Disruptive ER patients get the same good care as their cooperative counterparts—but at what price?

ER physicians make accurate diagnoses and sound clinical decisions even when feeling exasperated with problem patients who persistently act up and verbally lash out. 

This doesn’t mean these encounters have no effect on life in the ER. 

In fact, emergency doctors suffer more burnout than peers in any other specialty—and overall care quality can and often does suffer under the weight of the stress. 

The observations are from a study published July 13 in BMJ Quality & Safety. 

For the research, Linda Isbell, PhD, of the University of Massachusetts and colleagues had 134 emergency-med physicians assess four hypothetical patients in a randomized, vignette-based experiment. 

The exercise incorporated computer-simulated, interactive clinical encounters. Patient behaviors and backgrounds were assorted, mixing combinations of irritable vs. calm and mental illness history vs. none. 

After reviewing each patient’s medical records, physical exams and video-recorded encounters, the participating ER specialists delivered patient evaluations and made clinical decisions. They also ordered tests and gave a diagnosis.

Finally, the doctors indicated how they felt about each patient and completed a standardized form for gauging tolerance, or lack thereof, to uncertainty (similar to this one).

Isbell and colleagues note that they adhered to established guidelines on reporting vignette experiments conducted in a healthcare context. 

Unpleasantness can be contagious to clinicians 

The team’s key findings: 

• Physicians reported greater anger, anxiety and fatigue and less empathy, happiness and engagement during encounters with patients displaying irritable behaviors.  
   
• They also figured those with irritable behaviors were exaggerating their pain would continue to be uncooperative, disengaged and hard to like. 
   
• Further, the participants prognosticated the irritable patients would be less likely to adhere to treatment and less likely to return to work.  
   
• Interactions revealed that the stress-from-uncertainty scale amplified the impact of patients’ irritable behaviors. Higher scores on the scale were associated with greater physician anger, anxiety and fatigue, and with physicians evaluating these patients as poorer historians, less likely to adhere to treatment and less likeable. 
   
• Effects were similar regardless of patient mental illness history. No effects emerged for clinical decisions, behavior or diagnosis.

Clinical encounters with patients who display challenging behaviors—rudeness, unreasonable demands and the like—are “increasingly common in emergency departments,” Isbell and co-authors remark. Such episodes, they add, “can heighten negative emotions, compromise healthcare quality and impact physician wellbeing.”

In the ER, emotions are always in motion

In coverage of the work by UMass Amherst’s news operation, Isbell points out that emotions are normal and natural in every workplace.  

“For too long, the medical culture has expected doctors to leave their emotions at the door,” she adds. “This is just unrealistic.”

Medicine is inherently uncertain and emotional—especially in the ER, Isbell continues. 

“We need a systemic shift that acknowledges the human reality of uncertainty and emotions in medicine,” she says. 

The need is great, Isbell suggests, to support both doctors and patients as they “work toward a common goal: health and wellbeing for all.”

• Related reading: Emergency physicians lead the league in burnout—but when they quit, it’s often for another reason