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Difficult doctor-patient relationships: Preventing problems before they start
An article for physicians by physicians
Originally published December 2008
IS0892-E

Of interest to all physicians

The basis for a good doctor-patient relationship is mutual respect and understanding. At times, these relationships may be challenging, and may even result in ending the relationship. However, there are strategies that might prevent this and may also prevent medico-legal difficulties. The following cases from CMPA files illustrate some of the issues that may underlie difficult doctor-patient relationships.

Case 1

A 40-year-old man, well known in the emergency department for exhibiting drug seeking behaviour and being disruptive and aggressive, presented with a headache and demanded to be seen immediately. He smelled of alcoholic beverages and when the nurse attempted to take his blood pressure he refused and became verbally abusive. The emergency physician, upon hearing the confrontation and knowing this patient, went into the room to intercede. The situation escalated with both the physician and patient shouting and shaking their fists. The patient later commenced a legal action against the emergency physician, claiming verbal and physical assault.

Upon investigation, including review of the emergency department record, there was no evidence of physical assault; however, the allegedly aggressive verbal exchange had been documented by nursing staff and witnessed by a neutral third party. The patient claimed the incident caused him significant embarrassment and psychological damage. The CMPA was unable to find any support for the physician’s actions as the medical experts consulted opined the physician failed to take appropriate steps to calm the patient and defuse the situation.

Case 2

During a routine office visit a family physician became aware that an elderly patient had land for sale. He had cared for the patient for many years and they had often discussed business. The physician entered into a sales agreement with the patient to buy the land. The physician had a lawyer draft a sales and purchase agreement after having the land surveyed for water and sewage requirements.

Before the sale was finalized the patient changed his mind. The physician started a legal action to recover his legal and survey costs. Because of the legal action, the physician terminated the doctor-patient relationship, prompting the patient to complain to the provincial regulatory authority (College).

The College concluded the physician’s conduct was unprofessional. The physician subsequently abandoned the legal action and wrote a letter of apology to the patient. The College accepted the physician’s letter of apology and his commitment not to enter into personal transactions with patients and took no further action with the complaint.

Case 3

An elderly woman with multiple medical problems had been followed for many years by a family physician in her home because she was wheelchair bound. However, once the physician relocated to an office with open access, he told the patient and her son that she should attend the office for appointments to allow for more thorough examinations.

Despite discussion, the patient’s son continued to request house calls and prescription renewals over the phone. Although he had waived charges previously, the physician began to charge for the uninsured services, hoping to encourage the patient to attend at the office. After paying two invoices, the patient's son became irate upon receiving a third invoice for a missed appointment. He was verbally abusive to staff and used profanity.

On a follow up house call, the physician discussed the situation with the patient and informed her that she would have to talk to her son about the situation. He told her that if her son continued to be abusive he would have to discontinue with her care. The son continued to be verbally abusive, so the physician informed the son and subsequently the patient that, given the circumstances, he was terminating the doctor-patient relationship.

The son complained to the provincial College alleging that the family physician had billed for writing prescriptions, failed to return phone calls, overdosed his mother with medications, failed to carry out house calls, and intimidated the patient. The College, on reviewing the physician’s notes on the care he provided the patient and the documented incidents of verbal abuse by the son, supported the physician’s decision to terminate the relationship due to the son's threatening behaviour. The College stated the physician had provided exemplary care until the son’s extravagant expectations and unacceptable manner made termination of the relationship necessary.

As these cases illustrate, challenging doctor-patient relationships can result in medico-legal difficulties for the physicians involved. If you feel a relationship with one of your patients is becoming challenging, you may wish to consider the following suggestions for identifying the source of the difficult relationship.

Physician factors

As in Case 1, when a conversation with a patient leads to confrontation, the professional approach would be to take steps to defuse the situation. This creates a more positive atmosphere conducive to starting a new encounter on a calm note.

If your communication style does not match the patient’s needs, it may lead to difficulty with understanding and frustration for both parties. In such circumstances, it is sometimes useful to switch to another approach, such as using non-technical language, or ending a confrontational conversation calmly to defuse the situation. In other circumstances, such as with a non-compliant patient, requesting assistance from a physician colleague or other health care professional may improve the therapeutic relationship.

Case 2 demonstrates the importance of clearly separating your professional role as a physician from any personal transactions with a patient. One College has stated these personal transactions “can result in the physician’s actions being questioned and their motives maligned through perceptions and allegations of coercion, even if based solely on the fact of the acknowledged power imbalance between any physician and his/her patient.”

Patient factors

When a patient’s attitude or behaviour appears confrontational to an agreed upon plan for investigation or treatment, it is important not to assume such behaviour is directed at you. When a patient seems to be non-compliant, exploring the reasons for this might reveal a lack of understanding regarding medical problems. Good listening skills may help in detecting any underlying concerns.

Managing the differing expectations between physician and patient may lead to a more positive experience at the next encounter. Discussion of the differential diagnosis and a good consent discussion may improve a patient’s understanding and acceptance, thus reducing non-compliance. Adequate instructions regarding necessary follow up, and the signs and symptoms that require urgent or emergent care may help patients understand what is expected of them.

In some situations, a feeling of discomfort in the relationship may be due to conduct that occurs when a patient transgresses certain social boundaries. Clearly outlining your role as a physician, and the expected and appropriate patient behaviour can prevent further misunderstanding.

Family factors

Even the best intentioned family members, when faced with illness in a loved one, may interfere with treatment, communicate aggressively, or demand information or unnecessary investigations and treatments. In situations where there are many family members involved, you may find it useful to ask the family to appoint a spokesperson. An empathetic approach, recognizing a family member’s concern and fears, may change an uncooperative relative into an ally.

In a situation such as that in Case 3, where the physician’s best attempts at explanation were met with anger and resistance, careful documentation of the communication with the patient and family members will demonstrate your clinical care and attempts to resolve any friction.

Risk management considerations

The CMPA suggests the following risk management considerations when faced with a difficult doctor-patient relationship:

• Have you communicated clearly and empathetically when discussing diagnosis, investigation and treatment with your patient and his/her family?
• Have you managed your own feelings when faced with a confrontational patient encounter?
• Have you tried to identify and manage your patient’s expectations?
• Have you enlisted help from colleagues where appropriate?
• Have you enlisted help from the patient’s relatives, with the patient’s permission, or sought an opinion from a colleague or a specialist to help support your clinical decisions?
• Have you defined appropriate patient and staff conduct with an established office policy? Have you addressed recurring problems?
• Have you followed your College’s guidelines in situations where, despite your efforts, you have to end the doctor-patient relationship?