Managing Conflict in the Patient Care Setting

Keri T. Holmes-Maybank, MDMedical University of South CarolinaJune 18, 2013

Review the famous Groves article “Taking care of the hateful patient.”

Recognize physician characteristics that lead to a greater perception of a patient as “difficult.”

Recognize patient characteristics and patterns of behavior classified as “difficult.”

Practice the collaboration, appropriate use of power, and empathy approach recommended for managing conflict by Elder.

Learning Objectives

Illness can alter the patient’s psyche leading to uncharacteristic behavior.

Acknowledge and accept emotional responses to patients.

Physician awareness and acceptance of personal emotions may improve emotional intelligence and physician-patient relationships.

Most important is how the physician behaves toward the patient, not the emotion she is experiencing.

Empathy and collaboration are the keys to effective conflict management.

Key Messages

Dependent Clinger Entitled Demander Manipulative Help Rejecter Self Destructive Denier

Groves “Hateful” Patient

Appropriate need for reassurance Escalates to unreasonable, BOTTOMLESS

need for explanation, affection, and attention Constant reassurance Increasing dependency See MD as inexhaustible resource

Warning signs: Extreme gratitude MD feels special

Dependent Clingers

MD becomes exhausted, patient feels rejected, ramp up needy behavior with more desperate attempts at contact

Repugnance Dislike AVERSION

Dependent Clinger – MD Feelings

Empathy

Set limits early without feeling inhuman, without patient feeling deceived or disappointed

Difficult to refer to psychiatrist Interpret as abandonment/rejection Reassure you will still see them

Dependent Clinger - Suggestions

Overtly hostile, superior Intimidation, devaluation, induce guilt Control by threatening punishments

◦ Withholding payment, demands for more tests/consults, or litigation

Lack of control Compensation for MD power/knowledge Ultimately fear abandonment Entitlement = faith and hope in well-adjusted

Entitled Demander

Fear Depression Wish to counterattack

Entitled Demander – MD Feelings

Do NOT debate or belittle Acknowledge entitlement to have realistic

good care Very respectfully and non-confrontationally

to explain how behavior may compromise health

Cooperative decision-making process Rechannel energy into following the

regimen

Entitled Demander - Suggestions

Smugly satisfied with failure Do not want cure, want unending relationship with

MD No regimen will help Pessimism increases with MD’s efforts and

enthusiasm Manipulation Want MD close but keep them at significant

distance - fear Relationship will not end if they have symptoms Deny assistance/advice while spiraling into poor

health

Manipulative Help Rejectors

Anxiety treatable illness being missed, then irritation, then depression and self-doubt

Guilty Inadequate Demoralized Depression

Unproductive, time-consuming, exhausting

Manipulative Help Rejecter – MD Feelings

Don’t accuse of manipulation = doctor shopping

Share pessimism – say treatment may not be curative

Consistent, firm limitations – unrealistic expectations or demands

Regular follow-up

Patient’s fear of abandonment put to rest

Manipulative Help Rejecter - Suggestions

Simple explanations Hard to refer to psychiatrist Make sure they have follow-up with MD Empathy Patient education Encouragement and support

Manipulative Help Rejecters - Suggestions

Unconscious self-murderous/injurious behaviors

Spiral of self-destruction while requesting assistance

Glory own destruction Pleasure in defeating MD attempts to

preserve life Profoundly dependent Self-hate, project hate through the MD

Self-Destructive Denier

MD caught between ideal of saving patient and unwanted wish for patient to die

Malice Objectivity challenged by hatred, or

indifference (protects MD emotionally)

Self-Destructive Denier – MD Feelings

MD limited because patient will only allow so much care

All reasonable care for patient Compassion – terminal illness Do not abandon

Recognize without shame the feelings the patient provoke in MD

Cannot give perfect care

Self-Destructive Denier - Suggestions

Physician develops positive or negative feelings toward patient based upon personal experiences in her life

