A randomized simulation study reveals that challenging patient behavior can shape physicians’ emotions and perceptions, but experienced emergency doctors maintained the quality of their clinical decisions despite these pressures.
Study: When emergency physicians meet patients displaying irritable behaviours: a randomised vignette-based experiment investigating physicians’ emotions and clinical reasoning. Image credit: PeopleImages/Shutterstock.com
A recent BMJ Quality and Safety study examined whether patients’ irritable behavior influences emergency physicians’ emotions, clinical assessments, and clinical decisions.
Why difficult patient encounters may shape physician responses
Encounters with patients displaying uncivil or challenging behavior are increasingly frequent in emergency departments and correlate with heightened risk of compromised care. Such behaviors have been shown to reduce clinicians’ diagnostic accuracy and hinder engagement and decision-making in previous studies.
Although these behaviors are believed to elicit negative emotions in clinicians, direct empirical investigations remain scarce. Qualitative evidence links clinician anger, frustration, and irritation to lower engagement, impaired judgment, and reduced quality of care, yet the mechanisms underlying these effects remain poorly understood.
Uncertainty is inherent in medical practice and directly affects clinical reasoning and decision-making, especially in complex or ambiguous patient encounters. The degree of uncertainty experienced by clinicians varies with patient characteristics and situational factors, and challenging patient behaviors are known to amplify uncertainty.
The interaction between clinician traits, such as intolerance of uncertainty, and situational triggers like patient behavior remains underexplored. The affective component of uncertainty intolerance (e.g., stress from uncertainty) may heighten negative clinical and emotional responses, yet systematic investigation is lacking. These research gaps highlight the need for controlled experimental studies to clarify how patient behavior and clinician intolerance of uncertainty shape clinical decisions and outcomes.
Simulated emergency cases tested physician decision-making
A randomized vignette-based online experiment was conducted from June–August 2022 using Qualtrics survey software. Attending emergency physicians assessed four simulated emergency department (ED) patient cases in multimedia format. Patient behavior (irritable vs calm) and mental illness history (present vs absent) were systematically varied. For each case, participants reported clinical assessments, judgments, behaviors, and emotional reactions.
Attending emergency physicians were recruited from a random national list. Four cases were developed with specific clinical scenarios: fatigue (myocardial infarction), fever and sore throat (malaria), migraine headache (venous thrombosis), and abdominal pain (adrenal insufficiency).
Behavior and mental illness history were manipulated through written vignettes, electronic health records (EHRs), and 3–4 minute videos with standardized patient actors. Clinical information was consistent across versions; mental illness was indicated only in medical history, not in observed behavior.
Participants were randomly assigned to one of four case sets, each covering all experimental conditions, with randomized patient order. For each encounter, participants reported emotions, engagement, assessments, and clinical decisions. Measures were developed through literature review, expert input, and pilot testing.
Manipulation checks included irritability scores and ratings of perceived mental and physical illness. Additional measures included the 8-item Stress from Uncertainty Scale (SUS), an attitudes scale toward people with mental illness, and demographic data.
Clinical judgement remained stable despite emotional responses
Researchers mailed invitations to 1,000 attending emergency physicians, with 134 completing the study. Participants, who represented 46 US states and the District of Columbia, had an average of 14.2 years of emergency medicine experience after residency. Initial analyses confirmed that the experimental manipulation worked as intended, with physicians consistently perceiving irritable patients as more irritable, less calm, and more anxious than calm patients. Although both irritable patients and those with a history of mental illness were more likely to be perceived as mentally ill, perceptions of physical illness remained unchanged.
The researchers found that patient behavior, rather than mental illness history, drove most of the observed effects. Compared with calm patients, irritable patients elicited greater anger, anxiety, and fatigue in physicians, while reducing feelings of empathy, engagement, and happiness. They were also viewed more negatively, with physicians judging them as more likely to exaggerate pain, less cooperative, less likely to adhere to treatment or return to work, and suffering from slightly more serious medical conditions despite identical clinical information being presented. However, these changes in perception did not translate into differences in clinical decisions, diagnostic accuracy, or other aspects of patient management.
Physicians who scored higher on SUS were particularly susceptible to these effects. As stress from uncertainty increased, irritable patients provoked stronger negative emotional responses and were viewed as less likable and less likely to adhere to treatment. Despite these amplified emotional and interpersonal responses, higher SUS scores still had no measurable effect on clinical decisions, behaviors, or diagnoses.
Mental illness history had comparatively little influence on physicians' responses. No significant three-way interactions were observed, and there were no consistent effects of mental illness history across outcomes. The main exceptions were that physicians with lower SUS reported less confidence and felt they understood cases involving patients with a history of mental illness less well, whereas those with higher SUS reported similarly low confidence regardless of mental illness history. Physicians also expected patients with a history of mental illness to be less likely to adhere to treatment.
Overall, physicians considered all four cases challenging and frequently ordered diagnostic tests, sought specialist consultations, and admitted patients, regardless of the experimental condition. The correct diagnosis appeared in 37.1% of differential diagnoses and was selected as the final diagnosis in 53.2% of cases, with no significant differences between groups. Participants also reported generally low levels of stigmatizing attitudes towards people with mental illness, suggesting that stigma was unlikely to explain the study's findings.
Simulated scenarios cannot fully replicate emergency departments
The findings should be interpreted in light of the study’s limitations. The experiment used simulated patient encounters in which physicians had unlimited time and were not exposed to the interruptions and pressures of real emergency departments, potentially reducing the influence of patient behavior on clinical decision-making.
The study also relied partly on self-reported and newly developed measures, included only White standardized patients, and involved experienced US emergency physicians, which may limit the generalizability of the findings to other healthcare settings and populations.
Training could help clinicians manage emotional challenges
Physicians’ emotional reactions to irritable patient behaviors may threaten the quality of physician–patient relationships and physician well-being, particularly for those vulnerable to stress from uncertainty. However, the study found no evidence that these reactions altered clinical decisions, test ordering, admission decisions, or diagnostic accuracy during the simulated encounters.
The authors argue that enhanced medical education, training, and professional culture, alongside broader healthcare reforms to address systemic stressors such as overcrowding, may help clinicians better manage emotional responses and uncertainty. While comprehensive solutions are optimal, even modest, targeted interventions could improve healthcare quality and bolster clinician support, especially as many already struggle with burnout.
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