When emergency physicians meet patients displaying irritable behaviours: a randomised vignette-based experiment investigating physicians' emotions and clinical reasoning.

Authors

Linda M Isbell, Nathan R Huff, Guanyu Liu, Howard Bessen, Vincent Kan, Isabella Levesque, Matthew Bird, Peter Smulowitz

Published in

BMJ quality & safety. Jul 12, 2026. Epub Jul 12, 2026.

Abstract

Clinical encounters with patients who display challenging behaviours (eg, rude, demanding) are increasingly common in emergency departments and can heighten negative emotions, compromise healthcare quality and impact physician well-being. This study investigated the influence of patients' irritable behaviours on physicians' emotions, clinical assessments, decisions and behaviours, and the extent to which physicians' predispositions to experience anxiety and concern about bad clinical outcomes (ie, stress from uncertainty) may magnify these effects. We also explored whether these effects differed if patients had a stigmatised condition (mental illness history).
Experienced emergency physicians (n=134) completed a randomised vignette-based experiment between June and August 2022. Physicians assessed four patients in computer-simulated, interactive clinical encounters in which patient behaviour (irritable vs calm) and mental illness history (present vs absent) were varied within subjects. Physicians viewed each patient's health record, a video-recorded encounter and physical exam results, and provided patient assessments, clinical decisions, ordered tests and reported a diagnosis. Physicians also reported their emotional reactions to each patient and completed the Stress from Uncertainty Scale (SUS) after assessing all patients. We adhered to the Guideline for Reporting Vignette Experiments.
Physicians reported greater anger, anxiety and fatigue and less empathy, happiness and engagement during encounters with patients displaying irritable (vs calm) behaviours (all ps<0.001) and evaluated those with irritable behaviours as poorer historians, more likely to be exaggerating pain, less cooperative, engaged, likeable, likely to adhere to treatment and likely to return to work (all ps<0.001). Interactions revealed that SUS amplified the impact of patients' irritable behaviours with high SUS associated with greater physician anger, anxiety and fatigue (all ps≤0.04) and with physicians evaluating these patients as poorer historians, less likely to adhere to treatment and less likeable (all ps≤0.03). Effects were similar regardless of patient mental illness history (all ps>0.60). No effects emerged for clinical decisions, behaviour or diagnosis.
Although patients' irritable behaviours adversely influenced physicians' emotions, engagement and patient assessments, they did not affect the quality of care provided (ie, clinical decisions, behaviour, diagnostic accuracy). Despite this, our findings have important implications. Physicians' reactions to patients displaying irritable behaviours may reduce the quality of physician-patient relationships (eg, reduce trust, effective communication) and contribute to physician burnout-both of which can compromise patient care. Additional research is needed to investigate the multiple ways in which emotional factors can impact patient care quality and safety.

PMID:
42437698
Bibliographic data and abstract were imported from PubMed on 13 Jul 2026.

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