Use it to gain knowledge about where patient is coming from

Countertransference

Patient feels threatened = behavioral regression

Projects these feelings onto MD Patient feels relieved when these feelings

are reflected by MD Example: Patient feels helpless = complains

incessantly = MD feels helpless If MD recognizes can react supportively

Projective Identification

Patient autonomy Patients more educated Boundaries are being crossed by email and

info about physicians on internet Defensive medicine

Shift in Healthcare

Productivity pressures Changes in health care financing Fragmentation of visits Interrupted visits Outside information sources challenge the

physicians authority Less trust in their physicians Feel rushed or ignored may repeat

themselves or prolong visit

18% of encounters classified as “difficult”

Parts of Healthcare System Increase “Difficult” Behavior

Greater perceived workload/overwork Lower job satisfaction Lack of training in communication/poor

communication skills Inexperience Discomfort with uncertainty Poor attitude

Physician Characteristics Who Report Higher Rates of “Difficult” Patients

Professional identity ◦ I am unable to make better ***◦ Conflicts with my professional standards

Personal qualities ◦ Feel taken advantage of◦ Difficulty making relationship with patient

Time management ◦ Takes too much time

Comfort with patient autonomy ◦ Patient sets the agenda

Confidence in skills ◦ Too hard to solve

Trust in patient ◦ Lose trust in patient

Reasons for Perceiving the Encounter As Difficult

Increased dissatisfaction with services Become more demanding Repeated visits without medical benefit Seemingly endless complaints Unmet expectations Insatiable dependency Report worsening symptoms

“Difficult” Patients in New Era

Do not seem to want to get well Power struggles Focus on issues seemingly unrelated to

medical care Worried every symptom represents a

serious illness Reported greater symptom severity Chronic pain (+/- narcotics)

Patient Behavior

Psychiatric ◦ Axis II◦ Depression◦ Somatization (alcohol, borderline)◦ Mood d/o (insist on physical cause)◦ Anxiety (multi complaints, think cardiac, not enough being

done)

Lower social class Female Thick clinical records Older More medical problems Greater use of health care services Poor functional status

Patient Characteristics

Cluster A (odd or eccentric, fears social relations)◦ Paranoid◦ Schizoid◦ Schizotypal

Cluster B (dramatic, emotional erratic disorders)◦ Antisocial◦ Borderline◦ Histrionic◦ Narcissistic

Cluster C (anxious or fearful disorder)◦ Avoidant◦ Dependent◦ Obsessive-compulsive

Appendix B◦ Depressive ◦ Passive-aggressive (negativistic)

Axis II, Personality Disorders

“Difficult” Group

Dissatisfaction Difficult patients

Not-difficult

Physician's technical competence 9% 1% P<.001

Bedside manner 7% 0.7% P<.001

Time spent with clinician 13% 3% P=.002

Explanation of what was done 12% 3% P<.001

Higher number of visits 4 2 P=.004

Jackson, JL, Kroenke K. Difficult Patient Encounters in the Ambulatory Clinic: Clinical Predictors and Outcomes Arch Intern Med. 1999;159(10):1069-1075.

Helpless Inadequacy Frustration Anger Guilt Dislike

What Happens to the MD?

Leads to:◦ Unconscious punishment of the patient◦ Self-punishment by the doctor◦ Inappropriate confrontation◦ Desperate attempt to avoid patient ◦ Errors in diagnosis or treatment◦ Decreased quality of care◦ Work burdensome◦ Burnout

MD Feelings

Disproportionate emotional energy can be spent dealing with negative feelings

Strong negative emotional reaction is important clinical data about patient’s psychology (personality d/o)

Sensitivity to MD feelings◦ Improved physician well being ◦ Less destructive patient behavior ◦ Lower risk of litigation

MD Feelings

Collaboration Appropriate use of MD power Empathy

Managing Conflict by Elder

Priority setting ◦ Prioritize patient concerns

Diagnostic skills◦ Thorough history, physical, and testing

Decision making◦ Explain ◦ Be consistent and objective ◦ Be honest and fair◦ Facilitate patient decision making

