Top tips to deal with challenging situations: Doctor–patient interactions

Abstract

Interactions between patients and medical practitioners can sometimes be challenging. We have all had consultations where the interaction was not optimal, either as medical practitioners or as a patient ourselves. Neither normally wishes to cause a difficult situation but common misunderstandings, by both groups, often result in such an occurrence. Communication and listening skills are essential for every consultation but in particular, for situations where the interaction may become difficult.When challenging situations arise in doctor–patient interactions, how can we best manage them? http://ow.ly/J1GI30bD5wpMany thanks to Gill Hollis, Lisbeth Høva and Janette Rowlinson, who kindly provided feedback and gave us patients’ perspective on our manuscript.

Full text

http://doi.org/10.1183/20734735.006616 Breathe | June 2017 | Volume 13 | No 2 129
Top tips to deal with challenging
situations: doctor–patient
interactions
Doing science
Raise your words, not your voice. It is rain that
grows flowers, not thunder.
Rumi
Interactions between patients and medical
practitioners can sometimes be challenging. We
have all had consultations where the interaction
was not optimal, either as medical practitioners
or as a patient ourselves. Neither normally
wishes to cause a dicult situation but common
misunderstandings, by both groups, oen result in
such an occurrence. Communication and listening
skills are essential for every consultation but in
particular, for situations where the interaction may
become dicult.
In this article, we will discuss what may make a
consultation dicult and what outcomes this could
lead to, and provide some suggestions to help both
you and your patient.
What is a challenging
interaction and how
might it be perceived?
Many different challenging interactions occur
daily. These challenging interactions may arise
due to discrepancies in expectation, perception
and/or communication between the patient
and medical practitioner, and could be caused
by the doctor, by the patient or by both. We have
outlined a list of potential scenarios in table 1
and discuss how these might be perceived from
both a healthcare professional and patient
perspective.
Examples of scenarios include when a doctor:
 informs the patient of bad news without
ensuring that this is done in an appropriate
setting (e.g. breaking bad news in a busy corridor
at the accident and emergency department in
the presence of medical students and other
patients that are observing);
 delivers dicult news (e.g. a life-changing
diagnosis) without showing empathy or ensuring
there is appropriate support available for the
patient (e.g. counselling services or caregivers/
family members around);
 during a consultation, uses poor nonverbal
communication (e.g. no eye contact with
the patient, instead focussing solely on the
computer screen or notes; stance; gestures; or
tone of voice); or
 speaks ambiguously, not explaining, in plain
language, long-term management plans, or the
importance or implications of diagnosis.
Cite as: Hardavella G,
Aamli-Gaagnat A, Frille A,
et al. Top tips to deal with
challenging situations:
doctor–patient interactions.
Breathe 2017; 13: 129–135.
georgiahardavella@hotmail.com
Georgia Hardavella1,2, Ane Aamli-Gaagnat3, Armin Frille4,
Neil Saad5, Alexandra Niculescu6, Pippa Powell7
1Dept of Respiratory Medicine, King’s College Hospital, NHS Foundation Trust, London, UK. 2Dept of Respiratory
Medicine and Allergy, King’s College, London, UK. 3Dept of Clinical Science, University of Bergen, Bergen,
Norway. 4Dept of Respiratory Medicine, University of Leipzig, Leipzig, Germany. 5National Heart and Lung
Institute, Imperial College London, London, UK. 6European Respiratory Society, Lausanne, Switzerland.
7European Lung Foundation, Sheeld, UK.
@ ERSpublications
When challenging situations arise in doctor–patient interactions, how can we best manage them?
http://ow.ly/J1GI30bD5wp

