SUMMARY OF RECOMMENDATIONS AND CONCLUSIONS

Based on the principles outlined in this Committee Statement, the American College of Obstetricians and Gynecologists (ACOG) makes the following recommendations and conclusions:

Physicians have a commitment to follow their best medical judgment, to advance the patient’s best interests, and to foster the public’s trust in the profession of medicine. Given the inherent power imbalance within the patient–physician relationship, conflict between patients and physicians should be handled with empathy and professionalism at all times. Physicians have an ethical duty to attempt to resolve such conflicts in order to restore the therapeutic relationship when possible.

Patient-centered care practices and communication techniques that are recommended to help prevent as well as manage patient–physician conflict include a) fostering meaningful connections during the clinical encounter, b) establishing and restoring trust, and c) building and restoring an effective patient–physician relationship.

When possible, conflict resolution should involve exploration of the reasons behind the conflict, realistic expectation-setting, and clear articulation of the goals of care as well as the range of potential outcomes.

When it is not possible to reach a mutually acceptable decision through patient-centered communication, formal mediation using a third party, such as a mediator, ombudsperson, or clinical ethics consultation, may be considered to help resolve patient–physician conflict.

In clinically acute situations, it may be necessary to continue the patient–physician relationship when it otherwise may have ended.

Physicians should not compromise their own safety and well-being, the safety and well-being of their staff or other patients, or their professional judgment to comply with patient requests.

When the therapeutic alliance cannot be restored, the patient–physician relationship should be terminated in a manner that is respectful, optimizes continuity of patient care and patient safety, and follows state laws and state medical board regulations regarding written notice, emergency care, and referrals.

Practices and institutions should have policies that recognize the spectrum of potential conflict, help to ensure that conflict is managed in a nondiscriminatory manner, and balance institutional responsibilities to the patients they serve with their responsibilities to their physicians and other staff.

BACKGROUND

Physicians have an ethical obligation to foster a therapeutic alliance with their patients. Trust and respect are the cornerstones of this therapeutic alliance. As in all human interactions, conflict may arise between patients and physicians. In the clinical setting, conflicts may arise for various reasons, including disagreements regarding diagnosis and treatment plans; differing expectations; a breakdown in communication; disagreements about or nonadherence to the therapeutic plan; repeated missed appointments; failure to pay bills; conflicts of cultural, religious, or other personally held beliefs (eg, physician’s conscientious refusal of care [1], patient’s declining of medical care for religious reasons); and disruptive or abusive behavior by patients.

Some physicians may identify the source of the conflict as the “difficult patient.” However, it is more accurate to regard conflict as the result of a difficult relationship between the patient and the physician. For most conflicts, it is desirable to attempt to restore a therapeutic relationship even when it may be difficult to do so. Some situations make termination of the patient–physician relationship not only reasonable, but necessary. This Committee Statement provides an ethical framework for managing patient–physician conflict and evidence-based tools and interpersonal interventions to help rebuild meaningful connection with patients. Guidance for the ethical termination of care when the therapeutic alliance cannot be restored also is provided, including institutional responsibilities to patients and physicians. Further details on strategies to promote effective patient–physician communication and shared decision making to minimize patient–physician conflict are provided in separate ACOG publications (2–6).

ETHICAL ISSUES AND CONSIDERATIONS Prevention and Management of Patient–Physician Conflict

Physicians have a commitment to follow their best medical judgment, to advance the patient’s best interests, and to foster the public’s trust in the profession of medicine. Given the inherent power imbalance within the patient–physician relationship, conflict between patients and physicians should be handled with empathy and professionalism at all times. Physicians have an ethical duty to attempt to resolve such conflicts in order to restore the therapeutic relationship when possible.

Differences in values, expectations, and goals may lead to difficult interactions and even conflict between patients and physicians. Although physicians bring expertise in medicine to the patient–physician relationship, such knowledge or authority is best managed and shared with patients by acknowledging that patients are the experts in their own lived experience, goals, and values. Physicians have an ethical duty to work toward conflict resolution to restore a therapeutic relationship between themselves and their patients (7, 8).

Maintaining the therapeutic relationship through respect, empathy (ie, active validation), and compassion is crucial because a positive therapeutic patient–physician relationship is associated with improved patient outcomes, patient satisfaction, and physician well-being (9, 10). In circumstances amenable to resolution, it is important to de-escalate and resolve conflicts to restore the therapeutic alliance. For example, physicians may perceive a disagreement about treatment plans as a challenge to their expertise. In this situation, physicians should acknowledge their own feelings of frustration or diminished sense of efficacy and refrain from acting defensively and, instead, take steps to realign patient–physician goals that are described later in this document. Using this approach can preserve the strength of the patient–physician relationship as well as minimize the risk of physician burnout (11).

