Maintaining a Relationship with Patients in Disagreement

I was thinking about a comment a colleague recently made about patient satisfaction scores. He opined that they were really a reflection of how many antibiotics and narcotics you prescribed. While I do not think that the patient satisfaction surveys are quite that distorted, I recognize his point. As difficult as it is to admit, there have been times when I questioned the impact my medical decision would have on the survey my patient would receive.

However, I do believe that we can and have been successful at having difficult conversations with our patients. We’ve all had those conversations and we’ve all been successful at least part of the time. I had a fascinating patient once who had honest-to-goodness DSM diagnosed hypochondriasis. He was always delightful even as he challenged both my medical acumen and my diplomacy. In the era of the EHR, all is ultimately visible to the patient. His problem list contained his diagnosis - hypochondriasis - in bold print along with his high blood pressure and eczema.

At one of our first visits, as I was reviewing the notes from his psychological evaluation, I engaged in inner dialogue to figure out how to inform him that his health concerns were part of his psychopathology, not manifestations of the diseases he suspected. I’ve never told a patient that it was all in his head, but this was about as close as I could come to that. I don’t remember the specifics of the conversation, but I do remember that it was successful. We continued with a respectful and pleasant doctor-patient relationship, and I believe he trusted me, even when we disagreed about the cause of his symptoms. I didn’t say anything particularly eloquent or profound but I did three things that have proven successful in other difficult patient conversations. When they are absent, things usually do not go so well.

First, I put what I was about to say in context, acknowledging that I understood that his beliefs were real and that he was experiencing true symptomatology. I laid out the objective evidence and calmly explained what I had concluded.

Next, I explained why it was important for me to not only confirm the diagnosis but document it in his medical record. It was not to prove him wrong or to avoid providing care. I articulated what the purpose of the medical record was and why I needed it to reflect the best accumulation of what I had learned about him for his future care.

Finally, I reassured him. I left the door open for us to continue to have a rewarding doctor-patient relationship even if and when we disagreed with each other. I committed to taking all of his symptoms seriously and presenting diagnostic and treatment plans that I felt were most appropriate.

Amazingly, he took all of what I said, processed it, and was quite accepting of it, even though he continued to register his disagreement with the diagnosis.

We can have difficult conversations with patients in which we refuse antibiotics for viral infections, decline to fill narcotic analgesia, and make diagnoses with which the patient disagrees, and we can do it while maintaining a good relationship with our patient. However, it does take time, energy, effort, and attention. For all the frustrations of patient satisfaction surveys, if they serve as a reminder that we owe it to our patients to do our best to say hard things well, then they may just be worth it.