130 Breathe | June 2017 | Volume 13 | No 2
Top tips to deal with challenging situations
Alternatively, these scenarios may arise when
a patient:
 has done research online about their ailments
and is convinced by their findings of a conclusion,
and demands certain investigations/treatments;
 feels that they are not being listened to and
might become frustrated, or threaten legal
action or social media involvement;
 does not accept the doctor’s diagnosis or test
results and demands a second opinion;
 has symptoms aecting their quality of life but no
diagnosis despite thorough work-ups by various
medical teams, which can lead to frustration or
a lack of trust in medical professionals;
 will not follow the suggested treatment
but continues to attend consultations with
deteriorating health (e.g. a heavy smoker with
severe asthma who does not stop smoking and
believes that their inhalers do not work); or
 will focus on what went wrong rather than what
is the best way to progress things.
Factors contributing to a
challenging interaction
To prevent and resolve challenging interactions, one
needs to consider factors that might contribute to
these situations. Two important factors are the
local healthcare setting in which the interactions
take place, and the variation in clinical practice
between regions and countries. In particular, the
majority of healthcare settings are overworked
and overstretched to meet demand, and this
continuously aects interactions. Insucient time
for consultation or interaction with patients plays
an important role, as healthcare system pressures
are increasing patient numbers and expectations,
against a background of cost-cutting. Foremost, it
is important to bear in mind that both patients and
healthcare practitioners want a positive interaction
to ensure the best possible health outcome, as time
spent in consultations is valuable for both parties.
Figure 1 summarises several other important
contributing factors.
The patient
Each patient has their own medical and psychosocial
history that understandably will affect their
behaviour. Patients will walk into your clinic with
a set of beliefs and expectations aected by their
personality and the severity of their symptoms,
and the implications of this for their quality of life.
They may also have had negative experiences and
previous disappointments within the healthcare
system that may be challenging to overcome
Table 1 Most common real-life scenarios where an
interaction with a patient can be challenging
The patient presents a long list of symptoms
The patient feels they are not being listened to
There is no diagnosis despite thorough work-ups
Drug dose decrease
Delivering bad news
Noncompliance
System
· Overstretched system
· Lack of resources
· Long waiting times
· Clinic cancellations
· Inadequate documentation
systems
· Lack of time
Doctors
· Personality/feelings
· Lack of communication skills
· Lack of listening to patients
· Patient exclusion from decision-
making process
· Lack of job satisfaction
· Long working hours, sleep
deprivation
· Personal problems/disease
· Lack of empathy
Patients
· Past medical and psychosocial
history
· Expectations
· Personality
· Feelings (e.g. anger)
· Impaired quality of life
· Lack of/untreatable diagnosis
· Language barrier
Figure 1 Factors contributing to a challenging interaction.

Breathe | June 2017 | Volume 13 | No 2 131
Top tips to deal with challenging situations
and may generate some mistrust. They may feel
that their illness is beyond their personal control,
which can make them dependent on others’ help,
particularly their healthcare professional. Such
circumstances can, understandably, make a patient
feel anxious, worried, hopeless and uncertain about
their health, which can be displayed as tension
and negative reactions towards the healthcare
professional.
With increasing advances in medical research,
expectations of the healthcare system and in
healthcare practitioners have also increased.
Patients can have very high expectations and
trust in the system, and when it appears that
their condition is a medical “dead end” or that
their prognosis cannot be determined with
precision due to the nature of the disease,
it can be very upsetting. Language barriers,
cultural diversity and their previous interactions
with professionals or authority figures can also
contribute to and aect interactions, and lead to
misunderstandings. Moreover, patients may also
have other considerations to make, for example, if
their diagnosis may impact on other commitments
(professional, caring responsibilities, etc.). Patients
oen work, may care for children or parents, or
have other commitments that may be impacted
by the diagnosis or may have impacted on the
timeframe in which they seek help, all of which
will be going through their mind. Being defined by
their diagnosis and labelled as “a patient” is not,
and should not be, the only thing in their lives.
The healthcare practitioner
There is a wide variability in the development
of appropriate communication skills among
European healthcare practitioners and this has
been a challenge. Communication skills courses or
training are not included in the specialist curriculum
in all European Union (EU) countries, nor are they
included in the essential qualifications for specialist
post applications.
A lack of communication skills training can
result in:
 inappropriate choice of words and phrases,
perhaps due to assumptions being made
about the patient’s level of health literacy or
understanding of human biology;
 lack of planned structure in delivering dicult
news (e.g. scattered information confusing
patients or no clear plan at all);
 inappropriate choice of setting to deliver dicult
news;
 lack of options oered to the patient;
 not involving the patient in the decision-making
process (e.g. treatment decisions taken without
involving them and without addressing their
needs and wishes);
 rushing the patient to agree to a proposed
treatment plan;
 rushing the consultation due to other
pressures; or
 not referring the patient to appropriate support
services/resources (e.g. counselling, palliative
care, support groups and quality trusted
information).
Bad news may be broken in a nonempathetic
way, messages may be given to the nurses over the
patient’s head while interrupting the consultation,
dicult words may be used that the patient does
not understand, and the patient may feel excluded
from conversations with almost no concern showed
for their feelings and emotions. Oen, what is
everyday routine clinical data to the healthcare
practitioner may be completely unfamiliar to the
patient, giving the impression that the clinician is
cold and unsympathetic to the individual’s emotions
as they try to come to terms with the diagnosis and
its implications.
Overstretched clinic time may result in doctors
not having time to actually listen to the patient’s
concerns. What is the patient actually afraid
of? What do they want to know? What are their
experiences? These are questions that will be
overlooked due to lack of time. Insucient time
further impacts the consultation as there is not
time for the patient to verbalise, and for the doctor
to appreciate, the valuable contribution that the
patient brings in having the lived experience of
the condition, especially if this is a rare disease.
In a complex clinical case, doctors may seem so
preoccupied with finding the solution to the clinical
problem that it is sometimes easy to forget that the
patient might be overwhelmed by anxiety, frustration
and negative emotions, and require re-assurance to
feel safe, at ease and trust in the doctor.
Healthcare setting (either outpatient clinic
or wards) is a familiar setting for doctors to have
dicult conversations, whereas for patients, it
can be uncomfortable and sometimes awkward,
especially if they are at the point of receiving their
diagnosis.
In addition, a doctor’s emotions may get the
better of them or their behaviour might be aected
by a lack of sleep, hunger, their own health status,
lack of job satisfaction or other concerns. Finally,
the doctor’s approach and communication style will
influence their interactions and could have serious
adverse eects on the patient (e.g. if the healthcare
practitioner is arrogant or impatient and believes
they don’t have a responsibility to discuss the
situation with the patient or explain the condition
in terms the patient could understand).
It’s important for doctors to recognise that
some patients may be intimidated and perceive
inequality in the doctor–patient relationship, which
can be exacerbated by doctors acting in a way
that is perceived by the patient as condescending
or patronising. All this can be remedied with
appropriate training and relevant professional
development.

