Introduction

Demanding behavior is a pattern of acting characterized by an excessive need for attention, control, or validation from others. Patients who display demanding attitudes use health services more frequently, are seldom satisfied with received care, and often have poor general, physical, and emotional health. Their social functioning is impaired, and they can even experience physical pain.¹

Patients often expect physicians to prescribe medication, perform diagnostic tests, or refer them to a specialist or hospital. However, in almost half of the cases, doctors perceive these requests as unjustified.^2,3 Failure to meet these expectations is one of the main factors, alongside persistence of residual symptoms, that contribute to patient dissatisfaction. Such a demanding attitude may, in turn, lead to legal consequences for physicians or hospitals. In recent years, the percentage of patients in Poland claiming to have fallen victim to a medical error has increased. Subsequently, the number of lawsuits related to medical malpractice has also risen.⁴

This study aimed to assess the prevalence of demanding attitudes among patients, the most common manifestations of entitlement, and their impact on daily medical practice as well as subsequent diagnostic and therapeutic procedures. To do that, we conducted a survey among physicians working in Polish hospitals.

Patients and methods

Results

Most respondents had 11–20 years (30.3%) or less than 5 years (28.2%) of working experience. A hospital was most frequently indicated as the main place of work (99.2%). Among the medical specialties, the majority were noninterventional (65.1%), followed by interventional (25.6%), and diagnostic (9.2%). Adults accounted for 62.2% of the patients.

Almost 90% of the surveyed physicians stated that they encountered demanding attitudes among their patients. There was no association between the prevalence of demanding attitudes and the type of medical specialty (P = 0.2) or the patient’s age (adult or pediatric; P = 0.09). The most common response regarding the frequency of experiencing this type of behavior was “sometimes” (42.9%), followed by “rarely” (29%).

The majority of the respondents (80.3%) selected rudeness as the most common manifestation of a demanding attitude adopted by the patients. Over half of the participants experienced persistent requests (54.6%) and aggressive behavior (50.4%). Other reported manifestations were: direct request with an actual reason (31.1%), intimidation (30.7%), simulating symptoms of illness (26.1%), attempted bribe (8%), and other (2.9%).

When asked about the most common subjects of patients’ claims, 55% of the respondents selected imaging tests, 52.5% selected admissions to hospitals or specialist clinics, 37.8% marked laboratory tests, 24% indicated prescriptions, and 22.3% chose sick leave.

Moreover, the majority of the respondents (72.7%) felt that over the years, demanding attitudes have become more frequent. In comparison with previous years, 74.8% of the surveyed doctors felt more concerned about the possibility of making a medical error and facing legal consequences. An association between increased concerns about committing a medical error and years of working experience was found, with 85.7% of the physicians with 20 or more years of experience and 71.6% of those working less than 5 years having such concerns; P = 0.007).

The most common responses regarding how often a patient’s demanding attitude was the reason for ordering additional laboratory tests or issuing additional medical certificates were “rarely” (31.1%) and “sometimes” (29.8%). There was a relationship between the frequency of a demanding attitude as a reason for ordering additional laboratory tests or issuing additional medical certificates and increased concerns about making a medical error (P <⁠0.001). A higher level of concern about medical errors resulted in an increased number of ordered laboratory tests or medical certificates issued due to pressure from the patients.

More than half of the respondents (56.7%) claimed that patients’ demanding behavior was a moderately common reason for ordering additional imaging tests, such as ultrasound, X‑ray, computed tomography (CT), and magnetic resonance imaging (MRI). The χ² test showed an association between the frequency of demanding attitudes as a reason for ordering additional imaging tests and increased concerns about making a medical error (P <⁠0.001). The physicians expressing greater concern about medical errors tended to order more imaging tests in response to the patients’ demands.

When faced with demanding attitudes, 86.1% of the surveyed physicians tried to explain to the patients why their expectations lacked validity. More than half (51.7%) responded that they provided information about all possible health, legal, organizational, or financial consequences related to the subject of the patients’ claims. As many as 31.1% of the respondents declared that they did not succumb to such pressure without explaining it to the patient. If a patient presented symptoms of anxiety or hypochondria, 25.6% of the doctors expanded the medical interview and suggested a psychological or psychiatric consultation. After persuasion, 22.7% of the survey participants usually conceded to the patients’ requests. Only fewer than 1% of the respondents (0.84%) complied with the patients’ demands without taking any further steps.

The last 5 questions concerned referrals for laboratory and imaging tests in everyday medical practice. Almost 70% of the respondents (69.8%) declared that they always or very often informed their patients about possible adverse effects which might result from X‑ray and electromagnetic field radiation or intravenous contrast agents when ordering imaging tests, whereas 7% of the physicians did not provide information about these issues at all or did it very rarely.

