The issue of difficult patient interactions has been an all-too-common scenario during the last two years. Past studies suggest that between 10–20% of patient visits are described as “difficult” by physicians, and with the pandemic, the incidence seems to have increased. Examining how to navigate these types of situations is important for a variety of reasons: 

• Patient satisfaction is now a frequently measured parameter and poor interactions may lead to negative feedback that does not accurately reflect the medical care provided. 
• Personal satisfaction on the part of the provider is also an issue, and difficult situations can leave a provider confused, angry, and frustrated, and contribute to burnout.
• If the patient interaction is sidetracked into a contentious discussion, important parts of the clinical history might be missed. 
• Increased legal issues are seen in physicians who have frequent difficult interactions as medical board complaints or threats of lawsuits may result. 

Even those of us with the best bedside manner experience difficult interactions from time to time. What is a physician to do when confronted with these situations?

FOCUS ON DETERMINING THE CAUSE OF CONFLICT
Clear communication is essential when there is conflict or misunderstanding. In the case study, the patient has a chief complaint of dyspnea and a chief concern of getting Ivermectin. These two issues—a chief complaint and a chief concern—need to be differentiated early and then a provider should attempt to explore the patient’s knowledge and understanding of the issue. If the interview becomes argumentative, one needs to have a clear understanding of why the patient is angry, upset, or concerned. And it is important to maintain self-awareness as these types of discussions can trigger our own issues (e.g., narcotics abuse, professional boundaries, multiple somatic complaints) and contribute to the frustration. 

Although a difficult interaction may be inevitable, deescalating it early is vital. Don’t wait for the interview to blow up before saying “time out, what is going on here?” Often the patient starts a difficult encounter with a high emotion, such as anger or sadness. Physicians need to recognize this and not let their own emotional response escalate the situation. In the case study, the patient has a pre-conceived goal of getting a certain drug while the physician is opposed to giving this to him based on the medical research available—the genesis of the conflict. Care should be taken to not take conflict as personal. The case study also illustrates that the physician is not the true cause of the conflict although the patient perceives her to be. The challenge is to remain calm, objective, and focused on how best to respond to these situations.

Identifying and acknowledging a patient’s concerns and letting them discuss what their beliefs are may help calm him or her down. We need to understand the behavior of the patient in the context of their conditions. If one can understand where the anger is coming from (e.g., fears, past experiences, misinformation), one may find the path to deescalating the situation so they can work toward a mutual understanding and common ground.

USEFUL TECHNIQUES AND CONSIDERATIONS

• 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 or respectful way. Patients should be able to express themselves and the physician should listen and seek to understand their perspective.
• Reflective listening
  Repeating statements back to the patient in a summarizing fashion is a wonderful way of really hearing what the patient has said. This also builds empathy as the patient realizes you have heard him or her with phrases such as “I hear that you believe strongly that this medicine will help you….”
• Acknowledge the emotions
  Using succinct statements like “I can see you’re upset” helps reflect the emotion you are seeing to the patient. This builds empathy and rapport even in a difficult situation. The patient can tell you are listening and may realize how their own emotions are impacting the interaction. 
• Investigate the patient’s understanding of the issue
  Why does a patient feel certain ways about treatment options or medication? What have they read and could you provide patient education information that would help them to better understand the situation?
• Apologize if appropriate
  It really can be our fault sometimes. If that is the case, admit it and explore what you can do to address the patient’s concerns.
• Build a win-win partnership
  Let the patient know that you want to work with them with a focus on a treatment plan that is appropriate with statements such as “Let’s act as a team and monitor your symptoms closely” or “I will help you through this situation and we will work through this together.” 
• Stay calm
  The anger is really about the message not the messenger. Patients can be quite scared and their anger arises from a fear of their illness. Remind yourself not to take this personally. We always have the responsibility to do the right thing for our patients.
• Recognize that it may take time
  Behavior modification is not instant, and it may take time to convince patients to change their behavior or follow your advice. Understand that in these situations you may never convince the patient to do the right thing. And change is internal in the psyche of the patient. 
• Clinical communication can be taught, learned, and improved
  Poor communication is something that can be addressed with education and training. We hope that awareness of the importance of communication will encourage deeper investment in medical student, resident, and attending physician training in effective communication.  

MANAGING SITUATIONS THAT AREN'T RESOLVED
There are indeed behaviors that should not be tolerated. Office/hospital policies should be clear around offensive language, threats, and potential violence. Boundaries should be established about what you will tolerate and how to manage situations that go outside these thresholds. You should never put yourself or your staff in danger, and if you feel threatened, established protocols should be followed immediately. You should document conflict and inappropriate behavior in the medical record in a clear and non-judgmental fashion. 

Despite best efforts, a physician-patient relationship may not be salvageable. Terminating a patient or having them leave against medical advice (AMA) should be a last resort, but if behavior is intolerable or continues, that may be the only option. For noncompliance or difficult interactions in which the relationship can be salvaged, but there remain differences, the use of an informed refusal form can be helpful.

COPIC RESOURCES
Visit the Resource Center on our website for the following items:

• Downloadable, editable Against Medical Advice and informed refusal forms at www.callcopic.com/resource-center/guidelines-tools/consent-forms
• Sample termination of patient care letter at www.callcopic.com/resource-center/guidelines-tools/practice-management-resources
• COPIC offers an interactive presentation on “The Upset Patient: How to Manage Difficult Interactions” for insureds; please contact Carmenlita Byrd at (720) 858-6131 for information on this and other educational activities we offer.