Duties and responsibilities

Expectations of physicians in practice

Dealing with conflict in the doctor-patient relationship

Originally published June 2013
P1302-1-E

Learning how to prevent or manage conflict effectively is an important clinical skill for physicians.

Studies indicate that up to 15% of patient encounters have been described by physicians as being difficult. Patients involved in these encounters may have worse short-term clinical outcomes.1

The CMPA's advice about managing such conflicts is based on experience in medico-legal matters, medical literature, and consultation with experts.

Case example: Termination of doctor-patient relationship leads to College complaint


A physician first saw a 55-year-old female for a prescription renewal for hormone replacement therapy. She expressed concern, given the patient's slightly increased systolic blood pressure and family history of stroke. After some discussion, the physician stopped the hormone replacement therapy and suggested starting treatment for the patient's osteopenia. Nutritional and other lifestyle changes were also suggested, but the patient was adamant these were unnecessary. At a subsequent visit, another medication was prescribed but the patient stopped taking it of her own accord because of symptoms she considered to be side effects. The patient demanded that the physician do something about these new symptoms and the doctor made referrals to appropriate specialists. The patient later requested more referrals to other specialists, but because the patient was now asymptomatic, the physician did not make these additional referrals. The patient stormed out of the office, slamming the door.

The patient continued to experience issues over time which were addressed in emergency department visits as well as with other physicians and with the same physician. The patient frequently appeared quite angry, loudly accusing the physician of never sending her for tests or referrals, or providing treatment. The patient refused to allow her medical records from other physicians to be sent to the attending physician.

Recognizing the patient's dissatisfaction and lack of trust in the doctor-patient relationship, the physician suggested to the patient that she find a new family physician. A termination letter was drafted, but it was not sent immediately. When the patient called for a new appointment, the office receptionist indicated that she would have to obtain permission from the physician before scheduling an appointment and outlined the content of the letter to the patient. The patient swore at the receptionist and hung up.

The patient subsequently complained to the medical regulatory authority (College).
 

Outcome

In this case, the College found no deficiency with the physician's medical care and stated there was insufficient evidence to comment on the complaints about the doctor's interpersonal skills.

The College did, however, have concerns with the process of communicating the termination of the doctor-patient relationship. It reminded the physician that patients should be notified in a timely fashion of a decision to end the doctor-patient relationship, and that this should be communicated in writing and, as appropriate, by direct communication between the physician and patient.

Although some patients may have expectations, or even demands, that are medically inappropriate and may complain to the College, physicians are not required to accede to patient demands that are medically unnecessary or inappropriate. Should the patient lodge a complaint, the College will generally expect the physician to have provided sound medical advice, to have presented it in a professional way, and to have documented the discussion in the medical record.

Understanding conflict

To avoid misunderstandings that can lead to conflict, clear communication is essential. Physicians should always let the patient know their intentions, whether asking personal questions, performing a physical examination or procedures, or responding to patient requests.

Conflict is normal, understandable, and inevitable. Conflict cannot be avoided at all times and when it does occur, care should be taken to understand the situation properly without taking it personally. Conflict that is addressed before it becomes unmanageable may present an opportunity to better understand patients and their needs. Conflict that is allowed to escalate, however, may become destructive.

Despite best intentions, physicians cannot meet all patient expectations. All physicians encounter difficult behaviour and conflict with some patients or patients' families. Such behaviours can include patients not complying with recommended investigations and treatments, repeatedly doubting the doctor's approach to their care, reacting with anger to their doctor's suggestions, or avoiding a therapeutic alliance with their doctor.

Difficult patient behaviours may evoke negative reactions in physicians. Physicians need to be acutely aware of maladaptive responses to which they may fall prey. These responses can include getting angry, blaming the patient, being accusatory, telling the patient there is nothing wrong with them or that there is nothing more that can be done, and ignoring phone calls or emails from the patient. None of these responses are helpful. Rather, physicians must strive to remain calm and focus on understanding the patient's behaviour and considering how to best respond.2

Managing conflict is particularly challenging when the other individual is angry, aggressive, intimidating, or threatening. Anger is always a secondary emotion. By understanding what is underlying a patient's anger, physicians can learn to confidently negotiate many of these situations.

Physicians should try to understand patients' behaviours in the context of their medical conditions. Conflict arises when expectations are not met. Conflict resolution requires physicians to focus first on patients' needs, and later on solutions. Initially, physicians should listen to patients to determine their needs. It helps if the physician confirms awareness of a patient's concerns and viewpoints by verbalizing and stating their understanding of the issue back to the patient. This approach demonstrates empathy and is reassuring to patients.

Patients and physicians can use this knowledge to work together to reach an appropriate solution. Determining the problems, goals, and respective roles of both the physician and patient can help identify where there are differences in opinion and how the situation might be resolved. Finding common ground validates patients and includes them in the diagnostic and healing process.

Managing conflict

Communication and manner are paramount. Throughout negotiation of a solution, physicians should use non-confrontational vocabulary. It can be helpful to use "I-statements," as illustrated in the examples below, to verbalize observations, thoughts, feelings, and needs.3 Such verbalizations help clarify the perspectives of the individuals in conflict. Expressing feelings in a non-blaming way helps build empathy. However, it may be difficult for physicians to be empathetic when they are feeling negative about a patient. Physicians should recognize their own emotions, tune into the emotional messages the patient is giving, and attend to nonverbal communication to develop some empathy for the patient's situation.

