Navigating the Conflictual Patient-Clinician Relationship
December 2022
In December 2022 we addressed another common theme in our work: conflict between patient and clinician.
The conundrum
How can the clinician best navigate the use of uncivil, manipulative, and physically disruptive behavior that can occur among people who are ill, particularly when they feel disregarded?
Background
Clinicians may be taught and trained that they need to accept conflictual behavior as part of the job. A recent ethics piece questioned this tradition (1). Dr. Humbyrd recalls a friend asking, “Why would you let anyone treat you this way?” and remarks that “we are obligated to establish and maintain self-protective boundaries.”
The context may be a patient or a patient’s loved one focusing on ordering a test or doing a procedure as the measure of appropriate, skilled, and compassionate care, even when doing so goes against the clinician’s best clinical judgement. Compassion, guidance, and companionship can be seen as “doing nothing” or even “blowing off.”
One ICU provider shared that they were afraid to tell the family of a patient the truth for fear that one of the family members might react with violence. This atmosphere of fear changed the course of the care for that patient.
A clinician at an urgent care center, one of our coaching clients, noted that if she chose not to prescribe antibiotics, she had to brace herself from everything from mean comments in the patient satisfaction surveys to escalating verbal confrontations. It changed the way she approached these conversations, and she noted that she felt it had changed the way her colleagues chose to prescribe.
In all these relationships there are power dynamics that are being worked out with the demanding and conflictual stance being one way for a patient to claim a bit more power in the healthcare relationship. There may also be despair and worry as well as a sense of injustice. With compassion about why such interactions occur, what are some tactics that clinicians can use to establish and maintain appropriate boundaries while serving the best interest of the patient?
Highlights from the Think Tank discussion
"It may be part of the illness" - maintain compassion for the patient
Takeaways | Recommendations | Implementation/Examples |
|---|---|---|
Be mindful of the aspects of illness and care that can make a person conflictual | Remember: The conflictual nature of insurance, waiting rooms, the clock, and other aspects of care. We teach people to "be their own best advocate;" conflictual behavior is part of the map of self-advocacy People may think their access to tests and treatment is being limited Some people become hostile in response to stress | Put aside any feelings of disrespect and resentment Be generous in your consideration of civility vs. incivility |
Fear of abandonment: "Can you handle me?" If you can pass the test, then we can have a relationship | The person may want to talk about why they're coming in feeling adversarial, but we may not make a comfortable space for that | "No matter what, I will stand by you in this." Demonstrate that "If we disagree, there can still be a relationship." |
Maintain self-compassion
Takeaways | Recommendations | Implementation/Examples |
|---|---|---|
Ethical imperative: duty to self, trumps all | You may not be able to solve this today Be compassionate to yourself | Clinical teams and their leadership can work to develop a culture of self-compassion and join in work Spread things out: It can help to see people over time and build a relationship |
What can we do to help people feel more collaborative?
Takeaways | Recommendations | Implementation/Examples |
|---|---|---|
Part of it is the power imbalance | Transparency and vulnerability can help restore balance | Share: "Why am I here? Why do I get out of bed in the morning? What am I thinking about antibiotics?" |
Assume that people have experienced trauma or injustice | Acknowledge the injustice | "You have not been treated fairly" |
Anything less than solving the problem may seem uncaring | Frame success not as "solving the problem" but "they feel comfortable coming back through the door" | "I have some ideas for how to help. It may not be immediate, but I hope we can work together on this." |
People may start from a position of feeling disrespected | Find ways to demonstrate respect | Always ask for permission "Here's what I'm thinking, how does that sound?" "Can we talk about this? / Can we not talk about this?" |
People may personalize their disappointment with the illness to the clinician "You're not doing anything to help me" "You did XYZ, but I feel worse" | Work as a team | Try to identify a person who can help navigate the patient's health journey Someone less conflicted, such as a chaplain, social worker, or navigator |
For all the above reasons and more, things may start off on the wrong foot | Try to name what's happening in the room State your impression and let them correct it | "You've had a difficult time with this. People have not treated you with respect." "You're feeling uncared for and cast aside" |
People may place false hope on a test, diagnosis, or treatment that you don't feel is right | Name the ethical dilemma | "I'm not sure this feels right to me" |
Refusal feels negating | Name their opinion as a possibility, even if in your heart it may not be Find creative ways to make it about more than one option | "Yes, we could do XYZ. And there are some other ways to approach this" |
Restorative practice
Takeaways | Recommendations | Implementation/Examples |
|---|---|---|
Acknowledge the stress on you and your team | Check in with yourself and the team | Debrief: What happened? Have a plan for better interactions in the future Take notes that may help the next encounter be productive and respectful for all involved |
When the care is ongoing | Find ways to diffuse tension Position yourself side-by-side with the patient rather than face-to-face Avoid body language that may be interpreted as negative: folding arms, avoiding eye contact, appearing in a rush | Family conference: it's harder to feel conflictual when you are look at each other's faces |