BMJ Qual Saf doi:10.1136/bmjqs-2015-005150
  • Editorial

Unwanted patients and unwanted diagnostic errors

Press Release
  1. Edward E Etchells1,4,6
  1. 1Department of Medicine, University of Toronto, Toronto, Ontario, Canada
  2. 2Evaluative Clinical Sciences Platform, Sunnybrook Research Institute, Toronto, Ontario, Canada
  3. 3Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
  4. 4Division of General Internal Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
  5. 5Center for Leading Injury Prevention Practice Education & Research, Toronto, Ontario, Canada
  6. 6Centre for Quality Improvement and Patient Safety, University of Toronto, Toronto, Ontario, Canada
  1. Correspondence to Dr Donald A Redelmeier, Division of General Internal Medicine, Sunnybrook Health Sciences Centre, G-151, 2075 Bayview Ave, Toronto, ON, Canada M4N 3M5; dar{at}
  • Accepted 11 January 2016
  • Published Online First 7 March 2016


Real people have real emotions that motivate their thinking. For example, the hopes of having a child can lead women with infertility to undergo courses of intense hormonal treatments and the fear of dying can lead men with prostate cancer to undergo surgical castration.1 Much of the attention towards advanced directives and discussions about goals of care are intended to document and legitimize a patient's emotions related to death and dying. Indeed, guidelines for physician-aided-dying suggest that a patient's emotions are sometimes more important than life itself.2 In contrast, the emotions of a physician are usually considered as unwanted intrusions into medical decision-making that have no legitimate relevance.

Psychiatrists use the term ‘countertransference’ to denote a psychotherapist's emotions towards a patient. The basic concept is that a physician's own feelings may become entangled in the doctor–patient relationship and lead to missed diagnoses and ineffective care. Sigmund Freud first popularised the concept about a century ago emphasising how a physician's unconscious thoughts might include latent hostility or erotic feelings towards a patient.3 Different authorities over subsequent decades have also confirmed that countertransference is an undesirable but unavoidable component of medical diagnosis and treatment. The importance of these potentially disruptive physician emotions, however, is hard to judge in the absence of objective data.

Schmidt et al present two articles testing whether disruptive patient behaviours might provoke unhelpful physician emotions and thereby decrease a physician's diagnostic accuracy.4 ,5 The studies involve clinical scenarios eliciting diagnostic judgements. Each scenario appeared in either a ‘negative’ or a ‘neutral’ version depending on changing a few fragments of text. The negative version described the patient with unpleasant features such as “He is angry about the long waiting time and starts speaking harshly …”. The neutral version described the same patient with innocuous …

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