Dear Label_Name,

Greetings! I hope you are well.

I am writing on behalf of an international publishing house, Science and Education Publishing, USA (http://www.sciepub.com).

Science and Education Publishing (SciEP) is a multidisciplinary open access publisher of Journals covering the fields of Science, Technology and Medicine. All SciEP publications are subject to high-quality peer review, editorial and production processes and are freely available online.

Welcome to the April, 2013 edition of SciEP newsletter, providing monthly summaries of articles on science & education related topics of interest to scientist and professionals. The mission of our journals is to provide an open access forum for publishing new findings on issues pertinent to scientific and academic field. We also invite you to submit original research papers, review articles, short reports, or case studies are considered for publication in our Multidisciplinary Journals.

American Journal of Public Health Research
DOI: 10.12691/ajphr-1-1-3

The Implementation of a Tele-Homecare System with Service Oriented Architecture and HL7 Message Transmission Standard
Ching-Sung Wang

American Journal of Medical and Biological Research
DOI: 10.12691/ajmbr-1-1-2

The Influence of Ethanol on Pyruvate Kinases Activity in Vivo, in Vitro, in Silico
Lelevich Sergey Vladimirovich, Khrustalev Vladislav Victorovich, Barkovsky Eugene Victorovich, Shedogubova Tatyana Aleksandrovna

American Journal of Medical Sciences and Medicine
DOI: 10.12691/ajmsm-1-1-1

Clinical and Histological Features in Wegener Granulomatosis
Li Cavoli Gioacchino, Passantino Rita, Bono Luisa, Tortorici Calogera, Ferrantelli Angelo, Giammarresi Carlo, Rotolo Ugo

American Journal of Infectious Diseases and Microbiology
DOI: 10.12691/ajidm-1-1-2

The Curse of Lymphatic Filariasis: Would the Continual Use of Diethylcarbamazine Eliminate this Scourge in Papua New Guinea?
Anne Lanham, Lillian Mwanri

We have released issues of some journals on February 2013.
American Journal of Public Health Research
American Journal of Medical Sciences and Medicine
American Journal of Medical and Biological Research
American Journal of Pharmacological Sciences
American Journal of Clinical Medicine Research
American Journal of Nursing Research
American Journal of Cancer Prevention
American Journal of Medicine Studies
American Journal of Infectious Diseases and Microbiology
American Journal of Cardiovascular Disease Research
American Journal of Biomedical Research
American Journal of Mechanical Engineering
American Journal of Microbiological Research
Journal of Preventive Medicine
American Journal of Food and Nutrition
American Journal of Hypertension Research
American Journal of Sports Science and Medicine
Journal of Cancer Research and Treatment
American Journal of Zoological Research
Journal of Biomedical Engineering and Technology
American Journal of Microbiological Research
Biomedical Science and Engineering

We are pleased to announce that submissions are now being accepted for peer review for all the journals across all our subject areas in SciEP.

Please submit your manuscript via our online submission system:
http://www.sciepub.com/author/signin

To unsubscribe from our mailing list, please click on the following link: unsubscribe

I am looking forward to hearing from you.

Kind regards,

David Rain
Email:join@sciepub.com
Science and Education Publishing (http://www.sciepub.com)

Frequency of Appropriate Dealing with Difficult Patients among Primary Health Care Physicians, Ministry of Health, Taif City, Saudi Arabia

