Patientâ€“clinician conflict: causes and compromises

April 8, 2003

Journal of Cystic Fibrosis

Volume 2, Issue 1 , March 2003, Pages 42-45

Science B. V.

Patientâ€“clinician conflict: causes and compromises

Lask Department of Psychiatry, University of London, St s'

Hospital

Medical School, London, UK

Conflict is an everyday phenomenon, a part of everyday life. It is hardly

surprising that it also occurs in a clinical setting, not only between

clinicians and within teams, but also between patients, their families

and clinicians. This is all the more the likely in a setting that deals

with a chronic disease such as CF. The physical, emotional, social and

practical burdens of the illness are such that coping mechanisms are

stretched to their limits. Disagreements, misunderstandings, impaired

trust and different expectations may all challenge the patientâ€“clinician

relationship. In a context in which children and adolescents form at

least half the clientele, the potential for conflict is intensified

because of the involvement of parents. This paper emphasises the

normality of such conflicts, and using case illustrations, explains the

reasons for conflicts and explores how best to resolve them. The basic

principles of conflict-resolution are outlined, and useful techniques,

readily applicable in everyday practice, are described.

1. Introduction

There is nothing unusual or unhealthy about conflict, an everyday event

in most aspects of life. Conflict can occur between:any two or more

individuals;family members;friends;colleagues at work;patient and

clinicians; andfamily and clinicians.Conflict need only be a problem if

it recurs frequently or persists unresolved. In the clinical setting

conflict becomes a problem if it interferes with treatment or with the

therapeutic alliance, leading to poor adherence or non-attendance for

appointments. The potential for conflict in CF is far greater than in

other conditions. The emotional, financial and practical burden, the

chronicity and the relentless downhill course all stretch family coping

skills to their limit. Nor should we underestimate the emotional burden

on ourselves, and the challenge to our own coping skills, as our

therapeutic limitations are regularly exposed. This can readily lead to

conflict within terms, and between us, our patients and their families.

All this is intensified by the fact that approximately half of our

patients are children and adolescents. The combination of very

understandable parental anxiety and the natural and healthy

rebelliousness of teenagers allows considerable potential for conflict

not only at home but also in the clinical setting. The relative autonomy

of early adulthood offers another scenario ripe for conflict.

2. Case illustration 1

aged 15 had until recently remained relatively well but in the

previous 6 months had suffered a number of set-backs necessitating

hospitalisations. He changed from being friendly and outgoing to moody,

unpredictable and at times angry. He began to refuse to do his chest

physiotherapy, saying there was no point. He argued with his parents and

with members of the CF team, stating he was old enough to do what he

wanted. The paediatrician repeatedly advised him that his failure to do

his physiotherapy would make him much worse and that his attitude was not

helping. refused to attend subsequent appointments and was next

seen as a result of an emergency hospitalisation. During this time he

remained angry and uncooperative. He was seen by a child psychiatrist who

patiently explored with him what had been going wrong. was able to

express his shock and fear about the recent deterioration and his

distress at his inability to maintain a normal social life, including

dating. The psychiatrist sought 's agreement to have a joint

meeting with the paediatrician and his parents, in which she might help

him to explain what was upsetting him. This proved to be constructive and

led to mutual agreement to work on how best to help him tackle the

difficulties.

3. Case illustration 2

aged 23 had moderately severe CF with an FEV1 of 55 and

hospitalisations every few months. She had been living with her boyfriend

for 2 years and told her physician that she had decided to try to become

pregnant. The physician was very alarmed by the possibility that a

pregnancy would cause a severe deterioration in lung function and even

death. He stated very clearly his views and told she should not get

pregnant. At her next visit she told him that she and her boyfriend had

thought about what he had said but nonetheless they were prepared to take

the risk, because they were keen to have a baby before her health

deteriorated further. The physician maintained his stance that this was

dangerous and told her she was being irresponsible. Six months later

attended clinic, reported that she was 3 months pregnant and wanted

additional help through the pregnancy. The physician strongly advised her

to seek a termination of the pregnancy. refused and proceeded with

the pregnancy without significant deterioration. She had a spontaneous

delivery at 34 weeks and both she and the baby thrived during the

neonatal and postnatal period.

