A patient recently came to visit Jeanne Hatcher, MD, associate professor of otolaryngology–head and neck surgery at Emory University in Atlanta, for a laryngeal dilation for stenosis. It was not an unusual request, except for this: The patient had already been in to see Dr. Hatcher before, when she performed the procedure. And then the patient had gone to another ENT surgeon.
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March 2025Now, the patient was back, asking Dr. Hatcher for another rendition of the same procedure, and she had been wanting narcotics after each one. From a medical necessity standpoint, the patient did not need the procedure for breathing; she already had a trach.
This time, Dr. Hatcher refused. The patient insisted, saying, “I think it helps.”
“I said, ‘Well, I understand that, but no,’” Dr. Hatcher recalled.
The patient’s relief after the surgery may have been real, Dr. Hatcher reasoned, but it was transient. So, she began to wonder, “What are we really doing?”
Even when physicians and others are on the same page, practicing otolaryngology can be difficult; diagnosis might be a challenge, and there is always the potential for surprises or complications. But in some cases, direct conflicts can arise—between physicians and patients, between physicians and other members of the care team, between physicians and administration, and even between objective test data and patients’ subjective reports. These situations can present some of the trickiest terrain in otolaryngology and other medical disciplines.
Otolaryngologists say that carefully choosing the right words, understanding the goals and values of the other party involved, and having a good dose of self-awareness go a long way, both in helping to avoid these conflicts and in preventing their escalation when they arise. They also say that, although there are some general guideposts to bear in mind, this is not an area typically covered much in training and that a feel for it develops with experience.
Dr. Hatcher, who is also the co-chair of Emory’s Patient Advocacy Reporting System (PARS) and the physician’s working group in Emory’s Office of Well-Being, said that over the years, she has found that being forthright is usually effective.
“I am fairly blunt,” she said. “And I think most people, based on reviews and what they tell me, is they appreciate that, that there’s no beating around the bush or sugar coating.”
But she has found a few effective strategies that she turns to when needed, she said. If she senses she is at odds with a patient and is aware that she might be fatigued, she might take a quick break, letting the patient know she is going to check their chart “to make sure I’m not missing something.”
I am fairly blunt. And I think most people, based on reviews and what they tell me, is they appreciate that, that there’s no beating around the bush or sugar coating. — Jeanne Hatcher, MD
“I just walk out and take a minute,” she said. “Maybe I do look through their chart, maybe I don’t, whatever. But I exit the situation, reset, and go back in and try to be more focused.”
If a patient requests more pain medication than she believes is required, she might say, “‘Gosh, if you’re in that much pain, then I’m going to need to see you in the office to see if something’s going on or if something’s wrong.’ Usually, they don’t come in, and that’s that.” She also mentions to patients that there is a state law requiring a pain contract beyond a certain amount of medication, and she offers a referral to a pain specialist.
Physicians can also find themselves in a situation that is the opposite of Dr. Hatcher’s interaction: A patient might not want a procedure that is recommended. When that happens, understanding the force behind that hesitation is the goal, said Antoinette Esce, MD, an otolaryngologist who has experience in clinical ethics and is currently a fellow in palliative care at Icahn School of Medicine at Mount Sinai in New York.
“I usually start by making my observation: ‘I’m really worried about not doing the surgery—here’s why.’ Then I ask, ‘Please tell me what’s worrying you,’” she said. “And not focusing on the surgery and focusing on what they’re hoping for, what’s worrying them.” It is often the case, for instance, that a loved one had a bad experience with a surgery, and discovering this might offer a path forward, she said.
It could also be the case that the patient’s goals were different than what was articulated. A surgeon might have emphasized how a procedure would improve breathing when the patient’s main concern might be cough.
“I think that it’s very rare where you have a patient you can’t really negotiate with,” Dr. Esce said.