Ohood Ghurmallah Alrabie*, Saeed Yahya Alzahrani

Family Medicine Program, MOH, Taif, Kingdom of Saudi Arabia

Abstract: Background: Meeting difficult patients in complex encounters in Primary Health Care (PHC) is a common situation and creates a stressful moment for both the practitioner and the user. Objectives: To estimate the percentage of difficult patients met by primary health care physicians and identify their characteristics and the conditions that make them challenging for their physicians and to evaluate coding strategies and self-efficacy of.PHC physicians in dealing with these patients. Subjects and methods: It is a facility based descriptive cross sectional study carried out in Taif city, Saudi Arabia among all primary healthcare physicians (PHCPs) working at primary healthcare centers, Ministry of health (MOH). Self-administered valid questionnaire in English Language was used in data collection. It included personal characteristics of the physicians, details of dealing with “difficult patients”, and self-rating of physicians regarding coping strategies followed in dealing with difficult patients. Results: The study included 100 PHCPs; 39% aged 31-40 years, 55% were males, 69% were Saudi nationals and half of them were Family Medicine board holders. Majority of them had history of dealing with difficult patients (93%). Among them, 48.4% reported meeting less than 10% of challenging patients in their practice whereas 21.5% met more than 25% of challenging patients. Demanding patients ranked first of the difficult patients` traits with a mean±SD of 5.32±2.51. Regarding difficult patients` conditions, poly-pharmacy patients ranked first with a mean±SD of 5.64±2.54 while patients with high blood pressure (4.13±2.49) and depression (4.06±2.38) ranked the last two conditions. Regarding strategies followed by primary healthcare physicians during dealing with difficult patients, remain calm and avoid arguing most or all the time were reported by 55.8% and 48.4% of them, respectively The highest score of coping with difficult patients was observed among physicians with experience ranged between 6 and 10 years in healthcare, p=0.001. Conclusion: Majority of primary health care physicians, MOH in Taif city had history of dealing with difficult patients. Coping with difficult patients was highest observed among physicians with experience ranged between 6 and 10 years in healthcare.

Keywords: difficult, patients, communication skills, primary healthcare physicians

Received October 27, 2020; Revised November 28, 2020; Accepted December 07, 2020

Citation: Ohood Ghurmallah Alrabie, Saeed Yahya Alzahrani, Frequency of Appropriate Dealing with Difficult Patients among Primary Health Care Physicians, Ministry of Health, Taif City, Saudi Arabia. American Journal of Medical Sciences and Medicine, 8 (6). 229-237. January 2020. doi:10.12691/ajmsm-8-6-4

1. Introduction

Communication skills and problem-solving skills as well as the educational background, knowledge, and experience of doctors are important for establishing effective communication [1,2,3]. Doctors with good communication skills can conceive the problems of patients more accurately, can provide more compliance and satisfaction of patients with treatment, and can reduce stress while improving their professional work satisfaction [3,4,5].

Meeting difficult patients in complex encounters in Primary Health Care (PHC) is a common situation and creates a stressful moment for both the practitioner and the user [6]. The practitioners in PHC estimate that between 15 and 60% of PHC users are deemed “difficult” [7].

Weston defines a 'difficult patient' as one with whom the physician has trouble forming an effective working relationship [8].

Difficult patients have associated marks such as mental disturbances, being poly-symptomatic, chronic pain, unattended expectations and persistent lack of satisfaction with the care they receive, even as heavy users of health services [9]. There are also medical and behavioral issues determining the condition of difficult patients: lack of interest in self-care; excess of demands; manipulative behavior; conflictive families, multiple complaints [6].

In the literature, the definition of difficult patient includes patient groups such as female patients, patients of low socioeconomic status, and patients who need excessive medical care such as those with psychosocial problems and substance abuse, with multiple medical complaints, and those feeling constantly ill, exhibiting drug-seeking behavior, and with chronic pain [10,11,12,13]. During their daily practice, doctors encounter patients described as “difficult” who leave them in difficult situations, frustrate them, and make them feel helpless and inadequate [14,15].

Physicians working in Health of the Family Strategy (HFS) report daily clinical encounters with these patients, about one of every six visits, even though the impact in practice is more related to the emotional intensity than to the frequency of these encounters [9]. The difficult clinical encounter situation in PHC is aggravated in the circumstance of the lack of psychosocial skills in the professionals [9].

Physicians have to allocate a lot more time and energy for these patients to recognize and solve their problems [6]. In a study investigating effects of doctor–patient relationship on healthcare utilization, it was concluded that patients with lower level formal education use healthcare services more frequently, and have been labeled more difficult patients by physicians [16].

In a study investigating the demographic data and healthcare characteristics of difficult patients among 166 patients, it was found that the definition of difficult patient usually includes elderly patients, those divorced or widowed, and women with high percentages [11].

Dealing with “difficult patients” is a common problem. In Turkey, vast majority of physicians (92.8%) physicians claimed that they had experienced in dealing with such type of patients [17].

