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Does managerial science hold the key to managing the uncooperative patient?

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Learn some of the tools you can use to win over an uncooperative patient.

IT IS ESTIMATED THAT UP TO 30 PERCENT OF primary care visits involve a degree of difficulty due to uncooperative and disruptive patients. (1) These conflicts tend to be due to dissociation between expectations, perceptions and the actions of patient and doctor. This induces frustration, anxiety and noncompliance of varying degrees depending on a doctor's communication and medical abilities, and the psychosocial background of the patients.

Current medical literature does not adequately describe how to manage patients in the context of conflict resolution, and although physicians and medical students are taught how to deal with behavioral problems, key concepts within the abundant managerial literature can increase awareness of the multifactorial composition of conflict.

DEFINING CONFLICT--Conflict is an unavoidable aspect of day-to-day practice and is based in perceived interactional incompatibility, Le., the opposing person or group are standing in the way of one's objectives. In summary there are only really three parts to a conflict, the emotional background or "climate," the interaction and the resolution. Climate stems from the socio-psychological and historical interaction between individuals and perhaps is the most important factor in shaping conflict.

The interaction between individuals is discussed as a clash of "face." Colloquially many of us know "face" to be synonymous with honour or lien (of integrity); the salient points of managerial face are that it can be saved, given and challenged. "Face" concerns the public promotion and presentation of a positive self-image and how individuals respond to threats to that image.

Resolution of conflict is induced by how reliant each party is on the other's resources. Such resources are described as "power." Combining these definitions allow for an understanding of conflict to form.

Conflict is a struggle between incompatible perspectives that are shaped by socio-cultural values, maintenance of face and the interactional climate. It is propagated by patterns of behavior and limited by the level of interdependence. (2-6)

APPLYING CONCEPTS IN A CLINICAL SETTING--In the Dynamic Theory of Conflict there are two pathways that a conflict can take, one toward resolution and the other toward cyclical argument. (3) Perhaps we can all recall a time where heated emotions took over conversation, sharp words exchanged and abrupt exits were taken; such actions are part of the latter.

Craig Runde and Tim Flanagan suggest that constructive conflict responses stem from the ability to criticize ideas and not people, dissociation between ideas and self-worth, active listening to others and efforts to understand all sides of an argument. All this is done with the aim of reaching an outcome that is suitable for all. (6) Without making the effort to address a patient's concerns, it is easy to fall into a habit of forcing compliance instead of encouraging cooperation.

LEVELS OF INTERDEPENDENCE--Focusing on the doctor/ patient relationship, the General Medical Council reminds us that we are first and foremost a patient's advocate, counselor and aide. Within this realm one is to do no harm to our patients, and one is there to push for what one believes is in a patient's best interests. (7)

Reflection on these points highlights the value placed upon the doctor/patient relationship. Such a relationship has a very high level of interdependence; doctors have something valuable--medications, counsel, and education--that the patient is lacking and requires. At the point of contact, the health care professional and patient are aligned in one objective: helping the patient.

John Petreet and others highlight the difficulties occurring when trying to establish relationships with oncology patients. Relationships have to be based in an understanding of the socio-economical, cultural perspectives of the patient. Emphasis has to be placed on communication and acquisition of knowledge, to enable the patient autonomy of care and empower the patient. (8) People desire stability and productivity, and threats of removal of these factors generates uncertainly and frustration. (9) Frustration and uncertainly creates pressure, and this pressure is relieved through either agression or anxiety.

The literature states that successful conflict resolution lies in well-balanced conflict style; style being described in varying degrees of "assertiveness"--how well you push for your goals, and "cooperativeness"--how accepting one is of the opposition's goals. (3)

Harold Nieburg once said that "behind every quarrel, hidden deep within the Issues of every dispute, lies a fundamental authority issue." (10) The more assertive one is the less cooperation can be expected from a patient. Trying to force a patient into submission is perhaps akin to trying to drive a car with no fuel.

SAVING FACE--In situations where there is a possibility of conflict, engaging that conflict automatically puts the "faces" of the doctor and patient at risk. Joseph Folger and Gregg Walker suggest the next stage in negating threat to face is to express sympathy for the other party. (3,11)

Perhaps the greatest secret in managerial science is the use of face-saving techniques to show empathy while still achieving your goal. Communication, recognition of a patient's thought process, and respect of the patient's autnomy and ability to self-care are key to cooperation. By showing recognition of this, one shows respect of that indiviudal's rights. (12)