132 Breathe | June 2017 | Volume 13 | No 2
Top tips to deal with challenging situations
The system
Dysfunctional healthcare systems can only add
to the tension between patients and doctors.
Simple things like long waiting times in the clinic,
consecutive unjustified cancellations, or delays to
previous appointments or investigations; essentially,
anything that may have gone wrong in the patient
pathway can potentially lead to a challenging
interaction between patients and doctors. Doctors
are probably the first person patients will spend
some time with aer something has gone wrong
and therefore they will hear the patient’s immediate
frustrations first hand.
Lack of resources in terms of stang levels or
of maintaining patient privacy and dignity during
consultation is another contributing factor; for
example, during a consultation there may be several
doctors or nurses moving in and out of the room
that distract attention and may aect dignity and
privacy.
A lack of centralised documentation systems
can sometimes lead to asking the patient to
repeat the same information over and over again,
and consequently dedicating less time to actually
managing the clinical case and addressing the
patient’s needs. Constant repetition for every new
doctor may cause the patient frustration, while it
is dicult for the doctor to know what the patient
already understands.
Potential effects of a
challenging interaction
Above all, it should be acknowledged that patients
want a positive interaction with their doctor.
In reality, a challenging interaction between
patients and doctors should be considered within
the healthcare system in which it occurs. Patients
seek professional help because they are in pain or
are concerned.
When the three factors of the patient, the
doctor and the system interact, a particularly
dicult situation can arise. Figure 1 summarises
the most important contributing factors, which are
outlined below. We all respond dierently when
in a challenging situation but our behaviour or
response could have serious detrimental eects
(table 2).
Patients
Patients can be overwhelmed by a variety of beliefs
and emotions: frustration, feeling they have little to
no control over their diagnosis and health condition,
uncertainty over the course of their treatment and
prognosis, fear, worries, and overall dissatisfaction
with the healthcare system. Communication
between the patient and medical professionals may
then be prejudiced and result in the patient losing
trust in the doctor. This can be further aected
by the implications of the condition itself on the
patient’s psychology.
Due to the combination of all this, patients can
feel they are not heard and consequently feel more
vulnerable. They may have already arrived at the
clinic in a state of some anxiety aer various tests,
investigations or previous appointments. They may
be anticipating bad news or may be reluctant to
consider various treatment options, believing these
may disrupt theirs or their loved ones’ quality of life.
They may have had had previous poor experiences
of hospital or healthcare settings and may fear
that raising concerns or asking questions could
delay or otherwise impact on their treatment.
Their culture or upbringing may have led them to
believe they should not ever question somebody
in authority even if they have lots of questions.
A clinician rushing through an appointment may
be perceived as “harsh” or less considerate than
one who takes the time to listen to the patient’s
concerns.
Healthcare practitioners
A challenging interaction for a medical professional
already overstretched by the healthcare system
may increase levels of stress, anxiety and anger,
which in turn will impact on performance and
communication.
Generally, physicians tend to feel helpless aer
a challenging interaction with a patient, and may
be unsure about how to take things forward or
whom to consult for advice. As previously stated,
in most EU countries, there is a lack of training in
how to manage these cases and a possible response
might be to move the patient to another colleague
(i.e. avoidance).
Table 2 Potential implications of a challenging interaction
Patient
Anxiety
Concern
Frustration
Dissatisfaction
Vulnerability
Loss of trust in the doctor–patient relationship
Doctor
Stress, anxiety and anger
Helplessness
Dislike of the patient
Use of avoidance strategies (e.g. discharge)
System
Misuse of more resources
Appointment with another doctor for a second opinion
Increased attendance at the emergency department

