“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.”
Explore This Issue
March 2025If 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
Leave a Reply