The Breaking Point: Patient/Practitioner Conflict

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As much as we try to avoid arguments and disagreements, some form of conflict is almost inevitable in the workplace. While there is no one correct way to avoid a conflict, there are subtle ways to diffuse a bad situation. In the O&P field, where trial and error is the norm, a patient may become frustrated by the fitting process. Perhaps the practitioner is bothered by the patient’s lack of focus or willpower. Like any relationship, communication and listening skills from both sides are key to avoiding a conflict.

Patient frustration

According to Alice L. Kahle, PhD, clinical psychologist and author of “Practitioner/Patient Interaction: How to Avoid and Resolve Conflict,” many conflicts stem from psychological needs, such as respect, control or recognition, not being met. Should a patient lash out at a practitioner, it is important that the practitioner control his or her own emotions, not take it personally and better educate the patient about the process. The more educated the patient, the more in control they will feel.

“A well informed amputee is less likely to become agitated if problems arise,”

Jeffrey S. Lutz, CPO, regional vice president Hanger Inc., in Lafayette, La. said. “Practitioners must encourage questions, be accessible to answer them and follow-up on the patient’s progress.”

According to Lutz, one of the most common complaints from amputees originates from the fact that the volume of their residual limb has changed. Patients become irritated when the residual limb feels comfortable at the time of their visit, but becomes problematic soon afterwards.

“They can be left with the impression that their prosthesis was not made properly when they experience a volume change,” Lutz said. “When the patient has easy, comfortable access to ask questions, they tend not get frustrated by setbacks in the fitting process.”

Lutz recommended practitioners call their patients from home or on the way home from work. That personal touch and attention will go far in keeping the lines of communication open in the future.

“After often having gone through serious medical conditions, where face time spent with medical professionals is often hurried, patients welcome a chance to feel that they are getting the necessary attention,” Lutz said.

New paradigm

According to Steve Fletcher, CPO, LPO, director of clinical resources for the American Board for Certification in Orthotics, Prosthetics and Pedorthics (ABC), a fair number of patients are not sure why they are in his office, when asked.

“They tell me ‘I have this problem. The doctor gave me the prescription and told me to come over to you and that you could do something for me,’” Fletcher explained to O&P Business News. “That is as deep as it gets. At that point, there is a great opportunity to explain to the patient what it is you are going to be doing.”

Fletcher admits, however, that the days of taking the practitioner at his or her every word are essentially over. With answers to medical questions only a click away, more and more patients are becoming knowledgeable about their options before they even meet their practitioner.

“Patient education has changed dramatically, in my opinion,” Fletcher explained. “Patients who walk into an O&P facility today are significantly more educated in what kind of care they are going to receive than they were 15 or 20 years ago. It is just a different paradigm.”

Fletcher points out that a conflict may arise when a patient is referred to a practitioner who subscribes to the old paradigm of “I’m the expert. You are the patient. Just let me do my job.”

“That does not work anymore,” Fletcher admitted. “There is conflict that is raised because of that way of thinking. But I think that it is avoidable.”

According to Fletcher, practitioners tend to get defensive when they are asked a long list of questions or are shown articles from Web sites. They may take the questions personally, feeling as if their questions are an indication that they are not doing their job properly. The patient will sense the practitioner’s annoyance and a conflict may arise.

But if it is recognized that the average patient is going to know more than in the past and therefore ask more questions, the practitioner can talk with their patient in a more educated way and still be on the same page.

“Positive changes are achieved by proper education, fitting and encouragement,” Lutz said. “The expressed expectations of the prosthetist often become the goals and reality of the patient.”

Communication: A Factor in Patient Loyalty
Positive interactions with patients often develop into long-term working relationships
Positive interactions with patients often develop into long-term working relationships.
Images: Steve Fletcher.

According to a study by Dana Gelb Safran, researcher at Tufts-New England Medical Center, the leading predictors of patients’ loyalty to their primary physician’s practice were the patient’s trust in the physician, their assessments of how well their physician knows them and the quality of communication and interpersonal treatment. The study suggests that while quality of care is important, satisfactory personal treatment of the patient is also a critical factor and should not be disregarded.

“In an era marked by increasing pressure on clinicians and health care organizations to attend to such factors as market share, productivity and efficiency, these findings point to a set of attributes that might otherwise be overlooked,” Safran writes in the study. “They suggest that medical practices and health plans cannot afford to ignore that the essence of medical care delivery involves the interaction of one human being with another.”