Almost all primary healthcare physicians have to deal with “difficult” patients and most research in this area focused on describing these patients and their physicians, not on assessment of coping strategies. Furthermore, few studies have been conducted globally with no study has been conducted in Saudi Arabia and particularly in Taif. Therefore, this study was carried out to investigate the magnitude of the problem facing primary healthcare physicians in dealing with “difficult patients” and evaluate their coping and management strategies with those patients in Taif, Saudi Arabia.

2. Methods

2.1. Study Design

Facility based descriptive cross sectional design.

2.2. Study Area and Setting

This study was carried out in Taif city, which situated in the western region of Saudi Arabia in Makkah Province with an estimated population of [18] In Taif city, there are 19 primary health care (PHC) centers, belonging to Ministry of Health. The study was carried out at these centers.

2.3. Study Population

All primary healthcare physicians working at primary healthcare centers, belonging to Ministry of health in Taif city were eligible for inclusion in the study (n=100).

Inclusion criteria:

-Both genders

-All nationalities

-All job titles

Exclusion criteria

Dentists

Sample size/technique:

All primary healthcare physicians working at primary healthcare centers, belonging to Ministry of health in Taif city (n=100) were invited to participate in the study by filling the study questionnaire.

2.4. Data Collection Tool

Based on relevant literature review, the researcher developed a self-administered study questionnaire in English Language that included the following:

1. Personal characteristics of the physicians: Age, gender, nationality, educational level, experience in primary healthcare (years), attending any training course in communication skills and history of dealing with “difficult patients”.

2. Details of dealing with “difficult patients”, based on a questionnaire previously used by Goetz K, et al (2018) [19] that include questions about percentage of difficult patients met by physicians in their practice, characteristics and disease status of such patients.

3. Self-rating of physicians regarding coping strategies followed in dealing with difficult patients, based on 6 tips mentioned by Jacksonville University in proper dealing with such patients. These tips were: [20]

Remain calm: When dealing with difficult patients, the best way is to remain calm as this will allow you to keep control and address the patient in a way that will ease the situation.

Engage in conversation: Try to draw out the patient’s feelings by engaging in conversation.

Be empathetic: One of the quickest ways to calm an angry or difficult patient is by being empathetic.

Avoid arguing: Difficult patients may try to pull you into an argument. While you are completely entitled to voice your opinion, it’s important to do so respectfully.

Set boundaries: When it comes to difficult patients who make seemingly endless or unreasonable demands, a useful approach is to set limits.

Shake it off: After an unpleasant interaction with a difficult patient, it’s normal to feel upset or angry. Take a moment to let those feelings go, so your whole day isn’t ruined. Take a deep, cleansing breath and as you exhale, let out all the stress and anger.

Validity of the questionnaire was tested by three consultants (two family medicine and one community medicine), before its final application.

2.5. Data Collection Technique

The researcher collected the data through direct visits to all PHC centers, explaining the purpose of the study and the questionnaire to the physicians. The researcher distributed the study questionnaire to all physicians in the PHC centers and supervised them and replied to any of their inquiries. Then she received the filled questionnaires and revised them to make sure that there were no missing data.

2.6. Pilot Study

A pilot study was performed on 10 physicians from one of the PHC centers whose responses were included in the final report, since there was not significantly changed from the main survey. The purpose of that pilot study was to test the wording of the data collection tool as well as applicability of the study. All the necessary modifications were done (addition, removal, or re-wording) in order to reach the final copy of the tool.

2.7. Administrative and Ethical Consideration

• Written permission from Family Medicine program, MOH, Taif Region was obtained before conducting the research.

• Written permission from the director of the primary health care. MOH in Taif was obtained.

• Permission of all PHCCs directors was obtained.

• The researcher tried her best not to disturb the work in the PHC; she visited all the centers after arranging with their directors.

• The individual consent from each physician to participate in the study is a prerequisite for data collection. Accepting to participate by filling the questionnaire was considered consent.

2.8. Statistical Analysis

Collected data were verified and coded prior to computerized data entry. The researcher utilized the Statistical Package for Social Sciences (SPSS version 25.0) for data entry and analysis. Frequency, percentages, means, standard deviation (SD), median, interquartile range (IQR) and 95% confidence interval (CI) were used as descriptive statistics. Differences were tested using Mann-Whitney test for continuous variables in case of comparing two groups and Kruskal-Wallis test for comparison of more than two groups (as the data were abnormally distributed as shown through significant Shapiro-Wilk test). A p-value less than 0.05 was considered statistically significant.

