■ Duties and responsibilities:

Expectations of physicians in practice

Difficult patient encounters: What you can do to prevent, manage, and de-escalate

Originally published March 2020
20-01-E

Disagreements and difficult encounters with patients are inevitable at some point in a physician’s practice. Physicians who have frequent difficult patient encounters are more likely to report stress and burnout than those with fewer difficult encounters.1 Conversely, when there is a high level of trust in the doctor-patient relationship, patients are more likely to agree with the proposed course of treatment and experience higher overall satisfaction with the care they receive.2

Conflict may also arise when dealing with patients’ families, caregivers, and substitute decision-makers. “Because illness affects not only patients but also their families, physicians must be able to communicate effectively with everyone involved in the patient’s care.”3

Conflict in the context of clinical care may lead to complaints to regulatory authorities (Colleges) and other medical-legal difficulties for physicians. Physicians can take steps to avoid misunderstandings that may lead to conflict. When conflict does occur, it is beneficial for physicians and office staff to have the means to respond effectively and de-escalate it.

Prevention and management of conflict are important elements of a successful clinical practice. These elements can be attained through training and continuing education in conflict resolution, and by instilling conflict management principles and processes in the culture of the healthcare workplace.

Listening and communicating

Eliciting patients’ concerns and listening carefully to them contributes to patient-centred care. However, when a physician does not elicit patients’ concerns or interrupts too soon, the chance that the clinical encounter addresses the specific concerns that matter most to patients is reduced.4

The realities of medical practice necessitates efficiency in how patients’ health conditions are assessed, and this includes being skilled in active listening.

  • State your understanding of the issue back to patients. This helps to reassure patients and confirms that your understanding of them is accurate.
  • Be aware of language barriers, cultural distinctions, and patients’ overall health literacy that might affect how patients perceive your instructions and advice. Use language appropriate to patients’ ability to understand, avoiding medical jargon where possible. Confirm patients’ comprehension of the diagnosis and recommended care plan.
  • Be clear about your intentions, such as when asking personal questions and the clinical reason for performing a physical examination.
  • Consider using communication models such as ACE (Authority, Collaboration, Empathy) and FIFE (Feelings, Ideas, Functioning, Expectations) in providing patient-centred care.5
  • In a factual and non-judgmental way, document in patients’ medical records any inappropriate statements conveyed or behaviour displayed by patients toward you or your office staff. You may choose to include verbatim statements made by patients, clearly attributing these to patients and shown in quotation marks.

Managing expectations

Unmet patient expectations may result in conflict. For example, patients might not agree with your proposed care plan, they may be dissatisfied with the care provided, or their condition could worsen despite treatment. Similarly, patients who are experiencing other stressors are more likely to be combative, while patients recently diagnosed with a serious illness might similarly display signs of distress. Nevertheless, conflict that is addressed before it becomes unmanageable can be an opportunity to better understand patients and their needs and concerns.

  • Try to understand patients’ behaviour in the context of their overall life situation, mental health, and medical condition. More often than not, patients’ expectations can be met—such as fulfilling a request for information, expressing compassion in the face of difficult circumstances, and showing respect during treatment—thus reducing the potential for minor irritants to be magnified into major challenges.6

Handling more difficult situations

Despite a physician’s best efforts to resolve a conflict, there may be situations that do not improve. It is important to limit and de-escalate disagreements, thus mitigating the potential for verbal aggression or even violence.

  • Obtain training for you and your staff on effective patient interactions and conflict de-escalation from a trusted learning provider.7
  • Develop an office security policy that outlines how you and your staff will respond to offensive language and aggressive behaviour.
  • Develop an office safety plan, including considerations for the physical layout of the office or clinic, and any additional security measures such as a lockdown procedure and drills with office staff.
  • Communicate the security policy and safety plan with your staff, and consider renewing that communication annually.
  • Post a notice in a visible location in the office, conveying that inappropriate language and behaviours will not be tolerated.
  • If your efforts in changing a patient's aggressive behaviour are unsuccessful and there is a breakdown in the trust relationship that cannot be resolved, consider whether it is necessary to terminate the patient from your practice. Follow your College’s guidelines when contemplating terminating a doctor-patient relationship.

The bottom line

  • Prepare for difficult patient encounters through conflict management training, and implementing a security policy and office safety plan. Support office staff by ensuring they have adequate tools and resources to de-escalate conflict.
  • When faced with rising tensions with patients, strive to keep calm, explain the situation factually, and offer possible solutions. If you perceive the situation presents a danger to patients, yourself, or your staff, prioritize safety.
  • Following the event, document what had occurred in the medical record. Be objective and avoid emotional language.
  • Contact the CMPA for advice on handling incidents of conflict that arise in a doctor-patient relationship.

References

  1. An PG, Manwell LB, Williams ES, et al. Does a higher frequency of difficult patient encounters lead to lower quality care? J Fam Prac [Internet]. 2013 Jan [cited 2019 July 2];62(1):24-9
  2. Fuertes JN, Toporovsky A, Reyes M, et al. The physician-patient working alliance: Theory, research, and future possibilities. Patient Education & Counseling. 2017;100:610-5
  3. Royal College of Physicians and Surgeons of Canada [Internet]. Ottawa(CA): RCPSC; 2019. CanMEDS Role: Communicator [cited 2019 July 9]
  4. Singh Ospina N, Phillips KA, Rodriguez-Gutierrez R, et al. Eliciting the Patient's Agenda - Secondary Analysis of Recorded Clinical Encounters. J Gen Intern Med [Internet]. 2019 Jan [cited 2019 July 9];34(1):36-40
  5. Canadian Medical Protective Association [Internet].Ottawa(CA):CMPA; 2017 Jan. How to manage conflict and aggressive behaviour in medical practice [cited 2019 July]
  6. Royal College of Physicians and Surgeons of Canada [Internet]. Ottawa(CA): RCPSC; 2019. Conflict resolution [cited 2019 July 9]
  7. The CMPA subsidiary, Saegis, offers accredited learning programs aimed at advancing patient safety and practice management. Visit www.saegis.solutions for details

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.