Mr L was a young man coming 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 has been afflicted with depression, usually induced by life stressors. For example, he struggled with mood symptoms after the birth of his second child a few years ago. After moving to North Carolina for a new job this year, his depression recurred. The move and the new job understandably contributed to what Mr L was feeling.
Mr L told me he had started therapy the previous year, during a period when he was finding it really hard to fall asleep at night. He reported being unable to "turn off" at night, and then being extremely tired the next morning. He did not report having engaged in risky behaviors, gambling, or overspending during these periods. I asked explicitly if he had ever experienced mania, and he said no. But it turned out that he had been diagnosed with obsessive-compulsive disorder (OCD) in the past.
Mr L is not currently taking any medications. His only substance use includes marijuana "about twice a week." He has no pertinent family history nor a history of self-harm, suicidal ideation, or hospitalization.
To address his insomnia, we began by discussing sleep hygiene. I also brought up the idea that a mood disorder could be contributing to his insomnia and asked Mr L whether he had ever considered taking a selective serotonin reuptake inhibitor (SSRI). He had not, so we discussed indications, risks, benefits, and alternatives to SSRIs. I provided a handout to review at home about a specific medication, and Mr L said he would check back about a prescription after speaking with his therapist. All in all, I thought this was a very pleasant and easygoing first visit. I went back to my office to finish my encounter note and closed the chart.
A few days later, I received a message from Mr L in the electronic medical record. Although he claimed to have had a very positive experience during our visit, thanks to the 21st Century Cures Act, he subsequently read the medical note that I had documented in his chart. I was not expecting what came next.
How dare you suggest that I have bipolar disorder. I explicitly told you I was not manic and yet you still mischaracterized me. Then you had the nerve to also say I have a substance-induced mood disorder. You didn't ask whether I was smoking marijuana to cope with insomnia. You didn't contact my therapist. You simply recommended medication after one short visit. This is what medical racism against Black people looks like and I will not be returning to see you.
I was shocked. First, I identify as Black. Really, I identify as multiracial when given the opportunity to express this level of detail. However, to many (especially to my White counterparts in North Carolina) I appear to be Black. Second, I have dedicated my career thus far to diversity, equity and inclusion, bringing attention to systemic racism, and advocating for health equity. Being accused of racism was hurtful. And without meaning to, I had hurt my patient. I am always willing to be self-reflective and apologize for my mistakes. I went back to the chart and reread my note.
I was looking for anything that could have been a loaded statement. I routinely teach medical students about how our language in medicine can offend patients — how something we perceive as benign can be misinterpreted. For example, "patient complains of..." is commonly used to describe a chief complaint, but even calling it a chief complaint can be triggering! But nope, there was nothing like that in my note. My words describing the history of present illness were nearly a transcription of the patient's words. My assessment and plan included an extensive but standard differential for mood symptoms:
Differential includes major depressive disorder vs GAD [generalized anxiety disorder]. Consider substance-induced mood disorder given marijuana use. Less likely is bipolar disorder, although insomnia present. Known diagnosis of OCD likely contributing.
Resolving Doctor-Patient Conflict
This was not the first time a patient has been displeased by an interaction with a physician. Conflict with patients happens more often than those outside of medicine may think. The Cures Act adds another level of complexity to the issue because patients without medical knowledge can now view notes that healthcare professionals use mainly to communicate with one another. The clinician's experience of an encounter naturally differs from the patient's, and this difference is often reflected in the clinician's note, another potential source of misunderstanding.
Whether it's due to miscommunication or just not agreeing with my medical opinion, I know that I can't make every single patient I encounter happy. In fact, sometimes, what is in the best interest of the patient (for example, avoiding mixing benzodiazepines and opioids) is not what the patient wants. As a trained family medicine physician, I'm used to navigating these challenges.
What made this interaction different was that it came on the heels of a dissatisfied patient murdering his physician in Tulsa, Oklahoma. It 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 cause me harm? Now more than ever, conflict resolution with our patients is paramount. It is no longer just a matter of a bad online review or even a malpractice lawsuit. Today, conflict with our patients can be a matter of life and death.
I spent time reflecting on this patient interaction and others in my experience to come up with a list of steps to take with patients after conflict arises. Conflict resolution is as important as our morning LATTE:
L: Listen to the patient describe the situation and how they feel. It is important not to just hear the patient out but to really practice active listening to better understand their perspective. Here is a resource on active listening.
A: Ask the patient if you can provide any additional information or clarification on any specific point. This may help you both come to an understanding about where things went wrong. Words like "decline, refuse, complain" mean something specific to medical professionals but can have a negative connotation in everyday language.
T: Take responsibility for your part. More often than not, we actually do play a part 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 express themselves. Create a safe space for them to do so.
E: Extend the opportunity to revisit the topic again at a later date if that is helpful for the patient.
It is also very important to notify your supervisor. This can be your clinic medical director or other administrative leader, and in the case of trainees, an attending. It is especially important for trainees to notify their attending physicians early, even before debriefing with the patient. Attendings can help the trainee navigate conflict safely. Risk management can also be helpful in navigating the situation should it become a legal issue. Do not forget to provide your patient with the contact information for patient relations so that they have an opportunity to resolve the situation independent of you, if they prefer. If you work in an independent practice and have no one else to notify, you need to trust your gut. If you are concerned about your safety, notify law enforcement.
When conflicts arise, we have an ethical responsibility to do what we can to preserve the therapeutic relationship with our patients. Doing so may also help to defuse conflict. Today, we need to take further action to protect ourselves. Notifying our supervisor, risk management, patient relations, or even law enforcement early on can help protect us.
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Image 1: Alexa Mieses Malchuk, MD, MPH
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Cite this: Alexa Mieses Malchuk. Defusing Patient-Physician Conflict the LATTE Way - Medscape - Jun 24, 2022.