Team approach◦ Use referrals (mental health, pain, etc.)◦ Enlist/see family ◦ Provide quality care

Coaching◦ Set small, achievable goals ◦ Short term symptom relief

Collaboration

Encourage patient to start taking responsibility

Think of their care as a team effort Adjust expectations of what can be

accomplished Patient education

Collaboration has most impact on clinical interaction

Collaboration

Set clinical management rules◦ Schedule patient frequently, longer visits ◦ Clinic time management ◦ Good documentation

Set boundaries and limits ◦ Set general limits ◦ Make explicit rules when necessary◦ Limit number of patient concerns ◦ Limit time at each visit

Appropriate Use of Power

Understand patients psyche Focus on patient emotions Compassionate and firm Patient centered Reinforce positives Keep professional distance

Empathy

Protects MD from developing negative responses to difficult and challenging behavior

Allows insight into patient issues and why patient has resorted to negative response patterns ◦ Illness can alter patients – uncharacteristic, childlike

Creates an environment conducive to more suitable health care delivery, a healthier lifestyle, better work satisfaction

Empathy

Point person - may get conflicting info from consultants

Tactful assessment of patient’s distress/emotion

LISTEN Interrupt less Regular, brief summaries of patient’s

concerns Reconcile conflicting views of

diagnosis/illness

Additional Recommendations

Acknowledge problem Both parties may contribute to difficulty Use communication skills You can discuss that have poor relationship: “How do you feel about the care you are receiving

from me?” “It seems to me we sometimes don’t work

together very well.”

Use “I” statements ◦ “I feel it’s difficult for me to listen to you when you use

that kind of language.”

Confrontation

1. ***Does my patient prioritize health?***◦ Not if patient works with MD to prevent and treat disease.◦ Unpleasantness alone is not grounds.

2. Is confrontation of my patient ethically permissible?◦ If patients self-corrosive decisions come with expectations of

accommodation.◦ If MD bearing majority of burden in failing treatment.◦ If health deteriorating from patient action or inaction.

3. What if confronting my patient is emotionally gratifying?◦ Recognize countertransference v. projective identification.◦ Assess motives and emotions in real time and discuss with a

peer.

Questions to Ask Prior to Confrontation

Butler CC, Evans M. The “heartsink” patient revisited. Br J Gen Pract. 1999;49:230-233.

Elder N, Ricer R, Tobias B. How respected family physicians manage difficult. J Am Board Fam Med 2006;19:533– 541.

Feldman MD, Berkowitz SA. Role of behavioral medicine in primary care. Curr Opin Psychiatry. 2012;25:121-127.

Kontos N, et al. Fighting the good fight: Responsibility and rationale in the confrontation of patients. Mayo Clin Proc. 2012;87(1):63-66.

Fried TR, Bradley EH, O’Leary J. Prognosis communication in serious illness: Perceptions of older patients, caregivers, and clinicians. J Am Geriatr Soc. 2003;51:1398-1403.

Groves JE. Taking care of the hateful patient. N Eng J Med 1978;298:883-887. Haas LJ, Leiser JP, Magill MK, Sanyer

ON. Management of the difficult patient. American Family Physician. 2005;72(10) Jackson, JL, Kroenke

K. Difficult Patient Encounters in the Ambulatory Clinic: Clinical Predictors and Outcomes Arch Intern Med. 1999;159(10):1069-1075.

Mathers N, Jones N, Hannay D. Heartsink patients: A study of their general practitioners. Br J Gen Pract. 1995;45:293-296.

O’Dowd TC. Five years of heartsink patients in general practice. BMJ 1988;297:528-530.

Strous RD, Ulman AM, Kotler M. The hateful patient revisited: Relevance for 21st century medicine. European Journal of Internal Medicine. 2006 (17)6;387-393.

References