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Feroza Fatima1, Waad Ibrahim Kadori2
- Specialist Dermatologist, PHCC Qatar
- Consultant Dermatologist, PHCC Qatar
© Author(s) (or their employer(s) 2021. Re-use permitted under CC BY. No commercial re-use. Published by Pak J Surg Med.
Article Citation: Fatima F, Kadori WI. Challenging incidents in health centers and how to deal with it: Physician–Patient bad interactions. Pak J Surg Med. 2021;1(4):e284. doi: 10.37978/pjsm.v1i4.284
The physician-patient rapport is the basis of patient care and can have profound implications on clinical outcomes. Ultimately, the principal objective of the physician-patient rapport is to improve patient health outcomes. Stronger physician-patient relationships are correlated with improved patient outcomes. As the relationship between physicians and patients becomes more important, it is essential to understand the factors that influence this relationship.
Keywords: Challenging interactions, communication skills, confidentiality
The physician–patient relationship has been and remains a fundamental aspect of modern health care: the medium in which data are gathered, diagnoses and plans are made, compliance is accomplished, and healing, patient activation, and support are provided. It is a sacred bond and is one of the cornerstones of modern medicine. Physician-patient relationships can have profound positive and negative implications on clinical care. In the eyes of a patient, the physician is the ultimate healer, a person in which the patient can confide. Ultimately, the predominant objective of an effective physician-patient relationship is to improve patient health outcomes and their medical care. Robust physician-patient relationships are associated with enriched patient outcomes and improved patient satisfactions. As the relationship between physicians and patients becomes more important, it is essential to understand the factors that influence this relationship.
Interactions between patients and physicians in all fields can sometimes be challenging. Both the physician and the patient want to avoid un pleasant situations but misunderstandings do occur from time to time, leading to a challenging interaction. There are many factors that play an important role in such occurrence and as well as its solution. We can avoid such kinds of challenging interactions by keeping in mind these factors and working on them.
This paper highlights the factors that can predispose a “challenging interaction” thus making a consultation difficult. This paper also sheds light on how they can be prevented.
Challenging incidents and its perception
Challenging interaction occur when the patient is dis-satisfied with his / her treating physician. These scenarios are potentially preventable if the treating physician is aware of the confounding factors. They may be due to unrealistic expectations, lack of communication. It could be caused by the doctor, by the patient or both.[1-4] Challenging interactions can be prevented, if one of the parties is aware of the contributing factors. We have outlined a list of potential challenging scenarios in table-1 [Supplementary Material 1] and discuss how these might be perceived from both a healthcare professional and patient perspective.
Doctor patient relationship is developed over time and is based on mutual trust, bound by confidentiality, strengthened by reciprocated respect and regard by both parties. This is a delicate relationship which can be affected by a variety of factors, most important being; 
- Patient dependent
- Provider dependent,
- System dependent
- Patient provider mismatch
Below is a brief outline of these factors;
- Patient Dependent Factors:
With a new patient, the most important thing is to establish interpersonal trust. A patient bases his trust on;
- Competence of the treating physician
- Compassionate attitude
- Ensuring an environment where privacy and confidentiality are secured.
- Communication [6-9]
Each patient has his / her own unique medical history, symptomatology, past experiences with other physicians and previous history of bad interactions which makes it very difficult to establish trust. In case of chronic illness, a patient may feel dependent on others, which reduces self-esteem and predisposes the patient to have added psychological issues. When a patient walks into your clinic for the first time, he / she are anxious and uncertain about treatment. The physician needs to understand all this to communicate effectively with the patient and prevent a potentially challenging interaction. The patient needs to be taken on board about all the decisions and he / she should be communicated all the pros and cons of a treatment. The final decision should be a reflection of the physician’s competence, knowledge and patient’s beliefs, values and choices. With the advancements in medical sciences, patients expectations have become unrealistically higher and if the patient has a terminal condition, it’s advisable to have a chaperon present to avoid a challenging interaction. The patient and the physician want to have an amicable consultation, with a plan to move forward with available treatment options. And the healthcare provider should take all the necessary steps to avoid a challenging interaction [Table 2].
2. Provider Dependent Factors:
Burnout: Most healthcare settings are overworked and overstretched to meet demand, and this continuously affects interactions. In burnout state, it is difficult to establish rapport with the patient. Additionally, physician burnout is associated with an increased risk of jeopardizing the safety of patient.
Trainees and Residents: A patient may not trust a trainee or resident due to lack of competence, they may want another opinion due to lack of experience.
Poor Communication Skills: They may be dis-satisfied due to poor communication skills.[7-8, 3] Poor communication skills are usually a result of poor choice of words, breaking bad new insensitively, inappropriate body language, wrong setting for consultation, lack of appropriate consultation time, lack of options offered to patient, imposition of treatment option on patient and non-referral of patient. Poor communication skills play a major role in bad interactions as well as in the relationship between physicians and patients. Bad news could be broken to patients in an empathetic way while unnecessary conversation and medical terms should be avoided with nurses or co-staff over the patient’s head. In this scenario, the patient would take the physician as cold, non-empathetic and not taking care of his emotions. Sensible physicians attend to their patients in a professional and non-judgmental manner. This enables them to listen to patients in a more attentive manner, assess him / her thoroughly and establish trust and rapport in the process. It is noteworthy that the patients who have a challenging interaction with their physician on their first interaction usually have a chronic illness and associated anxiety disorder, which should be recognized by physician. Effective communication is an art and is developed over time.