The most notorious use of this in medical care is "ICE": ideas, concerns and expectations. Ideas are the patient's unemotional thoughts that pertain to the patient's condition. Concerns are the emotional triggers relating to the condition, the worries and fears. Expectations are what the patient would like to gain from the consultation, governing the patient's approach to the interaction. By asking this we are able to move on to the next stage, fully comprehending the patient's point of view. (3,13)

Another face-saving technique is simply an apology. An apology should always be part of the physician's tool box; a simple statement can negate conflict by restoring face to a patient who is threatened by their perceived lack of autonomy and has presented at their most vulnerable. Often apologies in medical practice are associated with liability; however, this is not always the case. Patients want to be listened to and reassured, and an apology does exactly that. (14)

INTRODUCING POWER, USING IT WISELY--Colloquialism and common misconceptions about power may lead one to believe that power is a force bestowed upon an individual; this is false. Power is endorsed, meaning that others must agree that another's resources are valuable to introduce restraints on others' freedom, e.g., take this medication at these times a day as opposed to whenever the patient wants. (3,15)

Uncertainty and anxiety put patients at high vulnerability and low power. A modern medical profession is focused on collaborative methods to resolve conflict, thus power plays cannot be allowed. Power must be shared as a resource, and parties must highlight a common goal and share resources to distribute power. (3)

This means it's important to explain all the available information to a patient before making a joint decision. Multiple steps should be taken to reassure the patient that they are also in the driver's seat during consultations.

It's important that as physicians who should be aware of the vulnerability of patients recognize the potential for face interactions and trying to negate conflict from the beginning through open and objective conflict communication.

Conflict should not be viewed as a "win-lose" situation, but rather as a way for parties to mutually benefit from each other. In an ideal situation both parties aim for maximal cooperation with recognition of each other's autonomy, a disregard for power plays and focus on the issues at hand and not each other. (15) It is always trying when faced with a difficult patient, however it is our duty to provide selfless, dedicated and pride-worthy health care to those in need, regardless of the character of the individual.


(1.) An, PG, Rabatin, JS, Manwell, LB, Linzer, M, Brown, RL, Schwartz, MD. Burden of difficult encounters in primary care: data from the minimizing error, maximizing outcomes study. Arch Intern Med 169(4):410-4, Feb 23, 2009.

(2.) Management study guide, understanding conflict--meaning and phases of conflict,

(3.) Folger, JP, Poole, MS, Stutman, RK. Working through conflict strategies for relationships, groups, and organizations, 7th ed. Boston, Mass.: Pearson, 2013.

(4.) Wilmot, WW, Hocker, JL. Interpersonal conflict, 7th ed. New York, N.Y.: McGraw-Hill, 2007.

(5.) Northouse, P. G. Introduction to leadership concepts and practice, 2nd ed. London: SAGE, 2012.

(6.) Runde, CE., Flanagan, TA., Center for Creative Leadership. Becoming a conflict competent leader: how you and your organization can manage conflict effectively. San Francisco, Calif.: Jossey-Bass in association with Center for Creative Leadership, 2007.

(7.) Tomorrow's Doctors, 2009. tomorrows-doctors.asp.

(8.) Peteet, JR, Meyer, FL, Miovic, MK. Possibly impossible patients: management of difficult behavior in oncology outpatients. J. Oncol. Pract 7(4):242-6, Jul 2011.

(9.) Pillay, SS. Your brain and business the neuroscience of great leaders. Upper Saddle River, N.J.: FT Press, 2011.

(10.) Nieburg, HL. "The threat of violence and social change," American Political Science Review 56(4):865-73, Dec 1962.

(11.) Walker, G. An Important Intangible: "Face" and Conflict Management. 2007. Oregon State University. Ref Type: Online Source http://oreaonstate. edu/instruct/comm440-540/face.htm

(12.) Kaptein, AA. Compliance: stimulating patient cooperation. Eur. Respir. J. 5(1): 132-4, Jan 1992.

(13.) Tate, P. Ideas, concerns and expectations. Medicine 33(2):26-7, 2005.

(14.) Armstrong, D. The power of apology: how saying sorry can leave both patients and nurses feeling better. Nursing Times 105(44):16-9, Nov 10-16, 2009 2009.

(15.) Coleman, P. and Deutsch, M., "Power and Conflict," In The Handbook of Conflict Resolution: Theory and Practice, P. Colemon, ed. San Francisco, Calif.: Jossey-Bass Publishers, 2000, pp. 108-30.

Michael Okocha is a Foundation Year 1 Junior doctor at Derriford Hospital, Plymouth, United Kingdom, and the University of Indianapolis in Indianapolis, Indiana.
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Title Annotation:Conflict
Author:Okocha, Michael
Publication:Physician Leadership Journal
Geographic Code:1USA
Date:Jul 1, 2015
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