How to Handle Conflict in Physician–Patient Relationships

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Studies suggest that physicians rate between 10 and 15% of patient visits “difficult.”¹ This is important for a variety of reasons: Patient satisfaction is a frequently measured parameter, and poor interactions may lead to bad ratings. Personal satisfaction on the part of the provider is also an issue, and frustrating interviews can leave the physician dissatisfied. If the patient inter­action is sidetracked into an angry discussion, important parts of the clinical history might be missed. Finally, increased legal issues arise for physicians who have frequent difficult interactions. Board complaints and even lawsuits may result.

Even those of us with the best bedside manner still encounter these interactions. What’s a physician to do when confronted with a difficult interaction?

Case Study

The rheumatologist saw a 45-year-old woman for diffuse aches and pains. She felt the symptoms were most compatible with fibromyalgia. A thorough workup was negative. Multiple medications were tried, but the patient was intolerant and had side effects to all medications. The patient returned with widespread pain and stated she had looked on the Internet and was sure this was multiple sclerosis. The neurologic exam was normal, and the symptoms seemed mainly musculoskeletal. The rheumatologist suggested not doing a referral to a neurologist because the symptoms were not suggestive of MS. The patient became angry and stormed out. The doctor drafted a dismissal letter, but it was not sent immediately. When the patient called to make a follow-up appointment, the receptionist stated she would have to check with the doctor first. The patient swore at the receptionist and hung up. The patient then wrote a complaint letter to the Medical Board.

Understanding Conflict

Clear communication is essential when there is conflict or misunderstanding. Rheumatologists should start all visits by setting the agenda. What are we talking about today? If the clinician has issues that he/she needs to discuss, he/she should let the patient know their intentions at that time. If the interview turns sour, one needs to have a clear understanding of why the patient is angry, upset or concerned. It can be you or the patient with the issue. Sometimes, we get upset when the patient triggers our own pet issue (e.g., narcotics, boundaries, multiple somatic complaints, someone who reminds us of our last difficult patient).

Care should be taken not to perceive the conflict as personal. Often, conflict may be inevitable, but deescalating it early is vital. Don’t wait for the interview to blow up before saying, “Time out; what’s going on here?”

Physicians may have emotional responses to a difficult encounter. Often, the patient starts a difficult encounter with a high emotion, such as anger or sadness. We need to be aware of our own maladaptive responses. This could include getting angry in return, telling the patient there is nothing wrong with them or ignoring calls or e-mails from the patient. The physician must remain calm and focus on how best to respond to these situations.

Don’t wait for the interview to blow up before saying, ‘Time out; What’s going on here?’

In the case above, the issue is that the patient was making unnecessary or unreasonable requests. Other behaviors that can be an issue include not following instructions, reacting with anger toward the doctor and undermining a therapeutic alliance with the physician. Managing conflict is especially challenging when the patient is angry, intimidating or threatening. If one can understand where the anger is coming from (i.e., fear), one may find the path to deescalating the situation.

We need to understand the behavior of the patient in the context of their conditions. Conflict may arise when the patient has irrational fears or unmet expectations. In this case, there was a deep fear of MS, which had crippled a friend of the patient.

For this situation, conflict resolution requires the physician to understand the patient’s concerns, address them and verbalize their understanding of how scary MS can be. This reflected listening technique would have helped develop empathy and, possibly, defused the situation. When the physician can identify the fear or concern, then he/she and the patient can work toward a mutual understanding, healing and common ground.

Manage the Conflict

Your communication skills and demeanor are paramount in a conflicted situation. Remember to use nonconfrontational language, such as “I statements” (see below) to verbalize your own feelings and thoughts. Expressing feelings in a nonblaming way can help build the relationship. Stay calm, and speak politely in a soft voice. Use active or reflective listening to verbalize what you heard and what the patient said.

Recognize your own negative feelings. If the patient has turned you off, you will have a difficult time in terms of caring for them.

Body language speaks volumes and is quickly picked up on in tense situations. Make sure you are sitting down, leaning in and using a calm, compassionate voice.

Try to come up with a win–win after hearing the issue or conflict.

There are indeed behaviors that should not be tolerated. Office policy should be clear around language, threats and name calling. Boundaries should be established about what you will tolerate. If difficult encounters are anticipated, they should be scheduled at a less busy time.

You should never put yourself or your staff in danger, and if you feel threatened, established protocol should be followed.

You should document conflict and inappropriate behavior in the medical record in a clear and nonjudgmental fashion.

Despite your best efforts, a physician-patient relationship may not be salvageable. Terminating a patient should be a last resort, but if behavior is intolerable or continues that may be the only option. If the decision is made to dismiss, each state will have guidelines. Consider a return-receipt-requested letter and a reasonable time frame that you will be available for emergencies.

Patient Interaction Pearls

1. Active listening—Physicians should listen in an open and attentive manner. Be careful of your own body language when tensions are high. Any probing should be done in a mild and respectful way. Patients should be able to express themselves, and the physician should listen.
2. Reflective listening—Summarizing what you heard the patient say and saying it back to them is a wonderful way to ensure you really heard what the patient said: “You are right. I did not refer you to that specialist when you requested it.” This builds empathy because the patient realizes you have heard them.
3. Acknowledge the emotions—“I can see you’re upset.” This reflects back the emotion you are seeing, and builds empathy and rapport even in a difficult situation.
4. Apologize if appropriate—It really can be our fault sometimes. If that is the case, admit it and promise to make it right. “I am sorry you felt that way. That was not what I intended to suggest. I felt a referral was not indicated because the symptoms were not neurologic.”
5. Build a win–win—“Let’s act as a team and monitor your symptoms closely. I will help you through this situation and we will work through this together.”
6. Remember to identify the “chief concern,” which is often different than the medical “chief complaint.” The most important questions try to elicit the chief concern: “What do you think this is? What is it that most worries you about this? Why today? How is this affecting your life now?”
7. If you have a problem, make an I statement. Often, we express feelings and opinions without assuming responsibility for them. I statements consist of a description of how you feel and why you have these emotions. An I statement might be: “I feel upset when you raise your voice, because this triggers my own anger response and makes it harder for me to understand what you are going through.”

Conclusion

Communication with the patient when there is conflict is a skill set that can be taught or learned. Poor communication is associated with poor clinical outcomes, reduced patient and reduced provider satisfaction, and ultimately liability claims. We hope that awareness of its importance will encourage deeper awareness and interest in effective communication skills.

Dennis J. Boyle, MD, is an associate professor of medicine and rheumatology at Denver Health and the University of Colorado.

Reference

1. Jackson JL, Kroenke K. Difficult patient encounters in the ambulatory clinic. Clinical predictors and outcomes. Arch Intern Med. 1999 May 24;159(10):1069–1075.