Breathe | June 2017 | Volume 13 | No 2 133
Top tips to deal with challenging situations
System
The potential eects to the patient and doctor will
put more pressure on the system, as they may
result in overuse of resources. This means that
the patient will either try the “doctor shopping”
approach, i.e. seeing several dierent doctors
for the same issue and trying to collect dierent
opinions, or inappropriately attending the accident
and emergency department frequently trying to find
a solution to a nonacute issue. Sometimes, patients
adopt both approaches, which can overstretch
healthcare systems in terms of capacity and costs.
Managing a challenging
interaction
The optimal approach in dealing with a challenging
interaction is to prevent it. If that is not possible,
then it is best to create the conditions for dealing
with a dicult situation in a manner that is open
and safe for all, and to develop the skills of active
listening and eective communication (table 3).
Plan your interaction in advance
 Think in advance how best to deliver that news
to that particular patient, and structure your
thoughts
Choose appropriate words that will not oend
or be perceived negatively. It is important to
break down information into small pieces
that are easy to understand and to ensure
the patient has a clear understanding before
progressing the conversation. Asking patients
to reiterate and confirm halfway through the
conversation, and summarise at the end, is
always ecient, and ensures both parties share
the same information and action plans.
 Do not under-communicate the diculties that
occur with the disease
Remember that it is far better for patients to
be prepared and to participate in the treatment
decision-making process than to be kept in the
dark or, even worse, be undermined. Try to
create a positive “teamwork” with the patient.
 Consider the role of the patient’s partner or carer
during the consultation.
This may be the patient’s spouse, parent or
friend who can help support the patient during
the consultation. They may also have their own
questions or concerns about the condition,
which should be addressed. The inclusion
of a partner or carer is essential, especially
in a “bad news” conversation. Two pairs of
ears are better than one, especially when
the information being received is negative,
unexpected and/or dicult to understand. In
such situations, it can be hard for the patient to
take in. For such conversations, find out when
the family member is available to be party to
the conversation
 Ensure you deliver the news in an appropriate
setting, check they can hear you and ensure
patient consent is obtained prior to having
multiple people observing your consultation
(e.g. students)
Pay attention to your nonverbal
communication
Nonverbal communication is equally important
as the actual words a clinician uses during their
interaction with the patient. Body posture, gestures
and eye contact can all combine with verbal
communication to facilitate a meaningful positive
communication with your patient.
Provide ways to access further
information and support
Some patients may not take in all of the information
you provide up front, particularly if they have
received a new diagnosis. Providing your contact
details, such as your e-mail address and telephone
number, may allow them to ask you questions in
their own time, aer the consultation has finished.
Avoid telling patients not to read anything on the
internet about their condition, but rather, consider
ways in which you can provide access to additional
information and support, including sign-posting to
Table 3 Tips on managing dicult interactions
Plan your interaction in advance
Pay attention to nonverbal communication
Discuss with colleagues and do not hesitate to seek additional training should this be required
Look for signs of anger or distress
Ensure safety and maintain control
Create bridges of communication and trust
Explain the diculty and try to find common ground
Help your patient get emotional control
Focus on highlighting solutions and resolve areas of disagreement