Patient-Centered Communication

Patient-centered care practices and communication techniques that are recommended to help prevent as well as manage patient–physician conflict include a) fostering a meaningful connection during the clinical encounter, b) establishing and restoring trust, and c) building and restoring an effective patient–physician relationship.

Open, patient-centered communication may increase patient involvement and may improve patient outcomes (9, 12–14). Good communication also may reduce the likelihood of medical liability litigation (2, 15, 16). Tools to help physicians prioritize a culture of humanism and respect for their patients, even in the setting of complex or challenging clinical encounters, can minimize patient and physician frustration and rebuild patient–physician trust (17, 18). A mixed-methods study that included a systematic review of the literature on interpersonal interventions, clinical observations, and interviews with physicians and patients identified the following five evidence-based practices to help enhance meaningful connections between patients and physicians: 1) prepare with intention (take a moment to prepare and focus before greeting a patient), 2) listen intently and completely (sit down, lean forward, avoid interruptions), 3) agree on what matters most (find out what the patient cares about and incorporate these priorities into the visit agenda), 4) connect with the patient’s story (consider life circumstances that influence the patient’s health; acknowledge positive efforts; celebrate successes), and 5) explore emotional cues (notice, name, and validate the patient’s emotions) (17). When possible, sources of potential conflict between patients and physicians should be anticipated and mitigated proactively.

Physicians bring their own background, personal beliefs, and experience to the patient encounter. Physicians should be aware of their own implicit and explicit biases (including those based on sex, gender, race and ethnicity, religion, nationality, and ability status, among others), which can affect the way in which they interpret and respond to a patient's beliefs and health care decisions. Respecting that patients’ values or manner of making health care decisions may differ from a physicians’ own beliefs is a key step to providing patient-centered care. The RESPECT model, which is widely used to promote physicians’ awareness of their own biases and to develop physicians’ rapport with patients from different racial and cultural backgrounds, includes seven core elements: 1) rapport; 2) empathy; 3) support; 4) partnership; 5) explanation; 6) cultural awareness, humility, and sensitivity; and 7) trust (2, 4, 19).

Recognizing the importance of social determinants of health (ie, the environmental conditions, both physical and social, that influence health outcomes) is a vital aspect of patient-centered care that can help physicians better understand patients, effectively communicate about health-related conditions and behavior, and improve health outcomes (4). This framework acknowledges that systemic racism and other forms of discrimination serve as social determinants of health and recognizes that the way society is structured (for example, through racial, economic, and gender inequalities) influences clinical interactions and health outcomes (4). Physicians can address social determinants of health by implementing key practices such as screening for social determinants of health through patient-completed intake questionnaires, expanded medical history questions, and integrated electronic medical records prompts; employing multilingual staff; ensuring adequate interpreter services; partnering with medical–legal organizations; and engaging with community resources (4).

Additionally, it is important to recognize that individuals with a history of trauma may have adopted coping strategies that influence their behavior. Given the prevalence of trauma, obstetrician–gynecologists (ob-gyns) should strive to universally implement a trauma-informed approach, which helps to ensure safety, transparency, collaboration, and empowerment. This can be used to prevent and manage conflict and improve outcomes in difficult situations (20–22). Engaging in patient-centered communication and care supports healthy autonomy, fosters patient resiliency, and improves overall health outcomes (22). Further discussion of strategies to implement a trauma-informed care approach is available in separate ACOG publications (23–26).

Conflict Resolution

When possible, conflict resolution should involve exploration of the reasons behind the conflict, realistic expectation-setting, and clear articulation of the goals of care as well as the range of potential outcomes.

Allowing patients to express their frustration, agreeing verbally on the problem and the goals, and assuring follow-up can reinforce to both parties that they are on the same team. At times, conflict resolution may involve providing limited or alternative care that aligns with both the patient’s and the physician’s goals but that may not have been the original plan of either party.

In the case of recurrent, disruptive behavior on the part of patients or their families, the physician should discuss the behavior and communicate clear expectations for ongoing care. This discussion should be documented in the medical record. Physicians should consider involving a second member of the health care team to serve as a witness in these circumstances.

Mediation

When it is not possible to reach a mutually acceptable decision through patient-centered communication, formal mediation using a third party, such as a mediator, ombudsperson, or clinical ethics consultation, may be considered to help resolve patient–physician conflict.

When conflict cannot be resolved through patient-centered communication, formal mediation using a third party, such as a mediator, ombudsperson, or clinical ethics consultation, can serve as a neutral facilitator to aid in discussion, clarify points of disagreement, and build consensus for a mutually agreeable solution (27–29). By focusing on patient-centered communication, trained mediators can assist in validating emotions, building understanding, clarifying the interests of all stakeholders, and helping to shape a mutually agreeable solution to the conflict (29). In the case of a patient with a mental health disorder, consultation with the patient’s mental health care professional or social worker can be additionally beneficial. If consensus cannot be reached through patient-centered communication and third-party mediation, in nonacute situations, it is appropriate to consider termination of the patient–physician relationship in accordance with state law and with referral to another ob-gyn while ensuring that patient safety is maintained.

