The Difficult Patient Encounter Is a Training Opportunity

Seventeen percent. That’s the share of clinic encounters in which physicians perceive the patient as “difficult,” according to a recent systematic review and meta-analysis by Jackson and colleagues published in Annals of Internal Medicine (1). The number itself didn’t surprise me. What stopped me was a different finding buried in the secondary analysis: Providers with less experience rated substantially more encounters as difficult. The weighted mean difference was 3.5 fewer years of experience among physicians who labeled patients this way. 

We need to sit with that for a moment. The language of “difficult patients” locates the problem in the person lying in the bed or sitting in the exam room. But if the same patient is difficult for one physician and manageable for another, and the distinguishing variable is years of practice, then what we’re really measuring isn’t patient behavior. It’s a skill gap. 

I run a hospital medicine division across 4 sites. Our physicians see many of these patients, not for a 15-minute clinic visit but for days at a time. The woman with chronic pain who fires her nurse by 7 a.m. The man with alcohol use disorder who leaves against medical advice on hospital day 2 and returns through the emergency department at midnight, when the overnight hospitalist has to start the whole process again. The patient whose family members rotate through the room in shifts, each with a different set of demands, none of which align with the care plan. We all know these encounters. We talk about them at sign-out. We warn incoming colleagues: “Room 412 is … a lot.” 

But Jackson and colleagues’ data reframe the conversation. Patients perceived as difficult were more likely to carry diagnoses of depression (relative risk, 1.9), anxiety (relative risk, 2.1), personality disorders (relative risk, 2.2), or chronic pain (relative risk, 1.9). These aren’t character flaws. They’re clinical conditions, each with its own pathophysiology, and each amenable to specific communication and management strategies that most physicians never formally learn. 

And here’s the part that keeps coming back to me as a division chief. The experience gradient in Jackson’s meta-analysis means that the physicians most likely to struggle with these encounters are the ones we deploy most heavily on the front lines of hospital medicine: early-career hospitalists, nocturnists in their first or second year, and advanced practice providers building their inpatient panels. We hire them, orient them to the electronic medical record, hand them a census, and expect them to manage the full emotional complexity of acute illness without structured training in the skills that would make those encounters survivable. 

I’m not talking about a lecture on empathy. I’m talking about communication techniques that can be taught and rehearsed, that change the interaction: eliciting the patient’s illness narrative before launching into the medical agenda, naming emotions explicitly (“It sounds like you’re frightened”), and setting expectations collaboratively rather than unilaterally. Programs like VitalTalk (2) have built evidence-based curricula for these exact conversations. We invest in simulation for procedural skills. We should invest with equal seriousness in simulation for relational skills—the kind that turn a “difficult” encounter into a therapeutic one. 

Jackson’s finding that patients from difficult encounters had more unmet expectations and lower satisfaction closes the loop. When we fail to manage these interactions well, the patient suffers too. Not just emotionally. The unmet expectations translate into missed follow-up, lower medication adherence, and (I suspect, though the data here are indirect) longer lengths of stay and higher readmission rates for the very patients who can least afford fragmented care. 

Seventeen percent is not a fixed number. It’s a training opportunity. The question isn’t how to avoid difficult patients. It’s how to build physicians who don’t need that label. 

References

1. Jackson JL, Kuriyama A, Whittle J, et al. The prevalence and characteristics of difficult patient encounters: a systematic review and meta-analysis. Ann Intern Med. 2026;179:382-393. [PMID: 41525693] doi:10.7326/ANNALS-25-01882
2. VitalTalk. Accessed at www.vitaltalk.org on 8 September 2026.

Ebrahim Barkoudah, MD, MPH, MBA

Ebrahim Barkoudah is the inaugural Chief of the Division of Hospital Medicine and Associate Professor of Internal Medicine at UT Southwestern in Dallas. Previously, he was System Chief of Hospital Medicine at Baystate UMass and Regional Chief Medical and Quality Officer at Baystate Health, after leadership roles at Brigham and Women's Hospital, Mass General Brigham, and Harvard Medical School. His work focuses on clinical outcomes research, quality improvement, and health care economics. A graduate of Damascus University, Harvard T.H. Chan School of Public Health, Oxford Saïd Business School, and St Hugh's College, he remains committed to mentoring the next generation of clinicians and to advancing cost-effective care for vulnerable populations.