3. Results

Table 1 summarizes the personal characteristics of the primary healthcare physicians participated in the study; 39% aged between 41 and 40 years whereas 24% aged over 40 years, 55% were males, 69% were Saudi national and half of them were Family Medicine board holders. Regarding experience in primary healthcare, 30% had experience between 6 and 10 years whereas 19% had experience exceeded 10 years.

History of attending training course in communication skills was mentioned by 68% of the participants as shown in Figure 1.

Table 1. Personal characteristics of the primary healthcare physicians, Ministry of Health, Taif

Figure 1. History of attending training course in communication skills among primary health care physicians, Ministry of Health, Taif

3.1. Experience of Dealing with Difficult Patients

Figure 2 demonstrates that majority of the primary healthcare physicians had history of dealing with difficult patients (93%). Among them, 48.4% reported meeting less than 10% of challenging patients in their practice whereas 21.5% met more than 25% of challenging patients. (Figure 3)

3.2. Characteristics of Difficult Patients

-Patients` traits

Difficult patients` traits are summarized in Table 2. Demanding patients ranked first with a mean±SD of 5.32±2.51, followed by patients with limited compliance (5.06±2.37) and critical patients (5.04±3.03) while patients with obsessive-compulsive personality ranked the last (4.24±2.68). (Table 2)

-Patients` condition

Table 3 presents difficult patients` conditions. Poly-pharmacy patients ranked first with a mean±SD of 5.64±2.54, followed by multi-morbidity patients (5.57±2.55), Schizophrenic patients (5.34±2.98) and patients with chronic pain (5.31±2.64) while patients with high blood pressure (4.13±2.49) and depression (4.06±2.38) ranked the last two conditions.

Figure 2. History of dealing with difficult patients among primary health care physicians, Ministry of Health, Taif

Figure 3. The percentage of challenging patients met by primary health care physicians in their practice (n=93)

Table 2. Traits of the difficult patients according to the primary healthcare physicians` opinions

Table 3. Conditions of the difficult patients according to the primary healthcare physicians` opinions

3.3. Communication Skills

Half of the primary healthcare physicians rated their communication skills as good whereas 15% and 8% rated them as excellent and fair, respectively as shown in Figure 4.

3.4. Strategies during Dealing with “difficult patients”

Regarding strategies followed by primary healthcare physicians during dealing with difficult patients, remain calm and avoid arguing most or all the time were reported by 55.8% and 48.4% of them, respectively whereas be empathetic and engage in conversation most or all the time were reported by 44.1% and 42% of them, respectively as shown in Table 4.

Overall the total score of coping with difficult patients ranged between 10 and 25 with a mean±SD of 18.8±3.2, median (IQR) of 19 (16.5-21). It was abnormally distributed as shown by significant Kolmogorov-Smirnov test, p=0.001. (Figure 5)

The highest score of coping with difficult patients was observed among physicians with experience ranged between 6 and 10 years in healthcare while the lowest score was reported among those whose experience ranged between two and five years (Mean ranks were 63.38 and 38.32, respectively), p=0.001. Other physicians` personal characteristics (age, gender, nationality and educational level) were not associated with strategies in coping with difficult patients.

Although attending training course in communication skills was associated with higher score of coping with difficult patients (mean ranks were 50.15 and 39.30, respectively), yet it didn’t reach a statistically significant level, p=0.077. (Table 6)

Figure 4. Self-rating of communication skills of physicians when involved in a difficult encounter

Table 4. Strategies followed by primary healthcare physicians during dealing with “difficult patients” (n=93)

Figure 5. Total coping with difficult patients` score among primary healthcare physicians

Table 5. Physicians` personal characteristics associated with coping with difficult patients

Table 6. Association between physicians` history of attending training course in communication skills and coping with difficult patients

4. Discussion

Effective communication of the physicians with their patients, particularly the difficult ones need perfect communication and problem-solving skills, in addition to good level of knowledge and greater experience in dealing with such patients [2,3]. It has been proved that physicians with good communication skills can deal more accurately with difficult patients and solve their problems as well as provide them more satisfaction and ensure their compliance with therapy [3,4,5]. The present study was carried out mainly to estimate the percentage of difficult patients met by primary health care physicians, identify the characteristics of difficult patients and the conditions that make them challenging for their physicians as well as to evaluate coping strategies and self-efficacy of primary healthcare physicians in dealing with these patient.

