correlated with difficulty (r = 0.39 and r = 0.37, respectively; P < 0.001), and the correlations remained significant after adjustment for physical and mental disorders (r = 0.20 for both correlations; P < 0.001). Difficult patients were more likely to have each of 16 physical symptoms; the odds of being difficult were greater for patients with 1 of 5 particular symptoms (stomach pain, fainting, loose stools/diarrhea, palpitations, and sleep problems), even after adjustment for physical and mental disorders. All 10 items on the DDPRQ-10 were influenced by physical symptoms, particularly those items that asked about physician frustration and whether patients were manipulative and time consuming.

Conclusions: The association between physical symptoms and difficulty is due in part to the association between physical symptoms and mental disorders, but symptoms also contribute independently to difficulty. The independent component of symptom-associated difficulty may be due to 1) differences between patient and physician in expectations about treatment and 2) the part that symptoms play in conferring the “sick role” on a patient.

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Appendix Figure. Scoring: Each item is scored from 1 (not at all) to 6 (a great deal) except items 1, 7, and 9, which are reverse-scored from 6 (not at all) to 1 (a great deal). The Difficult Doctor Patient Relationship Questionnaire-10 score is the sum of all items.
Difficult Doctor Patient Relationship Questionnaire, 10-Item Version.
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