134 Breathe | June 2017 | Volume 13 | No 2
Top tips to deal with challenging situations
counselling, support services and patient support
groups. Patient information resources published by
your organisation are also encouraged.
Keep the initial information simple
and try not to use too advanced
medical language
Reassure patients that it is a good idea for them (or
their carer/partner) to write things down, whether
at the time of a consultation or a list of questions
in advance of a consultation.
Discuss with colleagues and do not
hesitate to seek additional training
should this be required
What may be a challenging interaction for one
person may dier from someone else. The human
factor significantly contributes to the dierent
perceptions further complicated by different
experiences and subsequently dierent comfort
levels in dealing with dierent personality types and
situations. There is no “one size fits all” approach.
You need to be open to learning and developing
your practice, and discuss with colleagues or your
mentor as this will provide you with valuable advice.
On a similar note, never hesitate to seek additional
training to further develop your communication
skills (either online, face to face or at a professional
development workshop). In a scientific, evidence-
based, clinical setting, it may seem unfamiliar to
develop so called “so” or interpersonal skills but
the techniques learnt will be just as valuable when
communicating with colleagues and patients, and
building relationships generally.
Is this becoming a difficult
situation?
Look for signs of anger or distress, an increase in
speed of speech, or a change in behaviour or body
language. This may indicate that the patient is
uncomfortable with the conversation or procedure.
Steer the conversation away from the topic and
address it when the patient is more comfortable
discussing it or consider whether the procedure is
immediately necessary.
Create bridges of communication
and trust
Another fundamental requirement for a positive
interaction to occur is ensuring that the patient’s
psychological safety is ensured. This is particularly
relevant for taking small risks when interacting
with the patient while, at the same time, facing
uncertainty or ambiguity. The solution here is to
focus on creating favourable conditions in which
any interpersonal risks between you and the patient
are kept to a minimum. For instance, reassure the
patient that they can feel safe and communicate
openly with you in order to establish trust and
ensure there is sucient time scheduled for the
consultation, so that you are not rushed.
Explain the difficulty and try to
find common ground
Try to put the focus on the “elephant in the
room”, i.e. verbalise the problem in a kind yet
clear manner and find some common ground
with the patient. Establishing common ground
is a key point in reducing any tension that may
have arisen. The patient needs to have confidence
and actually recognise that you are listening to
them. For example, you can show understanding
towards the patient’s anxieties and worries, and
reflect this understanding back to the patient. This
shows empathy, and may help the patient feel
more comfortable, let o some steam and voice
any underlying problem or concern that contributed
to the challenging interaction. On some occasions
during these “de-escalation” conversations you may
realise that there is an alternative explanation to
the patient’s feelings and this may have increased
their anxiety or fear.
Help your patient get emotional
control
Feeling helpless and hopeless is a common
challenge encountered by a patient facing a dicult
health condition. Imagine being a patient yourself.
Not being in control can trigger negative emotions
and can make communication dicult. Empathy
and eective listening can help with this. Also,
keeping the patient informed and involving them
in the decision-making process is the basis for
giving them a sense of control. Bear in mind the
psychological impact of your conversations with the
patient and the possible symptoms it might cause,
particularly in respiratory patients. For example,
many of our patients develop problems with anxiety,
panic attacks and hyperventilation, which can prove
more debilitating than some of the other symptoms
of their condition.
Focus on highlighting solutions if
there are areas of disagreement
Aer summarising the situation and hearing
opinions from both sides, give the patient two
or three options with balanced information; this
changes the focus from any miscommunication or
argument to action, and helps to redirect the patient
to a solution-focused path. Allow time for questions
and discussion with the patient. The patient should
feel valued and involved in the decision-making
process.

Breathe | June 2017 | Volume 13 | No 2 135
Top tips to deal with challenging situations
Ask the patient how the
consultation went.
We must admit that most of us forget to do this.
Use open questions along the lines of “How do you
think your consultation was today?”. Take time to
listen and, where necessary, clarify.
Get some time to reflect
Aer any challenging interaction, it is important to
reflect on what happened and identify what could
be improved. How did your actions contribute to the
situation and what could you have done dierently?
Think about dicult people and situations as your
teachers, not your enemies. How will you take that
learning forward for next time?
This thought process will help you in future
challenging situations and provide better insight
as to how to manage similar cases in the future. It is
always useful to discuss this with peers/colleagues
to get some feedback and update your supervisor
or head of the department.
Regardless of the outcome, your personality,
patient characteristics and challenges in the
healthcare system, try to stay in line with your mission
to deliver optimal medical care to all your patients.
Acknowledgements
Many thanks to Gill Hollis, Lisbeth Høva and Janette
Rowlinson, who kindly provided feedback and gave
us patients’ perspective on our manuscript.
Conflict of interest
A. Niculescu is an employee of the European Respiratory Society and P. Powell is an employee of the
European Lung Foundation.
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ambulatory clinic: clinical predictors and outcomes. Arch
Intern Med 1999; 159: 1069–1075.
3. Kreger J. When your patients are in mourning. FPM. 2003; 10:
49–50.
4. Epstein RM. Mindful Practice. JAMA 1999; 282: 833–839.
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org/events/courses/how-to-communicate-eectively-with-
patients.aspx Date last accessed: March 23, 2017.