Challenging Encounters

Physicians experience up to one in six visits as ‘challenging’, taking a disproportionate amount of time and emotional energy, causing anxiety or frustration, and compromising our ability to provide good care.  Patients may feel just as frustrated and dissatisfied as their doctors, damaging therapeutic relationships, seeding distrust and leading them to seek more second opinions and emergency department care.

Challenging encounters are usually caused by a complex interplay of physicianpatient and situational variables.  Recognizing this complexity, we encourage you to explicitly consider each of these.  Regardless of specialty, almost all of us will experience challenging encounters throughout our career – learning to navigate them well is critical to maintaining our joy in the practice of medicine

Physician factors

The variable that you, as the clinician, have the most control over is yourself.  Whenever you feel upset or uncomfortable with a patient, start by examining the emotions and biases that you may bring to the encounter.  Countertransference was first described by psychoanalysts but can affect any patient-provider relationship. The clinician unconsciously projects feelings from a different personal or professional relationship onto the patient.  Does this patient remind you of a family member, previous patient, or someone you had difficulty with in the past?  If you are feeling fatigued, stressed, or burnt out are you attributing these feelings to the patient’s behavior rather than addressing them in yourself?

Clinician biases can affect every step of a clinical encounter from initial rapport building to developing  a plan together.  Our patients’ identities, interactional styles, beliefs and values may differ fundamentally from our own.  To provide good care, we need to know ourselves first and practice cultural humility when engaging with others.  Pay attention to the clinical scenarios that are particularly emotional or triggering for you.  These are different for different physicians, but often include uncertainty, serious illness, chronic pain management, substance use disorders, abuse or neglect, or multiple unexplained symptoms. Learn what your triggers may be and work to find ways to treat your patients equitably and respectfully

Patient factors

Patients also bring many things to an encounter, some of which we recognize but many of which we do not.  Acute and chronic health issues are inherently stressful for most people.  Mood disorders such as depression or anxiety, language or cultural barriers, and mistrust of the healthcare system caused by past mistreatment can all interfere with the development of a therapeutic relationship.  Patients’ interactional styles may also be quite different from our own. These underlying emotions, stressors or barriers may manifest in many different types of displayed behaviors.  We may perceive a patient as angry, defensive, resistant, anxious, withdrawn, or in denial.  But what lies behind what we see?  Curiosity and a willingness to explore the underlying reasons often lead to a better understanding and improved communication.

Situational and structural factors

Situational and structural factors also play into the mix.  Physicians and patients may have different agendas.  Financial and insurance barriers may limit the resources available, and short clinic visits, language and cultural differences, time pressures and frequent interruptions or suboptimal EHR use can get in the way of connection.

The power differential inherent to the doctor patient relationship can also contribute, placing us in a position of authority over patients who may feel quite vulnerable and out of control. They may try to increase their sense of control through their decisions to adhere or not adhere to our recommendations, or through behavioral expressions, like anger, boundary crossing, or showing up late.   When you find yourself in a challenging encounter, consider the possibility of a power struggle or disconnect between your and your patient.

Tools for navigating challenging encounters

Stay patient centered: The three commonly accepted models of patient-physician interactions are the expert model, the consumer model, and the patient-centered model. They differ primarily in how power is distributed between the participants, although it’s important to remember that the physician-patient relationship is inherently unequal.

The practice of relationship-centered care allows patient and provider to share a mutual understanding of values, goals and expectations and can lessen the power differential. The provider uses collaboration strategies to align with the patient, like agenda setting, a guiding communication style, boundary setting when appropriate, exploring emotions and displaying empathy.

Mindfulness Skills

Mindful practice can help to prepare clinicians for encounters they anticipate may be challenging and to reflect afterwards on WHY.

One family medicine residency practice developed a structured reflection tool, BREATHE-OUT, for use before and after a challenging clinical encounter and found that it improved clinician satisfaction with these visits.  If you anticipate an encounter may be challenging or you may leave a clinical encounter having felt particularly challenged, try using BREATHE-OUT to help process these interactions and to continue to build your mindfulness toolbox.

 

Caring for patients can be highly rewarding and can also at be times stressful or hurtful.  Most clinical encounters go smoothly, but some may involve microaggressions, biased comments or assaults toward you, your colleagues or your educators.  As we discussed in Immersion, we feel that it is important to acknowledge that these encounters will occur and to empower you with different tools and ways to potentially respond.  We encourage you to revisit the chapter on Responding to Microaggressions for some potential approaches.

Compassion 

With time pressures and our own feelings triggered by challenging encounters it can be hard to maintain compassion for patients. ​ Data support that when providers bring empathy and compassion to clinical encounters it can improve physical and psychological health outcomes for patients,  reduce physician burnout and lead to increased happiness and fulfillment in their careers. ​ Even 40 seconds of compassion can make a difference!​ “We’ve always heard that burnout crushes compassion. It’s probably more likely that those people with low compassion, those are the ones that are predisposed to burnout.”  ​  If you are interested in learning more you can explore this link to an NPR article summarizing the work of Trzeciak and Mazzarelli in their book Compassionomics:  The Revolutionary Scientific Evidence that Caring Makes a Difference. 

Resources and references

International Journal of Environmental Research and Public Health. The Patient, the Physician, or the Relationship: Who or What Is “Difficult”, Exactly? an Approach for Managing Conflicts between Patients and Physicians “2279 (nih.gov)

American Family Physician.  How to Manage Difficult Patient Encounters.

American Family Physician.   Managing Difficult Encounters: Understanding Physician, Patient, and Situational Factors. 

J Am Board of Family Med.  BREATHE OUT: a randomized controlled trial of a structured intervention to improve clinician satisfaction with “difficult” visits

Journal of General Internal Medicine.  A Cohort Study Assessing Difficult Patient Encounters in a Walk-In Primary Care Clinic, Predictors and Outcomes.  JGIM 2011; 26(6): 588–94.

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The Foundations of Clinical Medicine Copyright © by Karen McDonough. All Rights Reserved.