3. System Dependent Factors:
Time Constraints: Flaws in healthcare systems can add tension between patients and doctors. Long waiting times, unnecessary referrals in the clinic, unjustified cancellations, or delays to appointments can potentially lead to a challenging interaction between patients and physicians.
Documentation Burden: Usually, referrals are accompanied by incomplete documentation on part of the referring physician. This can be prevented by checking documents before confirming appointment. Flaws in centralized documentation systems lead to asking the patient to repeat the same information repeatedly, and consequently less time to manage the clinical case and addressing the patient’s needs. Repetition to the subspecialty physician may trigger the patient’s frustration, while on the other side; it is difficult for the doctor to take again complete details by history and patient’s prior understanding about medical issues. Sometimes, patients get angry and refuse to reply as they want the doctor to read previous notes but unfortunately dermatologist/ subspecialty physicians could not get much from there.
Space / Room: The consultation room should be private and patient should feel secure while discussing his / her ailment and treatment options with the physician. The poor referral notes about patient history and examination not only increase patient’s frustration as well as enhance the doctor’s confusion too. The proper referral notes can help us in tele-dermatology as well. As in case of any disaster like COVID-19, phone consultation was the only source of communication between dermatologist and patient. Referral notes were the only source of documented information by the health care worker to subspecialty physicians that could help in providing best care and management to patients.
High Patient to Provider ratio: In public sector institutions, due to limited resources, the patient to provider (doctor) ratio is high and patients have to wait for weeks and sometimes months to get a consultation. By the time the patient comes to see his doctor, the disease might have progressed and this predisposes to another challenge. This can be avoided by ensuring proper referral from primary healthcare units. In the primary health care system, initial treatment should be provided by a general practitioner or family physician, for example in common dermatological cases such as acne, eczema, contact dermatitis, hair fall, atopic dermatitis etc. But unfortunately, sometimes these cases referred to dermatologists without initial management and basic education/counseling. This issue increases workload in subspecialty clinics as well as increases the waiting time for the patients who are in need. In this scenario, many patients of common cases, treated or untreated get appointments while the patients who need urgent appointments for chronic or distressing skin disorders, wait for long. In these both above mentioned situations, it is difficult to satisfy the patient by any means sometimes due to raised levels of frustrations. The notion that hospitals and medical practices should learn from failures either small or large; their own or others, has obvious appeal.
Urgent care setting: In an urgent care setting (emergency rooms, coronary care units, intensive care units, operating theaters and post-operative ward), the patient and his / her relatives are apprehensive, anxious and agitated. This can predispose to a challenging interaction.
Potential effects of a challenging interaction
When miscommunication occurs, it can impede patient understanding, reduce the trust of patient in physician, reducing hope and adding to anxiety of patient[Table 3].
Challenging interaction can be easily prevented if the treating physician is aware of potential pitfalls. However, if a challenging interaction occurs, then the best course of action is to create an environment that is safe, where the patient can speak his heart out. This can only be possible if the physician has a sympathetic ear and active listening skills and is well versed with the patient’s history. Special attention should be paid to non verbal cues, which usually point to anxiety, fear and phobias. Patients should not be interrupted while they are expressing their apprehensions and sharing past experiences. In the first session, a detailed history including history of previous challenging interactions (if any) should be taken. The patient should be involved in the decision making process. This not only builds patients trust but also reflects positively on competence of the attending physician. If the case is difficult, the attending physician shouldn’t hesitate to get a 2nd opinion. All these efforts not only keep the physician in control of the session, but also helps in building trust, which is foremost in an ideal doctor-patient relationship. The physician should discuss all available treatment options with the patient and should be sympathetic while breaking bad news. The patient should never be rushed. Even if the patient has a terminal condition, the physician should assure the patient that he will stand by the patient till the end.
Patient-Physician good relationship matters a lot in our health system and can alter health outcomes for patients. Therefore, it is important for physicians to recognize when the relationship is challenged or failing. If the relationship is challenged or failing, physicians should be able to recognize the causes for the disruption in the relationship and implement solutions to improve care. There should be good communication between physicians and managers so that they can discuss matters without any hesitation or fear among team. After any challenging interaction, it is important to reflect on what happened and identify what could be improved. This thought process will help us in future challenging situations and provide better insight as how to manage similar cases. It is always useful to discuss this with peers/colleagues to get some feedback and update supervisor or head of the department. Regardless of the outcome, physician’s personality, patient characteristics and challenges in the healthcare system, we should try to stay in line with our mission to deliver optimal medical care to all our patients.
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FF: Conceptualization, Investigation, Methodology, Writing (original draft), Writing (review & editing), Project administration
WIK: Supervision, Writing (review & editing)
Conflict of Interest
The author declared no conflict of interest.
This article has been subjected to extensive editing and double blind peer review process. The following editors were involved in editing of this article;
Lead Editor: AR Malik
Editors: NH Maria, A Anwer
The views and opinion expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any other agency, organization, employer or company.