Occurrence of Conflict in Health Care Provider-Patient Relationships

By best estimation, conflicts occur within 25% to 40% of health care provider-patient interactions. For instance, more than one third of the 1,027 physicians surveyed reported experiencing interpersonal challenges in about 25% of their patient visits (Levinson, Stiles, Inui, & Engle, 1993), while another study reported that 31% of patients who suffered congestive heart failure experienced conflicts with their physicians involving their care (Zickmund, Blasiole, Brase, & Arnold, 2006).

Sources of conflict can be difficult to disentangle as there may be multiple sources of conflict and differing attributions between provider(s) and patient. Lask (2003) extracted eight sources of conflict from his case analyses of patients with cystic fibrosis and their physicians: (1) poor communi­cation, (2) impaired trust and confidence, (3) differing expectations, (4) power imbal­ance, (5) social-cultural differences, (6) emo­tional reactions, (7) developmental changes (e.g., children becoming teenagers), and (8) team reactions. Other researchers have identi­fied similar sources or expanded on the nature of these sources in their studies of health care providers and patients with various medical conditions.

Health Provider “Bedside Manner.” As of 2004, the board overseeing the U.S. Medical Licensing Examination mandated that medical students pass a clinical skills examination, or bedside manner test. “Bedside manner refers broadly and informally to the interpersonal behaviors shown by physician or other health care provider, especially those that foster trust and a sense of wellbeing in patients” (Martin & Friedman, 2005, p. 8). Zickmund, Hillis, Barnett, Ippolito, and LaBrecque (2004) found that being treated unkindly, being rushed, not being listened to, or being misunderstood were common patient complaints. These problems were then associated with patients’ disliking of the provider or perceptions of feeling dis­liked by the provider. Patients reported feeling particularly vulnerable when they perceived that the provider ignored them. Additional factors that produced patient dissatisfaction

Providers’ “bedside manner”

Interpersonal skills

Communication styles

Expectations of patients’ participation

Amount of information exchanged

Patient involvement

Power

Doctor-as-agent model

Shared decision model

Patient access to medical information

Patient characteristics

Communication style

Demographic characteristics

Medical condition

with the relational aspects of health care delivery included lack of feedback, insensi­tivity to and misinterpretations of relational needs, failure to express empathy, and disre­gard for the other’s input in decision making (Kreps, 1988).

Communication skills that are relevant to effective interpersonal communication and conflict management include self-disclosure, explaining, active listening, perspective tak­ing, reframing, and brainstorming (Deutsch, 2000). Deutsch pointed out that the ability to understand each other’s perspectives might lead to more trusting and open communica­tion by producing a reciprocal effect in inter­action. Other researchers have found that the strength of the doctor-patient relationship is related to the provider’s level of friendli­ness, empathetic behavior, and positive talk (Roter & Hall, 1989). Similarly, research has noted that the physicians who spent more time with their patients, used humor and laughter, employed more orienting statements (e.g., “I will examine you and then we will discuss your tests”), used more facilitating comments, elicited patient’s opinions, clari­fied patients’ understanding, and addressed patient questions were at lower risk for litiga­tion (Levinson et al., 1993). Harres (1998) analyzed types of tag questions for their ability to interrogate, confirm information, show empathy, encourage patient involve­ment, discourage patient involvement, and convey attitudes about the physician-patient relationship. Physician understanding of how communication affects patient comfort, sat­isfaction, and participation in the interaction is essential to effective doctor-patient conflict management.

Nonverbal communication is another skill area that has garnered communication schol­ars’ attention.

Expectations of the Patient’s Role in Health Management. Provider and patient commu­nication is strongly influenced by each party’s expectations regarding power differences and appropriate roles in the relationship. Cegala, McGee, and McNeilis (1996) found that perceptions about information exchange are a major source of misunderstanding between providers and patients. Their study revealed that information exchange is more important to patients and providers than relational com­munication when evaluating each other’s com­munication competence. Others have found that providers tend to underestimate patients’ desire for information (Waitzkin, 1989).

