70 “He's Bugging the Heck out of me…”: A Qualitative Study of the ‘Difficult Patient’ in Pediatric Medical Education

The ‘difficult patient’ is a well-studied concept in adult medicine that has never been explored in pediatrics. Difficult patient encounters are important learning opportunities. The objectives of this study were to identify ‘difficult’ patients on a pediatric teaching service, and to explore the educational impact of participation in their care.

Morning rounds of the pediatric in-patient teaching team at an academic children's hospital were observed and audio-recorded for 4 months (80 hours of observation). Rounds participants included (in rotation) 4 pediatricians, 4 senior residents, 11 junior residents, 11 medical students, 3 pharmacists, and 1 pharmacy resident. Observer effect was minimized by integration of the researcher as a member of the team for the team's entire rotation, and by observation and recording of the entire morning rounds, without apparent focus on ‘difficult’ patient management. During the observed rounds, 128 patients were discussed by team members. Data consisted of observation notes, post-observation reflective notes, and transcripts of relevant rounds discussions. The data were analyzed for emergent themes by three researchers using grounded theory methodology.

Analysis identified nine patients (7% of the patients discussed on rounds) who posed sustained and intense difficulty to the team. Markers of difficulty considered in the analysis included verbal labels (“It's just a frustrating kind of case”), non-verbal communication (slumped shoulders, sighs), and length of time spent and emphasis placed on the case during rounds. In the care of the nine identified patients, difficulty arose not only from patient factors, but also from clinical (including diagnostic ambiguity), parent (including challenges of the team's management decisions), professional (including conflict between clinical teams), and systems (including restricted access to investigations) factors. Consistent responses to the difficulty varied from the exclusion of junior trainees from discussions and care, to implicit responses (humor, gestures) that were patient- or parent-related, and explicit discussions that acknowledged multiple dimensions of difficulty and strategized to overcome them (e.g., team discussions about how to proceed in the face of conflicting specialty consultation advice).

The ‘difficult patient’ for the pediatric in-patient teaching team is better conceptualized as a case with multiple ‘sources of difficulty’ than as a ‘difficult patient’ per se. Junior trainees risk missing important learning opportunities by exclusion from difficult case management. Attention by clinical teachers to implicit as well as to explicit messages could improve the consistency of the educational impact of the management of these sources of difficulty.