Conflict between Patient and Health Care Professionals: Identify and Resolve: An Indian Perspective

Conflict between patient and health care professionals is increasing over time. Traditionally, the medical profession has been considered the most honourable profession and the professionals are held with great esteem as they are considered next to God. Unfortunately, there seems to have been developed a distinct discord between the patient and the health care professional relationship with disturbing incidents catching the headlines. These conflicts range from simple disagreements to major violence against the very people who are trying to undertake patient’s care. Ultimately, it is in the best interest of both the patient and the health care professional to have a harmonious relationship based on utmost trust which is the very keynote of mutual understanding resulting in the benefit both of them. Authors are now trying with deep sincerity for mitigation of distrust and exploring possible resolution strategies to apply in clinical practice in order to overcome them.

Conflict is a disagreement or argument between two parties where one believes that his interests are being opposed by the other party. In the medical profession, a trust between a doctor and a patient is a key to a mutual relationship. Conflicts may emerge because of differences in functional understanding and expectations. Conflict between patient and health care professionals is not new, most of health care professionals observed undisciplined and riotous attitude of the patient in their clinical practise atleast once a week [1-3].

Conflict between patient and health care provider that results in violence is a rising epidemic now-a-days. Many health care workers believe that violence at the workplace has become a part of the job, which is a type of negative reinforcement that has created barriers to reporting acts of violence. This conflict is causing an alarming situation in both developing as well as developed Asian nations, causing brain drain of health professionals from Asia to the western world [4]. In India, the incidence of violence against doctors has increased by 75%. In 2015, 75% of Indian doctors have faced workplace violence [5]. In Japan, in 2003, a major Japanese newspaper reported that 60% people from Japan were not satisfied with their health care professionals [6]. Another survey from the UK on General Practitioners (GP) found that over 60% of them had experienced abuse or violence by patients or their relatives over one year and nearly 20% reported some sort of abuse atleast once a month [7]. A study from India reported that about 87% of violent incidents were verbal, while 8.4% were physical [8].

Patient’s dissatisfaction is one of the causes of conflict but sometimes, it is not causally related to their medical condition but associated with a financial issue or personal agony in their family [9-11]. Doctors attribute the surge in violence against health care workers to a mix of ignorance, fear, and misunderstanding. Good communication skills, trust, empathy and appropriate professional boundaries are the very basis of attributing for a good professional relationship. Applications of these principles should obviate most of the conflicts. As per the study conducted in New Delhi, 73.5% of doctors attributed long waiting periods as a major cause of violence. Other causes perceived were delay in medical treatment, visiting-hours violation, and dissatisfaction with nursing staff. Doctors felt that patients came to the hospitals when complications had turned severe and then become impatient and violent [8].

Doctors facing violence due to escalation of the conflict are believed to face depression, develop insomnia, post-traumatic stress and anxiety causing absenteeism from work [12]. Whenever there is a conflict between a doctor and a patient, it impacts the physician’s mind and may demotivate a clinician. Conflicts lead to adverse clinical outcomes in patients and thus, they have a detrimental effect on both i.e., health care providers and patients [13,14]. Hence, successful resolution of conflict in health care is pivotal, transforming it into a positive force.

Social media platforms have become an area for patients and their kin to discuss and share about their medical condition, experiences and views. Social media (both print and electronic) at times sensationalise relevant news which may be misinterpreted or misunderstood. The sympathetic portrayal of complexity involved in clinical management of a patient in the media may support doctors and health care workers in undertaking their duty more effectively. Uncertainties in diagnosis and treatment are highlighted and safe management of patients to include such ambiguities is undertaken [15].

1. Good communication skills

It has been found that health care organisations that indulge in the development of effective ways of resolution of conflict can improve the efficiency of patient care [16-18]. During training in medical school, doctors do focus on acquiring knowledge, training and development of skills required for better patient care in the health care system. Despite a long journey in medical school, some of the doctors may lack the skills of dealing with conflict between patient and health care provider. Essential skills which are necessary for health care providers especially in doctors include listening to the issues of patient’s forbearing, mutuality, openness, and reflections. Due to the current enormous footfall in Indian health care system, the health care environment can be chaotic and complex. This is an occupational challenge for most of the doctors. Majority of the health care providers are concerned about the next patient, how to organise resources, fit in a clinical test or procedure, avail necessary rest including the ability to respond to multiple distractions and interruptions. It has become exceedingly difficult for the doctors to listen to the patients patiently as they seem to be worried about attending the next patient. Patients complains especially in geriatric age group are insignificant and do not fall in information needed for management, hence health care worker seems to ignore and is disinterested in listening to their complain. This leads to barriers in communication and confusion owing to which problems between the doctors and the patients arise. Good communication skill is an essential attribute to avoid misunderstanding and practice safe patient care within a chaotic clinical environment.