In the current study, majority of the primary healthcare physicians (93%) had reported dealing with difficult patients and among them, 48.4% reported meeting less than 10% of difficult patients in their practice whereas 21.5% met more than 25% of difficult patients. Other similar studies carried out in USA [21,22] and Germany [19] reported lower rates as general practitioners reported that 16% of their patients were perceived as challenging. In Turkey and in accordance with our finding, vast majority of physicians (92.8%) claimed that they had experienced in dealing with difficult patients [17].

Certain patients` traits and conditions were considered by the primary healthcare physicians as characteristics of difficult patients as a result of the difference between the perceptions of physicians from that of patients [23]. Also, physicians under certain conditions tend to describe patients as difficult and the relation between them became disrupted; these conditions include lack of job satisfaction, excess workload, work-related fatigue, and long working hours [13,17,24]. It is very important to note that, communication skills of physicians play the more essential part in their dealing with patients and a patient described as difficult by one physician may not be so for another physician [25,26].

In the current survey, demanding patients ranked first of the difficult patients` traits, followed by patients with limited compliance and critical patients while patients with obsessive-compulsive personality ranked the last. Demanding patients and those with limited compliance might receive less information from the physicians about their illness and its management due to their low education and/or socio-economic status and therefore might behave as challenging patients [27]. However, in a study carried out by reported that higher educated patients are more difficult by insisting on unnecessary investigations while lower educated patients are less challenging by being more cooperative during treatment [28]. In a study carried out by Sandikci et al (2017), 51% of patients experiencing negative communication with physicians were university graduates and 43.3% were illiterates [17]. According to an early study carried out by An PG, et al (2009), elderly patients, those divorced or widowed, and women were traits of difficult patients according to physicians as they were more insisting on nonindicated drugs, dissatisfaction with the treatment given, and their expectations cannot be fulfilled with the given treatment [10].

While regarding difficult patients` conditions, in the present study, poly-pharmacy patients ranked first, followed by multi-morbidity patients, schizophrenic patients and patients with chronic pain while patients with high blood pressure and depression ranked the last two conditions. In a similar study carried out in Germany by Goetz et al (2018) [19], patients with somatization disorder, chronic pain and alcohol addiction were perceived by general practitioners as difficult medical conditions whereas chronic conditions such as hypertension, diabetes type 2 and heart failure ranked the lowest medical conditions. In a Trukish study, the commonest condition of difficult patients was patients with multiple complaints and chronic diseases whereas the least common one was drug addiction [17]. Some other studies considered patients with psychiatric diseases as the most challenging patients whereas those with cardiovascular diseases are the least challenging [29,30]. Steinmetz and Tabenkin (2001) [25] and Goetz K (2018) [19] observed that aggressive patients ranked first regarding patients` challenging traits of patients. Lynch et al (2007) observed that low educated patients were more frequently utilizing healthcare services and consequently labeled as difficult patients by physicians [16].

Regarding strategies followed by primary healthcare physicians during dealing with difficult patients in the current study, remain calm and avoid arguing most or all the time were reported by almost half of them, whereas be empathetic and engage in conversation most or all the time were reported by less than half of them. Kutlu et al. observed that 71% of the surveyed physicians believed that understanding the emotional states of both the patients and their relatives is an essential element of their practice and 57.8% of them didn’t allow strong relationships with patients and/or relatives to affect them [31]. Unavailability of administrative policies and coping with difficult patients strategies may contribute significantly in the problem of “difficult patients”. Therefore, identifying and coping with difficult patients should not be a task of one person as should be a task of teamwork consists of all physicians, patients, and system-related problems and should be applicable to different situations in clinical practice [32,33].

