Do irritable patients influence physician judgment?

Clinical takeaway: When patients present as frustrated or angry, clinicians should be aware that these behaviors may unconsciously influence their emotional reactions and perceptions of patient credibility, engagement, and adherence, even when diagnostic decisions remain unchanged.

Difficult patient interactions are increasingly common in emergency departments. This study suggests that patient irritability can shape physicians’ emotional responses and judgments, potentially affecting the clinician-patient relationship and contributing to burnout.

In a randomized vignette-based experiment, investigators evaluated how patient irritability affects emergency physicians’ emotions, clinical reasoning, and decision-making. A total of 134 attending emergency physicians from 46 US states assessed four simulated ED cases featuring standardized patients who displayed either calm or irritable behaviors while providing identical clinical information. Physicians also completed a measure of “stress from uncertainty,” reflecting anxiety and concern about adverse outcomes.

Compared with calm patients, irritable patients elicited substantially more physician anger, anxiety, and fatigue, while reducing empathy, happiness, and engagement. Physicians also viewed irritable patients less favorably, rating them as poorer historians, more likely to exaggerate pain, less cooperative, less engaged in their care, less likely to adhere to treatment, and less likely to return to work. These effects occurred despite no differences in the medical information presented.

Notably, physicians who were more distressed by clinical uncertainty experienced an even greater emotional impact and were more likely to view irritable patients as untrustworthy, unlikable, and unlikely to follow treatment recommendations.

However, the study found no evidence that patient irritability affected test ordering, admission decisions, need for consultation, diagnostic accuracy, or final diagnoses. Correct final diagnoses were made in about 53% of cases overall, regardless of patient behavior.

“Medicine is inherently uncertain and emotional, especially in the ER,” lead author Linda Isbell, PhD, said. “We need a systemic shift that acknowledges the human reality of uncertainty and emotions in medicine and supports both doctors and patients as they work toward a common goal: health and well-being for all.”

Source: Isbell LM, et al. (2026 July 12) BMJ Qual Saf. When emergency physicians meet patients displaying irritable behaviours: a randomised vignette-based experiment investigating physicians' emotions and clinical reasoning