The majority of the study participants (77.3%) believed that they ordered an adequate number of laboratory tests considering the patient condition. According to 45.8% of the respondents, the overall number of laboratory tests ordered could be reduced without any harm to the patients. The χ² test demonstrated a relationship between this opinion and greater working experience (P = 0.04). Most respondents (81.1%) also thought that they ordered an adequate number of imaging tests considering the patient condition. The respondents had various opinions on reducing the overall number of imaging tests ordered without causing harm to the patients—40.8% of the surveyed physicians believed that it was possible, 39.9% disagreed, and 20.2% were undecided.

Discussion

In recent years, the attitude of entitlement among patients has become increasingly common. Nearly 90% of the surveyed physicians reported encountering this issue in their practice. We did not find a significant difference in the frequency of demanding attitudes among patients based on the physician’s specialty or the patient’s age. Available literature highlights several factors that foster the feeling of entitlement. Female doctors face more demanding patients than their male counterparts. Other factors include doctors’ poor communication skills, excessive workload, young age, lack of experience, and discomfort related to uncertainty.^3,5 In turn, patients displaying demanding behavior often have undiagnosed psychiatric illnesses, personality disorders, tendencies towards psychosomatic illnesses, or unrealistic expectations regarding health care.^1,5-7

In our study, the entitled attitude of patients most often manifested as rudeness (80.3%), persistent requests (54.6%), or aggressive behavior (50.4%). Interestingly, the most common subjects of claims were requests for additional imaging tests (55%) or referrals to hospitals (52.5%). In contrast, in a Norwegian study,⁸ the most frequent disputes concerned disagreements over treatment methods (requests for antibiotics or sedatives for individuals with addictions) and requests for unjustified medical certificates of illness.

Our survey showed that as many as 74.8% of the physicians felt concerns regarding the possibility of making a medical error and facing its consequences. The only factor influencing this finding was years of professional experience (P = 0.007), where the physicians with the most years of practice (>20 years) felt the greatest distress over this issue. This might be caused by changes in both the health care system (eg, favoring B2B contracts between doctors and hospitals) and patients’ mentality, as well as the increased workload of physicians.

These concerns are likely also related to numerous legal consequences of medical malpractice. According to the data from the National Prosecutor’s Office, in 2021, 1751 medical error investigations were initiated in Poland.⁴ Interestingly, most medical cases are ruled in favor the defendant, as demonstrated in the study by Tymiński et al.⁴ This is partly due to the inability of most patients to distinguish between medical errors and complications or adverse effects of the treatment provided, which are beyond physicians’ control. To protect themselves from potential errors, doctors often order additional tests. We found that the physicians who expressed concerns about making a medical error and facing its consequences were prone to order additional laboratory (P <⁠0.001) and imaging (P <⁠0.001) examinations. This not only increases the costs of diagnostics but may also expose patients to adverse effects from the use of radiation (X‑ray, CT), electromagnetic fields (MRI), or intravenous contrast agents, which they are not always aware of. This is an important issue, given the general increase in the number of imaging tests ordered. In the years 2010–2020, the number of CT scans performed at one of the largest hospitals in Silesian Voivodeship in Poland increased 1.8‑fold.⁹ This highlights the need for rational ordering of imaging tests to avoid unnecessary radiation exposure and its consequences, such as an increased risk of cancer development.^10,11 A study by Walderhaug et al¹² on avoiding excessive use of imaging by primary care physicians emphasizes the key role of building a long‑term, continuous doctor‑patient relationships based on trust for patients to accept physicians’ decisions. However, in our study, nearly all respondents worked in hospitals, where time and opportunities to build such relationships are limited.

In the case of encountering a demanding patient, various techniques and strategies can be employed to improve doctor‑patient communication, thereby increasing patient satisfaction, improving health outcomes, and reducing the number of complaints and lawsuits. Our study found that most physicians acted in response to the patients’ entitled attitudes (99.2%). The most common actions included explaining the lack of validity of the patients’ expectations (86.1%) and outlining the potential health, legal, organizational, or financial consequences associated with their claims (51.7%). Only 31.1% of the respondents did not agree to the patients’ requests without providing an explanation or justification, which indicates that most physicians attempt to resolve the situation through proper communication with the patient. Additionally, 25.6% of the doctors extended the interview and suggested psychological or psychiatric consultations when the patient exhibited symptoms of anxiety or hypochondria, which is supported by available literature.^1,6

The use of appropriate strategies in communication with patients appears to be the best way to handle entitlement and resolve potential disputes. Haas et al⁵ outlined a list of specific techniques that are helpful during encounters with demanding patients. These primarily include improving listening and understanding skills, adopting a collaborative doctor‑patient relationship model and an empathetic approach, and promoting continuity of patient care. In contrast, Ranjan et al¹³ indicate that few physicians have naturally good communication skills, and there is a need for their participation in organized, formal training in this area.