Disagreements about information exchange may reflect differences in perceptions about the patient’s role in health management. Goodyear-Smith and Buetow (2001) explained that disagreements are likely to occur when patients’ choices seem misguided to provid­ers, and providers are unwilling to accept the right of the patients to make informed deci­sions.

Power Relations Between Providers and Patients. Within the provider-patient rela­tionship, there are several different models of power relations (Goodyear-Smith & Buetow, 2001). At the one extreme are the paternalism and doctor-as-agent models (doctor makes a decision based on perceived patient prefer­ences). At the other extreme, the informed decision-making model specifies that the doc­tor’s role is to offer information to the patient or consumer while the patient makes the deci­sion (Mead & Bower, 2000). While the shared decision-making model attempts to strike a balance between doctor and patient input, the balance of power often favors the doctor (Charles, Gafni, & Whelan, 1997). The adop­tion of a provider-centered power relations model may be particularly prevalent with certain patient populations, such as the elderly and residential care patient populations, due to the patients’ declining or impaired mental/ communicative abilities, their resident status, and their need for routine care.

Several studies have examined the role of the Internet in leveling the power distance between providers and patients (Broom, 2008; Hurley, Kosenko, & Brashers, 2011). While increased access to health information may improve patient knowledge, providers may engage in strategies that discourage participa­tion (e.g., disapproving or arguing with the information gained from the Internet, treat­ing the patient as a problem patient), thus enforcing a more consultative model of com­munication. Providers also respond to patient attempts to participate nonverbally. Hurried entrances and exits, rapid speech, interrup­tions, longer speaking turns, sitting or stand­ing with a backward lean, looking at the chart while the patient is speaking, and so on indi­cate that the provider is not interested in the patient’s information sharing. Failure to match or mirror the patients’ affiliation cues further reinforces the power distance between the pro­vider and the patient, leading to lower levels of rapport and decreased patient involvement across the board (Martin & Friedman, 2005). Thus, whether use of the Internet and mobile technologies is empowering for patients depends, according to Broom (2008), on how receptive providers are to the information and how willing they are to include the patient in the decision-making model. The impact of information obtained via the Internet or other sources also depends on the patients’ willing­ness to participate actively in their health care by sharing this information with their doctor.

Characteristics of the Patients and/or Their Illness. Patients’ communication styles, demo­graphic and cultural characteristics, and the illness itself may also contribute to conflicts with health care providers. Street, Krupat, Bell, Kravitz, and Haidet (2003) have empha­sized the reciprocal relationship between providers and patients in examining commu­nication styles. In one study of doctor-patient interactions, active patient participation and physician partnership building were found to be mutually predictive of each other. Approximately 14% of patient participation was predicted by physician partnership build­ing, yet one third of physician partnership building occurred in response to active patient participation. So while the two communica­tion approaches are related, the physician’s accepting response to patient communication appears to be more important in creating a climate for shared decision making than the physician’s particular style of communication or attitude toward patient care overall. The finding suggests that training patients to com­municate effectively with physicians may pro­duce positive outcomes, yet it also underscores the power of the physician to set the tone and shape expectations for communication.

Patient communication style may be associ­ated with demographic characteristics such as age, gender, race, or ethnicity. The patient’s age may be a source of conflict as a result of perceived power differences (Calasanti, 2003), yet these perceptions are not consistent over time. Power may increase with age to some point but then decrease during the elderly years (Levy-Storms et al., 2011). Studies in nursing home contexts have described resi­dents’ perceptions of being treated like a child, being bossed around, or otherwise being disrespected by younger nursing assis­tants (Levy-Storms et al., 2011). Bergstrom and Nussbaum (1996) suggested that older patients might be less likely to question physi­cians and are likely to adopt differing conflict styles than their (often younger) physicians.