4. The presentation of conflict

Although conflict is usually obvious this is not always the case. In some

instances it is indeed overt and openly expressed. However, other times

the conflict may be suppressed, disguised or detoured. When covert,

conflict may be recognised by the behaviour of the protagonists. For

example a child may be silent, or a teenager sullen and withdrawn, as in

's case. Patients may fail to attend appointments. Levels of

adherence may fall as an expression of protest. Clinicians may find

themselves behaving differently from usual, e.g. a normally friendly and

caring clinician may become distant or critical toward the patient.

Sometimes the conflict between patient and clinician may be detoured into

the team so that team members express the conflict between each other.In

's case the conflict was initially covert, expressed through his

mood change and withdrawal. Later he expressed direct anger with all

around him but it took some time before he could explain that he felt let

down by them. The conflict could have emerged in the team had there not

been a joint meeting of all concerned. The conflict between and her

physician was more overt, in that was able to make a clear

statement of her intentions, directly in conflict with the advice of her

physician.

5. Causes of conflict

Although conflict is a perfectly normal aspect of everyday life, certain

phenomena may intensify, exacerbate or maintain it. The very presence of

CF, with its attendant burdens, physical, emotional, financial and

practical, is likely to play a major part. In addition, a number of other

issues are relevant.5.1. Poor communication

Miscommunications are common-place. The busy clinician may rush through

the provision of information, thus offering insufficient information or

contributing to misunderstanding. Alternatively, attempts to provide

sufficient information can lead to information overload with failure to

grasp certain key points. Such miscommunications can lead to the

clinicians, their patients and families each having different knowledge

and different assumptions about the knowledge held by the other.5.2.

Impaired trust and confidence

The chronicity and relentless downhill course of CF, despite all best

efforts, may gradually impair the trust and confidence in which the

clinician is held. This can to some extent be allayed by predicting the

emergence of such impairment and also by occasional discussion of the

therapeutic relationship.5.3. Differing expectations

This links to the above points. Patients and their families may have

different expectations of the content and course of the illness leading

to shock or disappointment, and subsequent resentment and conflict.5.4.

Power imbalance

The unavoidable nature of the patientâ€“clinician relationship is one of

power imbalance. The clinician is perceived as having power while

patients are likely to perceive themselves as relatively powerless. This

scenario has the potential for the emergence of conflict especially

between adolescents and their clinicians.5.5. Soci-cultural differences

Such differences are now common-place in many societies and are certainly

frequent within health-care provision. The rules of everyday behaviour

and the expression of thoughts, feelings and attitudes may differ

considerably between individuals from different cultures. The potential

for misunderstanding and miscommunication and, therefore, for conflict,

is much enhanced.5.6. Emotional reactions

The nature and course of CF inevitably leads to the emergence of intense

and painful feelings, such as fear, helplessness, anger and despair, in

our patients and their families. In turn, we may experience a similar

range of emotions when caring for our patients. This maelstrom of

emotions can exacerbate painful conflicts between clinician, patient and

family or within the team.5.7. Developmental changes

As children become teenagers and teenagers become adults, so their needs,

opinions and wishes change, their right to increasing independence

increases and possibly they begin to suffer more ill-health. The

associated tensions make conflict far more likely.5.8. Team reactions

Team members inevitably react differently to their patients, with

contrasting attitudes and feelings. Some clinicians may become

over-involved and others may defend themselves against this by keeping

their distance and appearing aloof. This can be the cause of conflict

within the team and confusing to the patient. It is not at all uncommon

for patients to `split' teams, i.e. team members differ in how best to

handle a particular situation.The main cause of conflict in 's case

was that he believed that he had not been warned of the possibility of

early deterioration and, consequently, felt let down. The paediatrician's

authoritative reaction exacerbated the problem and intensified 's

loss of trust and confidence. In 's case, the conflict had its roots

in the physician's almost authoritarian reaction to her determination to

become pregnant. While this was undoubtedly based upon his understandable

concern for 's well-being, it simply gave rise to an avoidable

conflict, and his persistence exacerbated the problem.

6. Conflict resolution

It is in everyone's interests to resolve conflicts when possible. It is

not the existence of conflict in itself that is problematic but rather

its persistence. Failure to resolve conflict impedes the therapeutic

alliance and threatens the health of our patients. There are many stances

and strategies that aid conflict resolution and others that impede it.

