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Do patients' disruptive behaviours influence the accuracy of a doctor's diagnosis? A randomised experiment
  1. H G Schmidt1,
  2. Tamara van Gog1,
  3. Stephanie CE Schuit2,
  4. Kees Van den Berge3,
  5. Paul LA Van Daele2,
  6. Herman Bueving4,
  7. Tim Van der Zee1,
  8. Walter W Van den Broek5,
  9. Jan LCM Van Saase2,
  10. Sílvia Mamede5
  1. 1Department of Psychology, Erasmus University Rotterdam, Rotterdam, The Netherlands
  2. 2Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
  3. 3Department of Internal Medicine, Admiraal de Ruyter Hospital, Goes, The Netherlands
  4. 4Department of General Practice, Erasmus Medical Center, Rotterdam, The Netherlands
  5. 5Institute of Medical Education Research Rotterdam, 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 Literature suggests that patients who display disruptive behaviours in the consulting room fuel negative emotions in doctors. These emotions, in turn, are said to cause diagnostic errors. Evidence substantiating this claim is however lacking. The purpose of the present experiment was to study the effect of such difficult patients’ behaviours on doctors’ diagnostic performance.

Methods We created six vignettes in which patients were depicted as difficult (displaying distressing behaviours) or neutral. Three clinical cases were deemed to be diagnostically simple and three deemed diagnostically complex. Sixty-three family practice residents were asked to evaluate the vignettes and make the patient's diagnosis quickly and then through deliberate reflection. In addition, amount of time needed to arrive at a diagnosis was measured. Finally, the participants rated the patient's likability.

Results Mean diagnostic accuracy scores (range 0–1) were significantly lower for difficult than for neutral patients (0.54 vs 0.64; p=0.017). Overall diagnostic accuracy was higher for simple than for complex cases. Deliberate reflection upon the case improved initial diagnostic, regardless of case complexity and of patient behaviours (0.60 vs 0.68, p=0.002). Amount of time needed to diagnose the case was similar regardless of the patient's behaviour. Finally, average likability ratings were lower for difficult than for neutral-patient cases.

Conclusions Disruptive behaviours displayed by patients seem to induce doctors to make diagnostic errors. Interestingly, the confrontation with difficult patients does however not cause the doctor to spend less time on such case. Time can therefore not be considered an intermediary between the way the patient is perceived, his or her likability and diagnostic performance.

  • Diagnostic errors
  • Medical education
  • Decision making

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  • Twitter Follow Tim Van der Zee at @Research_Tim

  • Contributors HGS, TG and SM conceived and designed the study. SM, SCS, KVB, PLVD, HB, TVZ, WWVB and JLS prepared the materials and acquired the data. HGS, SM, TG, SCS, KVB, PLVD, HB, TVZ, JLS and WWVB analysed the data. HGS and SM wrote the paper. TG, SCS, KVB, PLD, HB, TVZ, WWB and JLVS revised the paper. All authors approved the final version of the manuscript. HGS and SM 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.

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