The highest score of coping with difficult patients was observed among physicians with experience ranged between 6 and 10 years in healthcare while the lowest score was reported among those whose experience ranged between two and five years. In another cohort study, the primary healthcare physicians with 20 years of experience expressed better coping with difficult patients [22]. Among family physicians, those with 10 years of experience encountered less difficulty patients than those with less than 10 years of experience. Also in Turkey [17], the majority of physicians with less than 10 years of experience reported more frequent negative interactions with patients and/or relatives than those with more than 10 years of experience. This could be explained by the fact that the ability of physicians to recognize difficult patients became easier due to learning how to cope with them.

Although attending training course in communication skills was associated with higher score of coping with difficult patients, it was not significant in the current study; mostly due to relatively small size.

This study, up to our knowledge is the only of its type to be conducted at least in our Region and it carries great importance in identifying the perception of primary healthcare physicians regarding difficult patients and assess different strategies to cope with them with an aim of improving the whole process of quality of health care provided to them, However, the study has some important limitations. First, the cross-sectional design with its inherited limitation regarding the temporal cause-effect relationship is considered an important limitation. Second, other important factors were not investigated as the number of patients examined in a usual shift by physicians and satisfaction with job. The last limitation is the relatively small sample size, although we included all the available population of primary healthcare physicians.

5. Conclusion

Majority of primary health care physicians, Ministry of Health in Taif city, Saudi Arabia had history of dealing with difficult patients. A considerable proportion of them reported meeting more than 25% of challenging patients. Difficult patients` traits are demanding patients, patients with limited compliance and critical patients. Concerning difficult patients` conditions, the commonest reported were poly-pharmacy patients, multi-morbidity patients, schizophrenic patients and patients with chronic pain while patients with high blood pressure (4.13±2.49) and depression were the least frequently reported two conditions. Regarding strategies followed by primary healthcare physicians during dealing with difficult patients, remain calm and avoid arguing most or all the time were reported by most of physicians. Coping with difficult patients was highest observed among physicians with experience ranged between 6 and 10 years in healthcare.

6. Recommendations

Based on the results of the present study, the following are recommended:

1. Organizing specific training courses for physicians regarding communication skills and coping strategies to deal with “difficult patients” at primary healthcare centers.

2. PHC physicians should provide adequate information to all patients without differentiation between them as patients receiving less information from the physicians about their illness and its management therefore might behave as challenging patients.

3. Educational sessions should be conducted for patients at waiting room areas of primary health care centers on the way they should deal with their physicians.

4. Further study is recommended including larger sample of PHC physicians from different disciplines and including data about the number of patients examined in a usual shift by physicians and their satisfaction with job.

