Managing Challenging Situations: Doctor/Patient Interactions
Good communication is fundamental to providing high-quality, safe patient care and central to the doctor-patient relationship. However, interactions between patients and their clinicians can sometimes prove challenging.
Suboptimal communication leads to poor patient outcomes
Evidence (for example GMC 2018 and Birks Y et al, 2018) suggests that poor communication is a key contributing factor to patient complaints and litigation. At Premium Medical Protection, we are keen to explore issues that may affect you and your medicolegal risk and we believe this is a key area of concern for many.
A review of PMP cases, notified over a six-year period, identified suboptimal communication with patients as a contributory factor* impacting outcomes and/or patient expectations in 50% of cases.
*Contributing factors are multi-layered issues or failures in the care process that appear to have contributed to the patient outcome and/or to the initiation of a legal case or had a significant impact on case resolution.
Our findings reflect those documented in the GMC jointly funded and commissioned paper, A scoping review of evidence relating to communication failures that lead to patient harm 2018.
The GMC reported in a study Understanding communication failures involving doctors 2019, that the four most frequently reported communication failures were:
- “a failure to provide a patient with appropriate and timely information
- a failure to keep colleagues informed/share appropriate level of information
- a failure to listen to patients
- a failure to work in partnership or collaboratively with patients/families or carers.”
The study found that in secondary care, the most frequently reported complaints involving doctors and communication failures were those related to obtaining surgical consent and difficult conversations around prognosis and end of life care.
The GMC in Good medical practice (updated 2019), provides clear guidelines concerning communicating with patients. It states:
“31: You must listen to patients, take account of their views, and respond honestly to their questions.
32: You must give patients the information they want or need to know in a way they can understand. You should make sure that arrangements are made, wherever possible, to meet patients’ language and communication needs.
33: You must be considerate to those close to the patient and be sensitive and responsive in giving them information and support.”
Factors that contribute to a challenging interaction
Achieving effective doctor-patient communication can sometimes be a challenge. The complex and unpredictable nature of healthcare, workload and workforce issues, diverse cultures, different languages, and more engaged and informed patients can sometimes create challenging communication issues for both doctors and patients. These can arise from common misunderstandings and/or mismatched expectations and perceptions of the doctor and patient.
To help reduce the likelihood of challenging consultations, it is important to consider the reasons why such situations arise.
Possible contributory factors include:
- System triggers (work environment)
- Clinician triggers
- Patient triggers
Diagram 1 depicts some of these contributory factors, Hardavella G et al, 2017.
System issues such as scarcity of appointments, excessive workload, staff shortages and challenges in accessing services may all contribute to difficult patient interactions.
A lack of self-care, such as the clinician being ‘Hungry, Angry, Late or Tired’ (HALT), may also impact a clinician’s ability to successfully manage a challenging interaction.
Understandably, a patient’s medical history and/or present condition may affect their behaviour. Patients may attend a consultation with preconceived ideas of what they can expect to achieve from the meeting. This, compounded by the severity of their illness and how it is affecting their quality of life, may result in the patient feeling anxious, worried or uncertain about their illness. This can, in turn, cause tension, anger and negativity towards the clinician.
According to a report from LaingBuisson, increasing NHS waiting lists due to the COVID-19 pandemic are driving more patients to self-pay for private treatments/procedures. Therefore, patients may present at an initial consultation, already upset with the long wait for a procedure and often in significant distress and pain. In addition, they may well be frustrated that they are having to use their savings to pay for an intervention they believe the NHS should be providing. This may also be the first time the patient is paying for their own care and are feeling anxious or uncertain with this new pathway.
Exploring patients’ expectations at the outset of a consultation is crucial, especially for this cohort of self-funding patients. Every patient who attends a consultation has expectations based on their understanding of their illness, cultural background, health beliefs and attitudes. It is vital that the treating clinician is sensitive to the expectations of the patient and that both clinician and patient reach a mutual understanding of what is reasonably achievable in the circumstances. This will be key to ensuring a successful outcome from the consultation and should help minimise patient complaints.
Potential effects of a challenging consultation
A challenging consultation can impact the patient and clinician, leaving both feeling dissatisfied. This may lead to a breakdown in the doctor-patient relationship, which can, in turn, affect the quality of care provided.
For example, research published in 2017 by Schmidt H G et al, Do patients’ disruptive behaviours influence the accuracy of a doctor’s diagnosis? A randomised experiment, suggested that disruptive behaviours displayed by patients can result in doctors making diagnostic errors, ie:
- Clinicians are 42% more likely to wrongly diagnose a complex medical issue.
- Clinicians are 6% more likely to wrongly diagnose a simple medical issue.
Ten tips for managing a challenging interaction
- Be aware of a patient’s body language. Non-verbal cues can indicate how a patient is feeling and may signal that a situation is about to escalate. For example, raised eyebrows, eye-rolling, sighing, yawning etc. Avoid confrontational body language such as crossed arms, standing too close to or standing above a patient who is seated.
- Remain professional and make a conscious effort to stay calm. If you feel your own emotions getting the better of you, step outside the room and take a few deep breaths. While you are cooling down, ask yourself what the patient is really asking. Anger is often an outward expression of fear; recognising this can restore your sense of compassion.
- Be mindful of how human factors can affect your performance. Remember the HALT mnemonic (Hungry, Angry, Late, Tired); where possible, anticipate these and take action to mitigate their impact. Please see PMP articles: Avoiding Burnout, Enhancing Resilience and Looking After You.
- Engage in active listening. Set aside your agenda and give the patient your full attention. Summarise what the patient has said and acknowledge the emotion they are expressing.
- Read the patient; observe the emotions behind the words. Is the patient angry, afraid, frustrated or resentful? Be aware of the expectations and frustrations of those patients who have been waiting for a considerable time on an NHS waiting list and have now opted to self-fund a procedure. Respond to the emotion as well as the words.
- Try to find out what the problem is from the patient’s point of view. Ask open-ended questions such as “what can I do to help?”
- Acknowledge the patient’s frustration and the importance of the issue for them.
- Communicate clearly that you want to help and understand the patient’s point of view (which does not necessarily mean you agree with it).
- If you recognise that an error has occurred with the treatment of a patient, offering an apology can be key to de-escalating the situation. Whilst an apology is not an admission of liability, we advise all PMP customers to contact our 24/7 medicolegal helpline, provided by Clyde & Co, to obtain immediate advice and guidance on the wording of any verbal or written apology.
- Try adopting the useful tool ‘CALM’ by Armstrong D (2014), as detailed in chapter 24 of Safety and Improvement in Primary Care: The Essential Guide 2014.
If holding a telephone consultation, remember that visual cues will be lost. Consider the following:
- Take a deep breath
- Speak calmly
- Listen to what is being said
- Try not to interrupt the patient’s story
- Do not get hung up on emotional comments
- Control the tone of your voice
- Think before you speak
Remember that your personal safety is of the highest priority.
- Never stay in a situation in which you feel uncomfortable.
- It is always safer to leave the room than ask or insist that the patient leaves.
- Review the layout of your consulting room to ensure that there is a safe exit path, ie, a patient could not block your exit.
- Seek assistance from a colleague or via security measures such as a panic alarm.
- Avoid responses that may escalate or aggravate a situation.
If you have experienced a challenging consultation with a patient, it may be an ideal opportunity to have a ‘debrief’ with colleagues. Ensure you make a detailed entry of the consultation in the patient’s medical record, capturing that the patient appeared “distressed”, “unhappy” etc. and how the situation evolved.
Information correct at time of publication May 2022
(Originally published September 2021)