Article Text

Download PDFPDF
Why patients’ disruptive behaviours impair diagnostic reasoning: a randomised experiment
  1. Sílvia Mamede1,
  2. Tamara Van Gog2,
  3. Stephanie C E Schuit3,
  4. Kees Van den Berge4,
  5. Paul L A Van Daele3,
  6. Herman Bueving5,
  7. Tim Van der Zee2,
  8. Walter W Van den Broek1,
  9. Jan L C M Van Saase3,
  10. H G Schmidt2
  1. 1Institute of Medical Education Research Rotterdam, Erasmus Medical Center, Rotterdam, The Netherlands
  2. 2Department of Psychology, Erasmus University Rotterdam, Rotterdam, The Netherlands
  3. 3Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
  4. 4Department of Internal Medicine, Admiraal de Ruyter Hospital, Goes, The Netherlands
  5. 5Department of General Practice, Erasmus Medical Center, Rotterdam, The Netherlands
  1. Correspondence to Dr Sílvia Mamede, Institute of Medical Education Research Rotterdam, Erasmus Medical Center, Wytemaweg 80, Ae-242, Rotterdam 3015CN, The Netherlands; s.mamede{at}


Background Patients who display disruptive behaviours in the clinical encounter (the so-called ‘difficult patients’) may negatively affect doctors’ diagnostic reasoning, thereby causing diagnostic errors. The present study aimed at investigating the mechanisms underlying the negative influence of difficult patients’ behaviours on doctors’ diagnostic performance.

Methods A randomised experiment with 74 internal medicine residents. Doctors diagnosed eight written clinical vignettes that were exactly the same except for the patients’ behaviours (either difficult or neutral). Each participant diagnosed half of the vignettes in a difficult patient version and the other half in a neutral version in a counterbalanced design. After diagnosing each vignette, participants were asked to recall the patient's clinical findings and behaviours. Main measurements were: diagnostic accuracy scores; time spent on diagnosis, and amount of information recalled from patients’ clinical findings and behaviours.

Results Mean diagnostic accuracy scores (range 0–1) were significantly lower for difficult than neutral patients’ vignettes (0.41 vs 0.51; p<0.01). Time spent on diagnosing was similar. Participants recalled fewer clinical findings (mean=29.82% vs mean=32.52%; p<0.001) and more behaviours (mean=25.51% vs mean=17.89%; p<0.001) from difficult than from neutral patients.

Conclusions Difficult patients’ behaviours induce doctors to make diagnostic errors, apparently because doctors spend part of their mental resources on dealing with the difficult patients’ behaviours, impeding adequate processing of clinical findings. Efforts should be made to increase doctors’ awareness of the potential negative influence of difficult patients’ behaviours on diagnostic decisions and their ability to counteract such influence.

  • Decision making
  • Diagnostic errors
  • Medical education

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


  • Twitter Follow Tim Van der Zee at @Research_Tim

  • Contributors SM, TVG and HGS conceived and designed the study. SM, SCES, KVdB, PLAVD, HB, TVdZ, WWVdB and JLCMVS prepared the materials and acquired the data. SM, TVG, SCES, KVdB, PLAVD, HB, TVdZ, JLCMVS and WWVdB analysed the data. SM and HGS wrote the paper. TVG, SCES, KVdB, PLAVD, HB, TVdZ, WWVdB and JLCMVS revised the paper. All authors approved the final version of the manuscript. SM and HGS contributed equally to the work and are the guarantors. All authors had full access to all of the data, including statistical reports and tables in the study and can take responsibility for the integrity of the data and the accuracy of the data analysis.

  • Competing interests None declared

  • Ethics approval The Ethics Committee (ECP) from the Department of Psychology, Erasmus University Rotterdam, approved both experiments comprised in this study (decision letter issued on 15 December 2011).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Case level data are available from the corresponding author.

Linked Articles