Madison Clark, MD, director of facial plastic and reconstructive surgery at the University of North Carolina in Chapel Hill, said finding the right words can be difficult. But he said he is careful not to use the phrase “cannot meet your expectations,” because the patient might just say that the physician doesn’t understand those expectations.
“If I decide that I’m not going to operate on that person, I typically will say that I have listened very carefully to your concerns and I don’t feel in my hands that I can accomplish what you want to accomplish with this operation,” he said. “The verbiage has to be very precise because patients will pick up on any hesitation.”
He said telling a patient you are declining to do a procedure can be one of the most difficult things in medicine, especially if you have come recommended and are perhaps considered the final option.
“They often have unreasonably high expectations coming to see you, that you’re the only surgeon who can possibly help them,” he said. “And then if you try to say no to them or if you do decide to say no to them, it’s devastating.”
Conflicts between physicians and other members of the care team can also be a challenge to navigate, and they can arise because physicians can have anchoring and other kinds of biases just as a patient can have, Dr. Esce said.
A patient having a head and neck procedure who is also under the care of a nephrologist might result in a conflict over non-steroidal anti-inflammatory drug (NSAID) dosage, for instance, she said. The nephrologist, worried about the kidney, might want a lower dosage, while the otolaryngologist might think 800 mg is perfectly acceptable.
“Their focus is on the kidney, and your focus might be treating post-operative pain and avoiding other medications that in your experience have more risk,” she said. “Most patients don’t fit into a protocol, which we all notice when we start to practice. Most patients have something that’s slightly different about them than the average patient in a study or the patient in the guidelines. And so we’re constantly sort of having to readjust how we treat everybody. And all the specialties do that in different ways depending on their guidelines and their context and what they’re most worried about.”
The literature almost always leaves some amount of gray area, she said, but actions and judgments don’t always acknowledge this blur, and there is “a tendency to overemphasize the objectivity of the things that we are thinking or doing in medicine,” Dr. Esce said.
Two techniques for resolving these conflicts are to name how you’re feeling and recenter on the patient, she said.
“It’s the patient’s goals and the patient’s values that should have center stage,” Dr. Esce said. “And so, acknowledging your emotions and then making sure you’re reframing it in that context (and) focusing on what you know and understand about the patient’s values can often be helpful to setting aside potentially an intractable conflict between two providers.”
As multidisciplinary care continues to grow and care teams get larger, “that sort of exponentially increases the possibility of conflict,” she said.
Many of the tools needed to communicate well and navigate these situations come from experience outside the medical field, she said. Her experience with a public health organization, interdisciplinary team projects, and even student government have all strengthened her skills in this area, she said. Resources on conflict resolution, designed mainly for the business world, can be helpful, she said.
Sometimes, conflict can be larger in scope, such as a policy change coming down from the administration that is considered suboptimal for patient care.
When his institution’s pharmacy and therapeutics committee proposed eliminating Botox from its formulary for cost savings, Dr. Clark was worried about the effect on patient care in his department. He had recently hired a facial nerve specialist for whom Botox was standard in his procedures, although he had not started working there yet. Dr. Clark decided to take the lead in challenging the formulary change, to which many other specialties objected as well.
He said being outspoken about the issue resulted in a human resources experience that was professionally costly and unpleasant.
“In my opinion, that’s the definition of leadership—someone who’s willing to put their own reputation or take some risk to help people who are working with or working for you,” Dr. Clark said.
Matthew Miller, MD, director of the UNC Facial Nerve Center, the expert hired by Dr. Clark, said the overwhelming data in facial paralysis cases come from trials that used brand-name Botox, rather than the other botulinum toxin A products, Xeomin and Dysport. All the products behave somewhat differently, he said, and switching to another product would have meant taking a path less supported by the literature. He said this change would especially hurt patients who had already been treated with Botox for years, as they had gone through a treatment titration process that is specific to the neurotoxin used.