Clinicians should avoid:Arguments: disagreeing with our patients' or

colleagues' views is perfectly legitimate but how this is done is

critical. Acknowledgement of the legitimacy of difference of opinion,

followed by discussion of the differences, is acceptable to most

proponents; argument tends to exacerbate the differences.Dogmatic

statements, preaching and pontificating: statements that imply `I know

what I am talking about and I am right' are likely to have the same

adverse effects as argument. Such stances are often employed (as a

reflection of anxiety) in an effort to resolve an impasse, but commonly

have the opposite effect.Abuse of power: failure to allow differences of

opinion, either between clinician and patient, or within a team, is not

only an abuse of power but also totally counterproductive. Conflicts are

likely to intensify in such circumstances.The unhelpfulness of such

approaches is well-illustrated in both the cases of and .

Failure to acknowledge their view-points, dogmatising and `preaching from

on high' all exacerbated difficult situations.There are many far more

constructive strategies for the resolution of conflict.Recognition: it

helps to be aware of the possibility of conflict within the therapeutic

relationship. Such awareness promotes early recognition and

resolution.Listening: it is essential to listen to the differences of

opinion as a means of understanding their origins, content and

significance.Acknowledgement: differences should be acknowledged as a

means of showing they have been heard.Respecting autonomy: everyone has a

right to their opinion, and a right to disagree with others, however

wise, senior or powerful those others may be.Exploration: conflict occurs

for good, valid reasons. These need to be identified and understood by

exploration of the differing viewpoints and why they are held.Empathy:

regardless of our intellectual reactions to the reasons for disagreement

we need to be empathic to those with whom we are in conflict. Failure to

do so is very likely to impair conflict resolution.Compromises: rather

than a `battle to the death' (sometimes literally) it is better to seek

compromises. These are usually available in some form, often discovered

following sympathetic discussion with the patient and family. Once

accepted, compromises can lead to conflict resolution in the long run.In

's case, the conflict began to resolve when each of the above

strategies were employed by the psychiatrist. Sadly not all were

implemented in 's case. Although the physician must have been aware

of the conflict, listened to her and acknowledged the differences between

them, he failed to respect her autonomy, explore her reasons for such a

momentous decision, empathise with her profoundly instinctive wish to

reproduce whilst she could, and even to offer to meet with her and her

partner to talk through the situation. It is likely that much of his

behaviour stemmed from his anxiety concerning 's health but he could

have been far more helpful had he followed the above guidelines.

7. Prevention

Much conflict can be avoided or rapidly resolved by simple measures which

include:Ensuring the therapeutic alliance: this involves reaching an

agreement with our patients as to how we are jointly going to tackle the

illness, and an agreement to review progress regularly. It requires

mutual trust and respect, each of which we have to earn from our

patients. Within this alliance, prediction of possible conflict and

agreement to share it openly, should it occur, will often pre-empt

conflict or allow for its early identification, exploration and

resolution.Time and patience: the clinician should find as much time as

possible for the patient, and indeed colleagues, as a means of ensuring

good communication and understanding of potential problem areas.Clear

communications with discussion of facts and opinions: this helps to

prevent misunderstandings, inadequate knowledge and inappropriate

expectations.Check for disagreements: this is a simple measure that can

be very beneficial. It normalises the fact that disagreement may occur

and so allows it to be expressed more freely.Identify with the patient

and family: it helps to consider how it must feel to the patient and

family. By putting ourselves `in their shoes' we are more likely to

recognise areas of potential conflict and so pre-empt them.

8. Conclusions

Conflict is common-place in everyday life and most certainly occurs

within the patientâ€“clinician relationship in CF. Although usually overt,

conflict may be disguised or even detoured into the team. There are many

causes, the most common of which are: intense burden imposed by the

illness, as each patient goes through important life stages: the

relentless downhill course; and the anxiety, resentment and helplessness

this creates. Conflict resolution is achieved by recognition and

acknowledgement of the conflict, acceptance of the validity of opposing

views, exploration of the differences, empathy and the search for

compromise.

Becki

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April 8, 2003