References

[1]   | Aspegren K. Teaching and learning communication skills in medicine - a review with quality grading of articles. Medical Teacher 1999; 21: 563-570.
[2]   | Brown J. How clinical communication has become a core part of medical education in the UK. Med Educ 2008; 42: 271-278.
[3]   | Đorđević V, Braš M, Brajković L. Person-centered medical interview. Croat Med J 2012; 53: 310-313.
[4]   | Zolnierek KB, DiMatteo MR. Physician communication and patient adherence to treatment: a meta-analysis. Med Care 2009; 47: 826-834.
[5]   | Maguire P, Pitceathly C. Key communication skills and how to acquire them. BMJ 2002; 325: 69.
[6]   | Elder N, Ricer R, Tobias B. How respected family physicians manage difficult patient encounters. J Am Board Fam Med. 2006; 19(6): 533-41.
[7]   | Fiester A. The “difficult” patient reconceived: an expanded moral mandate for clinical ethics. Am J Bioeth. 2012; 12(5): 2-7.
[8]   | McWhinney I. A Textbook of Family Medicine. New York: Oxford, 1989: 96-8.
[9]   | Edgoose J. Rethinking the difficult patient encounter. Fam PractManag. 2012; 19(4):17-20.
[10]   | Dhar H, Dhar D. Difficult patient encounters in the developing world. Middle East Journal of Family Medicine 2013; 11: 41-47.
[11]   | An PG, Rabatin JS, Manwell LB, Linzer M, Brown RL, Schwartz MD. Burden of difficult encounters in primary care: data from the minimizing error, maximizing outcomes study. Arch Intern Med 2009; 169: 410-414.
[12]   | Magnus SA, Mick SS. Medical schools, affirmative action and the neglected role of social class. Am J Public Health 2000; 90: 1197-1201.
[13]   | Krebs EE, Garrett JM, Konrad TR. The difficult doctor? Characteristics of physicians who report frustration with patients: an analysis of survey data. BMC Health Serv Res 2006; 6: 128-135.
[14]   | Haas LJ, Leiser JP, Magill MK, Sanyer ON. Management of the difficult patient. Am Fam Physician 2005; 72: 2063-2068.
[15]   | Kroenke K. Unburdening the difficult clinical encounter. Arch Intern Med 2009; 169: 333-334.
[16]   | Lynch DJ, Mc Grady AV, Nagel RW, Wahl EF. The patient-physician relationship and medical utilization. Prim Care Companion J Clin Psychiatry. 2007; 9(4): 266-70.
[17]   | Sandikci KB, Üstü Y, Sandikci MM, Tetik BK, Uǧurlu DM. Attitudes and behaviors of physicians in dealing with difficult patients and relatives: a cross-sectional study in two training and research hospitals. Turk J Med Sci 2017;47: 222-233.
[18]   | Kingdom of Saudi Arabia. Taif Governorate. Available at: http://www.taifcity.gov.sa.
[19]   | Goetz K, Mahnkopf J, Kornitzky A, Steinhäuser J. Difficult medical encounters and job satisfaction - results of a cross sectional study with general practitioners in Germany. BMC Family Practice201819: 57.
[20]   | Jacksonville University. 6 tips for dealing with difficult patients. Available at: https://www.jacksonvilleu.com/blog/nursing/difficult-patients/.
[21]   | Hahn SR, Kroenke K, Spitzer RL, Brody D, Williams JB, Linzer M. The difficult patient: prevalence, psychopathology, and functional impairment. J Gen Intern Med. 1996; 11: 1-8.
[22]   | Hinchey SA, Jackson JL. A cohort study assessing difficult patient encounters in a walk-in primary care clinic, predictors and outcomes. J Gen Intern Med. 2011; 26: 588-94.
[23]   | Miles A. Complexity in medicine and healthcare: people and systems, theory and practice. J Eval Clinic Pract. 2009; 15: 409-10.
[24]   | An PG, Manwell LB, Williams ES, Laiteerapong N, Brown RL, Rabatin JS, Schwartz MD, Lally PJ, Linzer M. Does a higher frequency of difficult patient encounters lead to lower quality care? J Fam Pract 2013; 62: 24-29.
[25]   | Steinmetz D, Tabenkin H. The ‘difficult patient’ as perceived by family physicians. Family Practice 2001; 18: 495-500.
[26]   | Romano SE, Schwenk TL. The challenging patient encounter. In: Sloane PD, Slatt LM, Ebell MH, Jacques LB, Smith MA, editors. Essentials of Family Medicine. 5th ed. Philadelphia, PA, USA: Lippincott Williams & Williams; 2008. pp. 31-38.
[27]   | Celik F. Communication in health institutions; a research on patient and medical staff. PhD, Selçuk University Institute of Social Sciences, Konya, Turkey, 2008 (in Turkish).
[28]   | Atilla G, Oksay A, Erdem RA. Qualitative pre-study on the physician-patient communication. İstanbul University Faculty of Communication Journal 2012; 43: 23-37.
[29]   | Haas LJ, Leiser JP, Magill MK, Sanyer ON. Management of the difficult patient. Am Fam Physician. 2005; 72: 2063-8.
[30]   | Arndt B, Tuan WJ, White J, Schumacher J. Panel workload assessment in US primary care: accounting for non-face-to-face panel management activities. J Am Board Fam Med. 2014; 27: 530-7.
[31]   | Kutlu M, Çolakoğlu N, Özgüvenç ZP. A study on the importance of empathy in patient-doctor relationship. Sağlıkta Performans ve Kalite Dergisi 2010; 1: 127-143
[32]   | Lorenzetti RC, Jacques CM, Donovan C, Cottrell S, Buck J.. Managing difficult encounters: understanding physician, patient, and situational factors. Am Fam Physician 2013; 87: 419-425.
[33]   | Çelik C, Yurdakul M. Problem solving skills of hospital managers: a field research. Journal of the Cukurova University Institute of Social Sciences 2009; 18: 95-108.