Similarly, problems may arise in racially or culturally discordant provider-patient rela­tionships for many reasons, one of which is dis­crepant forms of conversational speech. Rawls (2000) argued that those who self-identify as White are more likely to engage in categorical talk, a form of conversation in which informa­tion about each other (e.g., occupation, place of residence) is freely asked and exchanged. Those who self-identify as Black, however, are more likely to engage in setting talk, empha­sizing topics about the immediate context. In interracial conversations, he proposed, Blacks may feel interrogated by White categorical talk because the information sought is seen as personal or private. Perloff, Bonder, Ray, Ray, and Siminoff (2006) extended this argu­ment to doctor-patient communication; Black patients may not see a White physician’s line of questioning as necessary, and White physicians may eschew small talk that could establish trust and rapport. Oliver, Goodwin, Gotler, Gregory, and Stange (2001) further found that physicians spend less time chatting with Black patients than with White patients and that Black patients ask fewer questions than do White patients. According to Oliver et al. (2001), Black patients also shy away from discussing their medical conditions and refrain from making inquiries that they think will be met with objection. As a result, doctors may believe that they are less concerned about their medical conditions or lack the ability to process health information. Not surprisingly, researchers have demonstrated that Black patients treated by White physicians are less satisfied, rate their visits as less participa­tory, and are less likely to use needed medical services than Black patients treated by Black physicians (Ashton, Haidet, Paterniti, Collins, & Gordon, 2003; Cooper-Patrick et al., 1999; LaVeist & Nuru-Jeter, 2002).

Language, religious, and cultural differ­ences can be sources of conflict or dis­agreement, as noted in nursing home and hospice care research. Nursing home resi­dents described feeling excluded or talked about when their nursing staff spoke in Spanish, for instance (Levy-Storms et al., 2011), and religious differences may contrib­ute to disagreements or misunderstandings over end-of-life treatment decisions (Norton, Tilden, Tolle, Nelson, & Eggman, 2003; Planalp & Trost, 2008). Cultural beliefs and practices regarding the institutionalization of aging family members were similarly cited as factors within family member-nursing home staff conflicts (Majerovitz, Mollott, & Rudder, 2009).

In addition to demographic character­istics, the patient’s medical condition may factor into conflict episodes. For instance, “revolving door” psychiatric patients often cause medical irritation due to lack of treat­ment success, lack of patient compliance, or perceptions of patient manipulation (e.g., a patient who is claiming to have certain disori­enting experiences in order to receive stron­ger medication; Shaw, 2004). Frustration with psychiatric patients can result in hostil­ity toward them, and there may be attempts by the physicians to refer them to another medical provider (e.g., psychiatric hospital). On the other hand, studies have found that patients who are anxious, educated, ask more questions, and express more negative affect actually receive more information from their providers during diagnosis (Street, 1991). Expressing negative affect, such as anxiety, sadness, or depression, may be more accept­able and expected during diagnosis and early stages of treatment, while anger may be less acceptable overall. It could also be that negative affect is more effective during diagnosis stages than in ongoing health management, especially with hard- or impossible-to-cure illnesses. AIDS patients, for example, were found to respond in both participatory and angry ways to their nurses at different stages of their illness and treatment regimens (Kemppainen, O’Brien, & Corpuz, 1998). In contrast, communi­cation problems occurred more commonly with breast cancer patients who were less optimistic about their disease and who had nonassertive coping styles (Lerman et al., 1993). Zaleta and Carpenter (2010) noted that doctors engaged in more positive rap­port building and patient activation behav­iors than emotional rapport building during dementia diagnoses.

To summarize, causes of provider-patient conflict include provider and patient commu­nication styles, expectations regarding roles and decision making, power relations, and characteristics of the patient such as commu­nication style, culture, and medical condition. Intense emotions, financial, and practical bur­dens and loss of autonomy combine to make conflict a rather frequent experience for health care providers and patients. Studies in nurs­ing home and hospice care contexts have also pointed to the contributions of patient impair­ments (e.g., speech, hearing, dementia) and changes in autonomy and lifestyle to frustra­tions and communication difficulties between nursing assistants, volunteers, and residents (Levy-Storms et al., 2011).