An instrument to assess difficulty among medicine inpatients, the difficult doctor patient relationship...

Medicine patients are sometimes experienced as difficult by their providers, particularly those with depression, anxiety, somatization, chronic pain and personality disorders. Our purpose was to create a valid and reliable instrument for assessing provider experienced difficulty among medicine inpatients.

Based on a literature review and a qualitative study, we created a bank of 28 questions on provider perceived inpatient difficulty. We randomly selected medicine inpatients and surveyed their inpatient providers to assess patient difficulty on a dichotomous (yes/no) and continuous (0-10) scale and the 28-item survey. The reference standard used for validation was answering yes to the dichotomous measure as well as a score 5 or more on the continuous scale. Questionnaire reduction was done using factor analysis and Item Response Theory. Reliability was assessed using Cronbach's alpha and predictive validity based on association with known correlates of patient difficulty.

Three hundred and seven surveys were completed on 195 inpatients. Based on factor analysis and item reduction theory, we reduced the questionnaire to 10 items. Scores ranged from 10 to 53; a score of 20 of higher identified 20% of inpatients to be experienced as difficult by their inpatient providers. The questionnaire had a Cronbach's alpha of 0.96 and a C-statistic of 0.96 (95% CI: 0.94-0.98) and was 81% sensitive and 94% specific. It also correlated well with the continuous measure of difficulty (Pearson's Correlation = 0.81) and patient characteristics associated with inpatient difficulty.

This is potentially a valid and reliable instrument for assessing inpatient difficulty. It could be used to assess the impact of patient difficulty on patient satisfaction, trust and outcomes as well as provider satisfaction and burnout. It needs to be validated in other, more diverse populations before it can be recommended for general use.