■ Safety of care:

Improving patient safety and reducing risks

Challenging patient encounters: How to safely manage and de-escalate

Male doctor leaning against sink and looking down

Published: June 2021
The information in this article was correct at the time of publishing
21-09-E

Difficult encounters and disagreements with patients are inevitable at some point in a physician’s practice. Conflict can also arise with others affected by patients’ illnesses, such as family members, caregivers, and substitute decision-makers. And with the COVID-19 pandemic, the potential areas of conflict have expanded.

A combination of skills and strategies can help you and your staff deal with challenging encounters safely, productively, and effectively. These skills and strategies can be developed with training and continuing education in communication and conflict resolution, and by instilling conflict management principles and processes in the healthcare workplace.

Emotions may affect the doctor-patient relationship

Emotions may intensify disagreements. As a physician, you may be affected by stressors such as time pressures during patient appointments, unconscious and conscious biases that may influence your view of a situation, or personal matters. Similarly, patients may be experiencing stressors such as a recent diagnosis of a serious illness, language barriers, poorly defined symptoms, difficulty adhering to medical advice, or underlying health issues.

Listening and communicating

Just as good communication skills are necessary for effective patient care, communication is also at the heart of working through conflict or disagreements with patients.

Asking patients about their concerns, actively listening without interruption, conveying empathy, and communicating clearly can help you understand what matters most to patients.1

The following tips may help improve your communication with patients:

  • Restate what patients have told you, using their words. This reassures patients that they are being heard, and confirms you understand their concerns.
  • Use language appropriate to patients’ ability to understand, avoiding medical jargon, where possible. Be aware that potential language barriers, cultural distinctions, and health literacy may affect how patients perceive your instructions and advice.
  • Be clear about your intentions and the clinical reasons for your actions, such as when asking personal questions or performing a physical examination.
  • Confirm patients’ comprehension of the diagnosis and recommended care plan by asking them to restate these to you in their own words.
  • If you are in the middle of a challenging interaction with a patient, avoid arguing, talking over the patient, or making judgmental statements.
  • In a factual and non-judgmental way, document in patients’ medical records any inappropriate statements or behaviour by patients toward you or your staff. You may choose to include verbatim statements made by patients, clearly attributing these to patients and shown in quotation marks.

Managing patients’ expectations

Patients may have unmet expectations for their care that can result in conflict. For example, they may ask for specific care that cannot be provided or for treatments that are not clinically indicated. During the COVID-19 pandemic, areas where patient expectations could not be met expanded. For instance, patients may have preferred in-person care, but been informed that only virtual care was being offered for everyone’s safety.2

Often, patients’ expectations can be met by expressing compassion in difficult circumstances, fulfilling a request for information, or explicitly showing respect while providing care. These actions can reduce the potential for minor irritants to become major challenges.3

Handling violence and threatening behaviours

Despite your best efforts to resolve conflict, some situations may not improve and could escalate to threatening behaviours, even violence.

Imminent violence or threats

  • If you are faced with imminent violence or threats of assault, harm, or disorderly conduct, move away from harm and prioritize protecting yourself, your patients, and your staff.
  • Call security or 9-1-1, as appropriate in the circumstances. For more advice on dealing with violence in your practice, see “When physicians feel bullied or threatened”.

Escalating threatening behaviour

When behaviours start to become threatening, such as the use of abusive language and threats of violence, consider the following immediate strategies:

  • Tell the individual(s) their behaviour is unacceptable and outline the consequences of continuing or repeating the behaviour. In hospital or large clinic settings, consider using other available resources such as security, social work, and patient advocacy.
  • Your safety is paramount. Call security or police, if you feel it is appropriate. If reporting to police, only give the information necessary for the police to address the threat, such as the threatening individual’s name and the nature of the incident. Avoid divulging any further patient medical information that could be considered a privacy breach.

Be proactive to protect your safety

To prepare for the possibility of encountering threatening behaviour in any setting (e.g. office, clinic, hospital), consider the following strategies:

  • Make time for training for you and your staff. Consider learning about effective patient interactions and conflict de-escalation from a trusted education provider.4
  • Recognize the value of both a workplace security policy and workplace safety plan.
  • A workplace security policy should outline how you and your staff will respond to offensive language and aggressive behaviour. In a hospital or large clinic, be familiar with the organization’s policy and discuss it with your staff. In an office, develop and implement the policy, discuss it with your staff, consider renewing it annually, and post it in an area visible to all.
  • A workplace safety plan should provide guidance on making the workplace environment safer. In a hospital or large clinic, be familiar with the organization’s plan and discuss it with your staff. In an office, adopt a safety plan that could include giving staff a clear view of patients in the reception area; using controlled access to certain areas (e.g. having a code entry system); ensuring everyone can make a rapid exit; securing medical records, computers, and medical equipment; storing medications in designated areas; having security alarms; having sufficient lighting near entrances and parking lots; and having additional security measures such as a lockdown procedure accompanied by drills with staff.

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, assess if it is necessary to terminate the patient from your practice. In a clinic or hospital environment, there may be opportunities to develop and update protocols for managing difficult behaviours. Consulting with colleagues or your hospital director may help guide you in managing individual cases. Follow your College’s guidelines when contemplating terminating a doctor-patient relationship.

Document any abusive behaviours clearly and factually in the medical record. The medical record is the appropriate place for these types of notes.

The bottom line

  • Consider continually improving your communication skills to manage difficult encounters with patients.
  • Prepare yourself and your staff for disagreements that may escalate with conflict management training. If the encounter becomes threatening or violent, call security or 9-1-1, as appropriate.
  • Recognize the importance of having and being familiar with a security policy and a safety plan.
  • Document difficult encounters in the medical record. Describe the individual’s behaviour and not their intent. Be objective and avoid emotional language.
  • Contact the CMPA for medico-legal advice. Disagreements may lead to medical regulatory authority (College) and hospital complaints and other difficulties. When a patient is exhibiting aggressive behaviour or threatening a physician’s personal safety, certain legal measures can be taken to protect a physician in these circumstances.

References

  1. 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
  2. The CMPA analyzed calls from members looking for medico-legal advice between March and September 2020. During these calls, the pandemic-related topics most frequently discussed by members were telemedicine, COVID-19 tests, personal protective equipment, deferring care, self-isolation, long-term care facilities, dealing with patients who refuse to wear a mask, and reopening of healthcare services.
  3. Royal College of Physicians and Surgeons of Canada [Internet]. Ottawa(CA): RCPSC; 2019. Conflict resolution [cited 2019 July 9]
  4. Learning opportunities in communication and conflict resolution skills are available from various organizations. For example, physician communication courses are offered by Dalhousie University’s Faculty of Medicine; the CMPA subsidiary, Saegis; and the University of British Columbia’s Faculty of Medicine. Conflict resolution courses are offered by a number of Canadian universities and other professional organizations.

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.