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Studies suggest that physicians rate between 10 and 15% of patient visits “difficult.”1 This is important for a variety of reasons: Patient satisfaction is a frequently measured parameter, and poor interactions may lead to bad ratings. Personal satisfaction on the part of the provider is also an issue, and frustrating interviews can leave the physician dissatisfied. If the patient interaction is sidetracked into an angry discussion, important parts of the clinical history might be missed. Finally, increased legal issues arise for physicians who have frequent difficult interactions. Board complaints and even lawsuits may result.
Even those of us with the best bedside manner still encounter these interactions. What’s a physician to do when confronted with a difficult interaction?
Case Study
The rheumatologist saw a 45-year-old woman for diffuse aches and pains. She felt the symptoms were most compatible with fibromyalgia. A thorough workup was negative. Multiple medications were tried, but the patient was intolerant and had side effects to all medications. The patient returned with widespread pain and stated she had looked on the Internet and was sure this was multiple sclerosis. The neurologic exam was normal, and the symptoms seemed mainly musculoskeletal. The rheumatologist suggested not doing a referral to a neurologist because the symptoms were not suggestive of MS. The patient became angry and stormed out. The doctor drafted a dismissal letter, but it was not sent immediately. When the patient called to make a follow-up appointment, the receptionist stated she would have to check with the doctor first. The patient swore at the receptionist and hung up. The patient then wrote a complaint letter to the Medical Board.
Understanding Conflict
Clear communication is essential when there is conflict or misunderstanding. Rheumatologists should start all visits by setting the agenda. What are we talking about today? If the clinician has issues that he/she needs to discuss, he/she should let the patient know their intentions at that time. If the interview turns sour, one needs to have a clear understanding of why the patient is angry, upset or concerned. It can be you or the patient with the issue. Sometimes, we get upset when the patient triggers our own pet issue (e.g., narcotics, boundaries, multiple somatic complaints, someone who reminds us of our last difficult patient).
Care should be taken not to perceive the conflict as personal. Often, conflict may be inevitable, but deescalating it early is vital. Don’t wait for the interview to blow up before saying, “Time out; what’s going on here?”
