WHY DO DOCTORS FIND SOME PATIENTS DIFFICULT TO HELP

Almost all doctors encounter difficulties in managing some patients. P revious studies have examined the characteristics of such patients: we have additionally studied the reasons why hospital doctors find these patients 'difficult to help'. Three clinics (two medical and one surg ical) were studied. The consultants rated 60 (22%) of 293 attenders as severely or extremely difficult to help. Difficulty was associated wi th greater patient distress (odds ratio 3.9; 95% Cl 2.0-7.7), less pat ient satisfaction (2.6; 1.3-5.0) and chronic attendance (5.0; 1.4-17.3 ). An interview study of 40 'difficult' patients indicated that doctor s considered psyche-social factors more important in difficult patient s (3.2; 1.3-7.7). Objective differences between the doctor's and the p atient's aims for care also occurred more frequently for difficult pat ients (2.8; 1.1-7.2). Three common types of difficulty were identified ; medically unexplained symptoms; co-existing social problems; and sev ere untreatable illness. A review of the management aims for patients whom doctors find 'difficult to help', combined with improved access t o psyche-social care, could improve both the quality and the cost-effe ctiveness of hospital out-patient services.