According to Steve Fletcher, CPO, LPO, director of clinical resources for the American Board for Certification in Orthotics, Prosthetics and Pedorthics (ABC), the O&P field has a unique perspective of the patient/practitioner relationship.

“When surgeons perform an amputation, it is seen as a failure, not all the time, but there is a kind of negativity there,” he explained. “Even if the amputation saved your life and it was necessary, many times it is seen as a destructive surgery, rather than a constructive surgery. When you go to the prosthetist, he or she is there to get you back on your feet. It is a fairly positive interaction, so that relationship develops well.”

The O&P practitioner has a unique advantage among health care providers in that their positive interactions and personal communications are on more of a human level as opposed to the more traditional doctor/patient plane. Quality communication and encouraging discussions with their amputees could result in a more loyal and dedicated patient.

For more information:

  • Safran, DG. Switching doctors: Predictors of voluntary disenrollment from a primary physician’s practice. The Journal of Family Practice. 2001; 50: 130-136.

Active listening

Communicating and listening in a busy work environment can be difficult, especially when a patient’s concerns can be considered unreasonable or irrelevant. Fletcher mentioned how older patients tend to write down their questions in a list that they prepare at home. This has been known to cause irritation among practitioners who may deem the questions unnecessary.

“It is common when you are in a busy practice setting that you already know what you want to do and what you want to accomplish,” Fletcher said. “Prosthetists are naturally task-oriented. They want to get the job done. What gets lost in that is listening to the patient about their concerns.”

Good communication skills do not require a practitioner to constantly speak throughout the appointment. Practitioners must recognize when to hold back and let the patient indicate their concerns. This is called active listening.

“When active listening is used, one temporarily suspends one’s own thoughts and ideas and gives full attention to the speaker, listening carefully for the underlying meaning of the words,” Kahle wrote. “Verbal prompts, such as, ‘um-hum’ and ‘I see,’ as well as nonverbal behaviors, such as good eye contact, an open posture and an avoidance of distracting behavior, encourage the patient to share information.”

Simply listening to the patient or asking a follow-up question could trigger another question from the patient that they may have previously forgotten.

“Our patients rely on us to not only answer questions but to bring questions out of them,” Lutz said.

Continued setbacks

If setbacks continue to occur with the residual limb or any aspect of the prosthetic device, Fletcher recommends stopping and taking a step back. If all options have been exhausted and there is frustration and anxiety with the patient, bringing in a different practitioner and getting that person involved is another option.

“If you work with multiple practitioners, then it is always a good idea to get another set of eyes on the problem,” Fletcher said. “That communicates to the patient that you are willing to not just push your way through and say ‘I am the expert and I know what’s best.’ Instead, you let another practitioner in and see if another perspective can help with the problem.”

Multiple practitioners is a great asset to an office, especially if there is a conflict or disagreement between a patient and practitioner. There is a tendency to lose the proper perspective, once a conflict has reached a certain level. If this is the case, it is crucial for a third party perspective to become involved. An outside perspective can zero in on the issues that perhaps you could not see. This helps move the process forward.

“Hopefully, long before a patient/practitioner relationship is irrevocably broken, the prosthetists will recognize that there is an issue and ask a colleague to join the case,” Lutz said.

Clinical outcomes

“Although technical and mechanical skills are essential, the entire treatment process — from the initial evaluation to the final fitting — is impacted by the relationship that emerges between practitioner and patient,” Kahle wrote. “Optimal outcomes are more readily achieved when practitioners and patients establish and maintain effective working relationships.”

“I have told every patient over the years that your willpower is probably just as important as my ability to make the prosthesis,” Fletcher said. “We’ll do the technical part, but I can’t create your willpower.”

The positive interactions and unique relationship between an O&P practitioner and an amputee tends to lend itself toward friendship as opposed to conflict. The prosthetic care plan is dependent on the lifestyle of the patient. Because of this, practitioners generally spend a great deal of time finding out about their patient’s daily life and aspirations. Over time, a trust develops and a bond is formed due to this personal care.

It is this personal care that could potentially lead to greater clinical outcomes. Therefore, the conclusion can also be made that a deteriorating working relationship between practitioner and patient, could negatively affect clinical outcomes. Practitioners and patients alike should keep that in mind when in the midst of a potential conflict. — by Anthony Calabro

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