Mr L was a young man who came to see me for the first time. The reason for the visit was to establish care with a new primary care clinician, but he was also experiencing insomnia. In the past, Mr L suffered from the Depression, usually induced by life stressors. For example, he battled mood symptoms after the birth of his second child a few years ago. After moving to North Carolina for a new job this year, her depression returned. The move and new job naturally contributed to how ML felt
Mr. L told me that he had started therapy the previous year, during a period when he had great difficulty falling asleep at night. He said he was unable to “power off” at night, then was extremely tired the next morning. He did not report engaging in risky behavior, gambling or excessive spending during those times. I explicitly asked if he had ever suffered from mania, and he said no. But it turned out that he was diagnosed Obsessive Compulsive Disorder (TOC) in the past.
Mr. L is currently not taking any medication. His substance use alone includes marijuana “about twice a week.” He has no relevant family history or history of self-harm, suicidal ideation or hospitalization.
To remedy her insomnia, we started by discussing sleep hygiene. I also brought up the idea that a mood disorder might be contributing to his insomnia and asked Mr. L if he had ever considered taking a selective serotonin reuptake inhibitor (SSRI). He hadn’t, so we discussed the indications, risks, benefits, and alternatives to SSRIs. I provided a document to review at home on a specific medication, and Mr. L said he would verify a prescription after speaking with his therapist. All in all I thought it was a very pleasant and easy going first visit. I went back to my office to finish my meeting note and closed the board.
A few days later, I received a message from Mr. L in the electronic medical record. Although he said he had a very positive experience during our visit, thanks to the 21st Century Cures Act, he then read the medical note that I had documented in his file. I did not expect the sequel.
How dare you suggest I have bipolar disorder. I told you explicitly that I was not manic and yet you always misinterpreted me. Then you had the nerve to also say that I had a substance-induced mood disorder. You didn’t ask me if I smoked marijuana to deal with insomnia. You haven’t contacted my therapist. You simply recommended medication after a short visit. This is what medical racism against black people looks like and I won’t be coming back to see you.
I was shocked. First, I identify as Black. Truly, I identify as multiracial when given the opportunity to express this level of detail. However, to many (especially my white counterparts in North Carolina), I look black. Second, I have dedicated my career so far to diversity, equity and inclusion, bringing attention to systemic racism and advocating for health equity. Being accused of racism was hurtful. And unwittingly, I had injured my patient. I am always ready to reflect on myself and apologize for my mistakes. I went back to the board and re-read my note.
I was looking for anything that could have been a loaded statement. I regularly teach medical students how our language in medicine can offend patients – how something we perceive as benign can be misinterpreted. For example, “the patient is complaining about…” is commonly used to describe a chief complaint, but even calling it a chief complaint can be triggering! But no, there was nothing like that in my note. My words describing the history of the present illness were almost a transcription of the patient’s words. My assessment and plan included an extensive but standard differential for mood symptoms:
The differential includes major depressive disorder vs GAD [generalized anxiety disorder]. Consider substance-induced mood disorder given marijuana use. Bipolar disorder is less likely, although insomnia is present. Known diagnosis of OCD likely to contribute.
Resolving Doctor-Patient Conflicts
It wasn’t the first time a patient had been unhappy with an interaction with a doctor. Conflicts with patients occur more often than those outside of medicine realize. The Cures Act adds another level of complexity to the matter, as patients without medical knowledge can now view the notes that healthcare professionals primarily use to communicate with each other. The experience of a clinician encounter naturally differs from that of the patient, and this difference is often reflected in the clinician’s score, another potential source of misunderstanding.
Whether it’s because of miscommunication or simply because I disagree with my medical opinion, I know I can’t make every patient I see happy. In fact, sometimes what is in the best interest of the patient (eg, avoiding mixing benzodiazepines and opioids) is not what the patient wants. As a trained family physician, I’m used to meeting these challenges.
What made this interaction different was that it happened after a disgruntled patient murdered his doctor in Tulsa, Oklahoma. This was the first time I even had to think about my safety in response to a patient’s message. Had I offended him so much that he wanted to hurt me? Today more than ever, conflict resolution with our patients is essential. It’s not just about a bad online review or even a malpractice lawsuit anymore. Today, conflicts with our patients can be a matter of life and death.
I spent time reflecting on this interaction with patients and others in my experience to come up with a list of steps to take with patients after a conflict arises. Conflict resolution is as important as our morning LATTE:
L : Listen to the patient describe the situation and how he is feeling. It is important to not just listen to the patient, but to really practice active listening to better understand their point of view. Here is a resource on active listening.
A: Ask the patient if you can provide additional information or clarification on a specific point. This can help you both figure out where things went wrong. Words like “refuse, refuse, complain” mean something specific to healthcare professionals, but can have a negative connotation in common parlance.
T: Assume your share of responsibility. More often than not, we actually play a role in the conflict. Even if you didn’t mean to make someone feel bad, the fact that they feel that way is reason enough to apologize.
T: Tell the patient that you appreciate their honesty and willingness to speak up. Create a safe space for them to do this.
E : Extend the possibility of coming back to the subject at a later date if it is useful for the patient.
It is also very important to notify your supervisor. This may be your clinic’s medical director or other administrative officer and, in the case of interns, an assistant. It is particularly important that trainees inform their attending physician early, even before the debriefing with the patient. Attendance can help the trainee manage the conflict safely. Risk management can also be helpful in managing the situation should it become a legal issue. Remember to provide your patient with patient relations contact information so that they have the opportunity to resolve the situation independently of you, if they prefer. If you work in an independent firm and you have no one else to tell, you have to trust your instincts. If you fear for your safety, inform law enforcement.
When conflicts arise, we have an ethical responsibility to do what we can to preserve the therapeutic relationship with our patients. It can also help defuse conflict. Today, we need to take extra steps to protect ourselves. Notifying our supervisor, risk management, patient relations, or even law enforcement early can help protect us.