Managing Conflict in the Patient Care Setting

1. Managing Conflict in the Patient Care Setting Keri T. Holmes-Maybank, MD Medical University of South Carolina June 18, 2013

2. Learning Objectives • 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.

3. Key Messages • 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.

5. Groves “Hateful” Patient • Dependent Clinger • Entitled Demander • Manipulative Help Rejecter • Self Destructive Denier

6. Dependent Clingers • 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

7. Dependent Clinger – MD Feelings • MD becomes exhausted, patient feels rejected, ramp up needy behavior with more desperate attempts at contact • Repugnance • Dislike • AVERSION

8. Dependent Clinger - Suggestions • 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

9. Entitled Demander • 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

10. Entitled Demander – MD Feelings • Fear • Depression • Wish to counterattack

11. Entitled Demander - Suggestions • 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

12. Manipulative Help Rejectors • 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

13. Manipulative Help Rejecter – MD Feelings • Anxiety treatable illness being missed, then irritation, then depression and self-doubt • Guilty • Inadequate • Demoralized • Depression • Unproductive, time-consuming, exhausting

14. Manipulative Help Rejecter - Suggestions • 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

15. Manipulative Help Rejecters - Suggestions • Simple explanations • Hard to refer to psychiatrist • Make sure they have follow-up with MD • Empathy • Patient education • Encouragement and support

16. Self-Destructive Denier • 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

17. Self-Destructive Denier – MD Feelings • MD caught between ideal of saving patient and unwanted wish for patient to die • Malice • Objectivity challenged by hatred, or indifference (protects MD emotionally)

18. Self-Destructive Denier - Suggestions • 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

19. Countertransference • 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

20. Projective Identification • 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

21. Shift in Healthcare • Patient autonomy • Patients more educated • Boundaries are being crossed by email and info about physicians on internet • Defensive medicine

22. Parts of Healthcare System Increase “Difficult” Behavior • 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”

23. Physician Characteristics Who Report Higher Rates of “Difficult” Patients • Greater perceived workload/overwork • Lower job satisfaction • Lack of training in communication/poor communication skills • Inexperience • Discomfort with uncertainty • Poor attitude

24. Reasons for Perceiving the Encounter As Difficult • 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

25. “Difficult” Patients in New Era • Increased dissatisfaction with services • Become more demanding • Repeated visits without medical benefit • Seemingly endless complaints • Unmet expectations • Insatiable dependency • Report worsening symptoms

26. Patient Behavior • 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)

27. Patient Characteristics • 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

28. Axis II, Personality Disorders • 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)

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

30. What Happens to the MD? • Helpless • Inadequacy • Frustration • Anger • Guilt • Dislike

31. MD Feelings • 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

32. 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

33. Managing Conflict by Elder • Collaboration • Appropriate use of MD power • Empathy

34. Collaboration • 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

35. 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

36. Appropriate Use of Power • 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

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

38. 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

39. Additional Recommendations • 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

40. Confrontation • 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.”

41. Questions to Ask Prior to 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.

42. References • 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. CurrOpin 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.