I try to understand where the other side is coming from and then work toward a resolution where all of us are happy. — Matthew Miller, MD
More recently, Dr. Miller said, he was again approached by administration and pharmacy on substituting Botox with a less costly option, and he talked to them about how that process could take shape. He said he is open to using an alternative such as Xeomin for patients new to chemodenervation but would study this change to make sure it is as effective as Botox. He would not expect patients already receiving Botox to change, though, to which the administration and pharmacy agreed, he said.
While each situation is different, Dr. Miller said, “I try to understand where the other side is coming from and then work toward a resolution where all of us are happy.”
He said he would be open, perhaps, to using another product, but only after it was studied, and never for patients who had already had their treatment process started using the brand-name Botox.
When to take a stand is a complicated question with no simple answer, depending on where you are in your career, your experience, the issue you’re fighting for, and other factors. But Dr. Miller was appreciative of the efforts of Dr. Clark, who he said is an “incredibly passionate physician wanting to always do right for his patients.”
Dr. Clark said that sometimes an administrative decision requires action. Botox has stayed on the outpatient formulary, where it is most essential, he said, and the key was presenting clear evidence that the treatment is best for patient care.
“You can’t just sit there and throw your hands up and say, ‘They can’t do that,’” he said. “We have to advocate for our patients, including making an impassioned argument for keeping it on the formulary.”
Some of the most common conflicts facing physicians might not involve a dynamic between people, but may happen when interpreting test data and patient-reported symptoms that seem to be at odds with each other, said Jennifer Shin, MD, associate dean for faculty affairs at Harvard Medical School in Boston.
This can happen, for instance, when a patient feels like their sinuses have an ongoing infection but a CT suggests otherwise.
“Even if the patient and clinicians are perfectly aligned, that mismatch between the subjective and objective results can lead to a conflicting directive, for both clinical care and research,” Dr. Shin said. “It actually is a real conundrum for clinicians, because it could leave us treating for objective tests, and less focused on whether a patient says they still feel symptomatic.”
Much medical literature shows that subjective and objective outcomes are not in sync, she said, at least with how patient symptoms are used, even with well-known, established, validated instruments.
“When funding is allocated for research projects, you typically pick a primary outcome, and that primary outcome can be either subjective or objective, so if they are not aligned, it also creates a conundrum in study designs,” she said. Practitioners might have simply defaulted to the objective test in the past, she said. But we are now in an era in which the government-sponsored Patient-Centered Outcomes Research Institute (PCORI) and Agency for Healthcare Research and Quality (AHRQ) emphasize patient-centered assessments and their importance beyond diagnostic test results, and researchers are increasingly examining the objective tests to determine whether they should be revamped to better reflect what patients experience.
Research also is shedding light on how the psychological status of a patient can affect how well objective testing lines up with patient-reported symptoms.
In a study on which Dr. Shin served as the senior author, researchers found that results on the Sino-Nasal Outcome Test-22 (SNOT-22) were in more concordance with CT imaging for patients with better psychological status than in those with worse psychological status, for whom SNOT-22 scores were non-discriminatory for CT findings (Otolaryngol Head Neck Surg. doi: 10.1177/0194599820926129).
In another study, Dr. Shin’s group found a similar theme within hearing loss and developed a novel way to overcome the discordance. Subjective Inner EAR scores were associated with objective audiometry results in patients with better mental status but not in those with worse mental status, when a static form of the Inner EAR test was used. When an adaptive form of the Inner EAR test was used, however—in which previous responses determine which subsequent questions are posed—those subjective findings retained their association with audiometry, even in those with worse mental status (Otolaryngol Head Neck Surg. doi: 10.1001/jamaoto.2024.0898).
“People often try to figure out how to gain more information by asking more questions,” she said. “But what we’ve realized is that you can actually ask fewer questions—you just have to ask the right questions under the right circumstances to the right patient at the right time. An adaptive mechanism can really help.”
Thomas R. Collins is a freelance medical writer based in Florida.
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