2. Trust

The doctor patient relationship lies at the heart of health care, and patient trust is a fundamental aspect of this relationship. If a patient shares all the information pertaining to illness, then the physician will be in the position to take the utmost care of the patient. But how does one build patient trust? Firstly, doctors need to be calm and sincere while giving treatment to a patient and vice-versa. For establishing trust and strong bond between patient and health care provider, detailed counselling regarding the treatment is important. Patients should be informed thoroughly pertaining to the advantages and disadvantages of treatment. Planning treatment is a decision making process shared between a doctor and a patient. Both the patient and the doctor need an open discussion about the implications of the intended treatment. An ’Informed consent’ is an essential part of this process. Advantages, disadvantages, risks and benefits of the intended surgery or medical procedure should be discussed and recorded. These need to be explained in a language that the patient can understand. Problem arises when surgeons start selling the surgery, especially in private settings. Surgeons should impart all the information related to surgery and let the patient think and decide accordingly as this will reduce the dissatisfaction rate and conflict.

It is extremely important to identify patients who can cause conflict. Some patients indulge in conflicts because of ignorance about treatment or dissatisfaction in the treatment. When the patient and the physician disagree with each other regarding ongoing treatment, then the patient feels vulnerable and distressed. It has been hypothesised that patients report their complaints differently depending upon the behaviour, language skills, ethnicity, and level of specialisation of the health care provider [19]. Thus, health care providers need to be efficient in understanding the patients’ problem overall and then develop holistic ways for its resolution. The ability to work with challenging patients is essential to finding happiness [9]. On the other hand, some difficult patients want some secondary gains like monetary gain, workman’s compensation or emotional gain and they need to be dealt with a different strategy. The identification of these two types of patient is important to reduce the conflict.

3. Empathy

Acknowledgement to a patient’s emotions and to address them with concern is very essential. Health care providers need to give time to the patient and family members to assimilate the facts. Sometimes, patients’ anger is a way of expressing dissatisfaction that the treatment is not working and the physician should not take offence in that and take adequate measures to modify the treatment or bring changes to the same. Let the patient express his/her anger as it is often a secondary emotion and venting it out brings out the primary emotion which can lead to a better understanding of the problem. It is important to listen to the patient completely as interruption might aggravate the situation. In my opinion, sometimes it is necessary to ask patients and their relatives the prudent questions like, why they are frustrated or what are the causes of their disappointment or what provokes them in the hospital. This can be time consuming, but asking open ended questions is the only way to get to the heart of their actual problems. Once we do that, we can provide alternative options but before that, a physician must understand the personal problems and agony of the patient.

4. Inform “shared decision” making in consent process

It is of utmost importance to explain the facts about treatment to the concerned patient. First of all, explain explicitly the evidence based practice guidelines that the patient must follow. Maintain a steady voice and try to win the patient’s heart through simplicity while giving treatments. Both preoperative and postoperative records along with the treatment given on that day and course should be explained to the patient in detail. Defining the treatment timeline for the patient would give him/her a substantial perspective of the treatment and would deviate the patients’ emotions from immediate misconceptions. Showing the preoperative records including clinical picture and disability level to the patients make them acknowledge the magnitude of the problem before the surgery and improvement achieved henceforth. The revelation of complete information of records from the initial visit to the present helps in building trust and confidence as the patient may perceive that no information is withheld [20]. Multiple events in the treatment timeline would subject the patient to the realisation of efforts that have been put by the health care provider and team. Once the patient realises the facts about treatment and efforts behind that, then time should be given to the patient for an emotional reaction to the facts.

5. Professional boundaries

Professional boundaries give an important scaffold for patients and health care provider to develop a healthy relationship. Patients vulnerability is protected by physical and emotional limits and thereby protecting staff from being over involved. A healthy relationship between a health care professional and patient are kept understandable by professional boundaries and hence, the focus remains on patients. The provider needs to pay heed to how a person’s health is responding as that experience can help doctors understand things in detail. The boundary has to setup by the health care provider as he is at a state of power regarding this relationship and thus is responsible for maintaining boundary limits and issues, even if patient’s behaviour seems to be violating boundary norms [21].

6. Evaluation of high risk patient

It is especially important to identify high risk patients or patients with a motive for secondary gains. Separate measures are required when it comes to dealing with such patients. These high risk patients may also have violent behaviour. Identification of such patients in the early stage is indispensable to avoid untoward escalation of conflict. Violence is not an isolated event but as a process with three behavioural phases, baseline or relative calm, a person’s normal demeanour before becoming disturbed. Pre-assault, as the person becomes disturbed, emotionally and financially, they exhibit aggressive behaviour i.e., Pre-assault. Assault, the acute excitement phase, includes violent verbal and physical behaviour. Identifying difficult patients beforehand in such stages can help the health care worker to protect themselves [22]. If the situation gets worse, the involvement of different parties may be prudent. Measures of defensive strategy like referral of the patient to the legal team or involving a counsellor might be the best step at that moment.

A health care provider, devotes his life for caring of patients, and this is one of the unique perspectives that can be brought into medical conflict resolution. While it is inevitable to have conflicts with patients, this stepwise strategy can be beneficial to health care providers especially, young surgeons in dealing with conflicts. The strategies to do so must be inculcated in a medical training program to improve and prevent the occurrence of conflicts and their resolutions. It is important to realise that despite putting maximum efforts it might be difficult for both doctors as well as patients to be fully satisfied with the resolution. In the heat of this debate, it is worth remembering that despite being caught in the pincer of a compromised public health sector and an expensive private sector, a large majority of patients show tremendous tolerance, resilience and trust in their interaction with us. This would encourage young doctors to live a long and peaceful life.

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