When a patient is agitated and confrontational, remaining calm and speaking politely in a soft voice often helps to diffuse emotions. Excellent communication skills are needed to de-escalate conflict. The environment must be safe and the discussion non-judgmental.

Five useful steps physicians can take in de-escalating the conflict include:

  1. Active listening. Physicians should give patients their full attention and use verbal prompts and nonverbal behaviour (e.g. body language) to encourage patients to share information. They should listen to patients. Any probing should be done in a gentle and open way. Statements or questions that could be seen as accusatory, such as "Why are you angry?" should be avoided as these may bring out negative emotions. Patients should be allowed to express themselves. Physicians should confirm what patients have said through reflection or summarizing.
  2. Agreeing. Patients need to feel they are being heard. Physicians should try to find a fact that they can agree with. "You are right. I did not refer you to the specialist when you requested that."
  3. Acknowledging the patient's feelings. "I can see this has made you quite upset." Reflecting the emotion back to the patient helps demonstrate empathy. When physicians show they understand why patients are experiencing a particular emotion, the situation usually improves. Through gentle questioning, physicians should explore the impact of the issue and acknowledge the patient's reaction. "I can see that you might have felt that I was not listening or did not care."
  4. Apologizing may be helpful. "I am sorry that you may have felt that way. That was not my intent. A referral was not necessary at the time since your symptoms had resolved."
  5. Acting as a team and working together without blame or judgment. "Even though I'm not referring you immediately, I am going to continue to monitor your condition very closely and we will work through this together." Statements that demonstrate a partnership are surprisingly important in establishing collaboration in the doctor-patient relationship.

Demonstrating genuine respect for the patient should weave through all aspects of the doctor-patient relationship and may need to be communicated more explicitly: "I know this is difficult for you. I'm impressed at your determination to get an explanation for your symptoms. That's a great quality and I'm going to help you get that explanation in whatever way I can. Let's work through this together step by step."

Practice management considerations

Office procedures and behavioural expectations should be made clear to patients from the start of a physician-patient relationship. Office brochures given to patients at the initial visit may help to educate them about these points.

Physicians may need to be explicit about what behaviour is unacceptable, for example, no shouting, name-calling, or threats. Once the boundaries are established, physicians should follow and apply them consistently. Patients should be encouraged to voice their concerns early so physicians or their staff can address these.

Patients who are known to be difficult can be scheduled at times that are less busy. Appropriate scheduling allows for time to manage such situations and avoids inconveniencing other patients.

There should be procedures in place on how to deal with abuse of staff. Physicians should not place their staff or themselves in danger. Office staff can be trained on how to set limits and deal with conflict. They can be offered scripts with suggestions on what to say and do in specific difficult situations. Staff must be reassured that physicians will support them if they follow the suggested protocol.

Inappropriate behaviour should be carefully documented in the medical record. Office staff subjected to inappropriate behaviour or discussions should also document these in a factual and non-judgmental way in the medical record.

Managing more difficult situations

Despite a physician's best efforts to prevent or resolve conflicts, there will be situations that do not improve.

If a physician feels unable to continue with a patient encounter because of the negative emotions and behaviour, it is reasonable to verbalize these feelings politely in a factual way, end the interview, and reschedule the remainder of the visit or have someone else take over. "I am finding it difficult to plan the next steps in your care when you are shouting. We will have to complete the remainder of the visit at another time. Let's schedule a new appointment."

Physicians should plan in advance for the next scheduled appointment and be prepared to give clear feedback. The following approach may be considered by physicians:

  • State the constructive purpose of the feedback.
  • Describe specifically what is known or has been observed.
  • Describe their own reactions or feelings.
  • Give the patient an opportunity to respond.
  • Offer specific suggestions for improvement.
  • Obtain a commitment for change from the patient.
  • Summarize and express support.
  • Plan another appointment to follow up, monitor, and re-evaluate.
  • Document the discussion factually in the medical record.

In general, terminating a patient from a practice is a last resort if the feedback does not lead to changed behaviour. In terminating a physician-patient relationship, physicians should follow the guidelines set out by their College. Also see "Ending the doctor-patient relationship."

 

References

  1. Hinchey, S.A., Jackson, J.L., "A cohort study assessing difficult patient encounters in a walk-in primary care clinic, predictors and outcomes.," Journal of General Internal Medicine (2011) Vol. 26, no.6 p.588-594
  2. For more information, see: Gautam, M., The Tarzan Rule: Tips for a healthy life in medicine, Book Coach Press, Ottawa 2011 ISBN 0978470176
  3. Farnan, P.A., Conflict Management, in: The CanMEDS Physician Health Guide, The Royal College of Physicians and Surgeons of Canada, 2009 p.60-61, ISBN 978-1-926588-03-2

DISCLAIMER: The information contained in this learning material is for general educational purposes only and is not intended to provide specific professional medical or legal advice, nor to constitute a "standard of care" for Canadian healthcare professionals. The use of CMPA learning resources is subject to the foregoing as well as the CMPA's Terms of Use.