ACP 2019: How to overcome conflict with patients

Not only are disagreements between physicians and patients uncomfortable, they also can negatively impact health outcomes and patient satisfaction. It’s no surprise, therefore, that most physicians would rather avoid conflict than engage with patients to overcome it.  

But being able to navigate conflict is an important skill for physicians. When handled correctly, conflict can lead to positive change, says Rebecca A. Andrews, MD, FACP, general medicine clinic director and associate program director for categorical internal medicine at UConn Health in Farmington, Conn. The key, she adds, is knowing how to communicate effectively when emotions run high. 

Equipping physicians with the knowledge and communication tools to do so is the goal of the session Andrews and Auguste H. Fortin, VI, MD, MPH, MACP, professor of general medicine at Yale School of Medicine in New Haven, Conn., will present at this year’s ACP Internal Medicine Meeting in Philadelphia.

They will begin the session with a discussion about implicit bias, or the unconscious attitudes and beliefs about an individual or group that impact decisions and actions. “You might have thoughts or opinions developed by your experiences, your gender, your culture growing up that might affect how you approach a different situation,” Andrew says. 

Andrew emphasizes that having implicit bias does not mean that an individual is bad or has done anything wrong, but it can compromise patient care. So it’s crucial that physicians identify the issues they are overly sensitive about and make a conscious effort to check those views or feelings at the exam room door. 

Once they are in the exam room, Andrew says there are three communication models that physicians can use when conflict and strong emotions arise. 

1. NURS = Name > Understand > Respect > Support 

The NURS model illustrates how to empathetically address emotion. The physician will name the emotion that the patient is expressing (“You’re worried.”), convey understanding of why that emotion is present (“I can see why you’re feeling this way. Many people in your situation would feel like this too.”), demonstrate respect for the patient’s experience (You’ve been through a lot.”), and offer support (Let’s see what we can do to get to the bottom of this.”).  

2. ADOBE = Acknowledge the difficulty > Discover meaning > Opportunity for empathy > Boundary-setting > Extend the system 

The ADOBE model delineates how to effectively communicate when there are a lot of strong emotions present. The physician will acknowledge the emotion out loud (“You seem angry.”), request more information to discover the cause (“Help me understand why you’re angry.”), find an opportunity to display empathy (by using the NURS model), set boundaries to the conversation (“I’ll work with you as long as you exhibit the same respect towards me that I am giving you.”), and extend the care if the patient has needs that the physician cannot address (refer the patient to a specialist).  

3. Non-violent communication = Observe > State > Connect > Make

The non-violent communication model demonstrates how to express and receive emotions with empathy. A physician will observe the situation objectively (“I see that you’re frustrated because your current medication is not alleviating your pain.”), state the feelings that the situation is causing (“I understand how difficult this is, but I am uncomfortable prescribing medication that is not recommended for your condition.”), connect to a need (“I need to balance helping you feel better and prescribing a safe treatment.”), and make a request (“Why don’t we look into approved treatments and create a plan?”).  

These models are effective when used alone or in conjunction. “A doctor might find that one approach might work better for them than another approach. Another might find that they like to do the different approaches depending on what they’re talking about,” Andrew says. “But as long as you’re using empathy and [patients] can understand that you’re caring, you can’t help but get to a good place.” 

Andrews’ ACP 2019 session, “Communicating Effectively When You Don’t Want To,” will take place on Saturday, April 13 at 9:30 a.m.