In clinically acute situations, it may be necessary to continue the patient–physician relationship when it otherwise may have ended.

Physicians should consider the value of continuity of care for patients facing medically and emotionally difficult, time-sensitive decisions (eg, a poor prognosis, emergent care, or advanced pregnancy). In these situations, additional physician commitment to continue the patient–physician relationship may be necessary due to limited potential for mediation or referral. Conflict in these situations also may be compounded by involvement of other parties such as family members and surrogate decision makers. Given these additional potential stressors to the patient–physician relationship, increased efforts toward maintaining patient-centered communication, realistic expectation setting, and articulating clear goals of care are recommended.

Ending the Therapeutic Relationship

A physician’s ethical responsibility to care for patients is not without limits. Sometimes conflict may not be resolved successfully by mediation and may result in irrevocable erosion of the therapeutic alliance. Although many physicians have experienced discharging a patient, there is a paucity of published data on the prevalence and specific factors that influence this decision. One study of primary care physicians showed that approximately 90% of physicians surveyed had discharged a patient within the previous 2 years. Examples of reasons for patient dismissal included disruptive or persistently inappropriate behavior toward clinicians or staff, violation of chronic pain and controlled substance policies, and repeated missing of appointments without notice (30).

There is no universal standard for determining the appropriateness of a patient dismissal. Physicians can discharge a patient for any reason as long as it is nondiscriminatory; does not violate applicable laws; and does not immediately compromise the patient’s health, safety, or welfare (31). Examples of discrimination include discharging patients differentially based on characteristics such as age, gender, sexual orientation, race and ethnicity, and religion. Physicians may ethically terminate care with a patient who has initiated legal proceedings against the physician. Physicians also may ethically discharge patients for financial reasons such as chronic nonpayment of medical bills or repeated failure to keep appointments. However, physicians should be mindful of their responsibility to mitigate health inequities for patients from under-resourced communities. Less legitimate grounds for ending a patient–physician relationship would be, for example, a patient’s disagreement with physician recommendations (32).

Physicians should not compromise their own safety and well-being, the safety and well-being of their staff or other patients, or their professional judgment to comply with patient requests.

Certain situations may not warrant an attempt at mediation, such as abusive patient behavior. Immediate dismissal of a patient is appropriate when a patient is physically abusive, or threatens to be physically abusive, to a physician, staff, or other patients. In such circumstances of threat to physical safety, it is advisable to contact hospital security or law enforcement, if necessary, to protect staff and patients.

When the therapeutic alliance cannot be restored, the patient–physician relationship should be terminated in a manner that is respectful, optimizes continuity of patient care and patient safety, and follows state laws and state medical board regulations regarding written notice, emergency care, and referrals.

Either the patient or the physician can terminate the patient–physician relationship. Regardless of who initiates the process, termination of the patient–physician relationship should adhere to a process that is respectful and follows state laws and state medical board regulations. Failure to end the relationship properly may be considered patient abandonment, which is clinically, ethically, and legally problematic. Increased consideration should be applied to the termination of the obstetric patient–physician relationship, especially in the third trimester of pregnancy, when establishing medical care with another physician may be difficult.

When the relationship is terminated by the physician, adherence to the following steps for the transition of care to another physician will help to optimize communication, continuity of care, and patient satisfaction, which in turn will help protect the patient’s and the physician’s well-being (15, 33–35):

The physician should counsel the patient regarding recommendations for ongoing care, if necessary and able, and provide subsequent physicians with sufficient information to ensure continuity of medical treatment (36). The physician should make reasonable efforts to notify the patient in writing of the termination of the patient–physician relationship. This letter may state objectively the reason for dismissal and should include the last day the physician will be available to render medical care. The physician should include this information in the medical record as well, including documentation supporting the reason for dismissal. The timeframe specified by local policies and state laws should allow the patient adequate time to find another physician and arrange to receive alternate care from an equally qualified replacement. The appropriate period can vary and may be dictated by state law. Plans for the provision of emergency treatment and necessary prescriptions should be made during this transitional timeframe. A written authorization for the release of medical records should be executed to facilitate timely transfer of care to another physician. Referrals to alternate sources of health care (ie, other physicians by name or to the local medical society) should be given (although physicians are not obligated to ensure that patients who are dismissed from their care initiate care with another clinician), as well as notice that the emergency department is available at any time in case of an emergency. Obstetric patients require special consideration when terminating the patient–physician relationship. Pregnant patients may need more time to find another physician. The physician should provide information to patients in the first or second trimester of pregnancy to assist them in finding other sources of obstetric care. This could include providing a list of other ob-gyns in the community, the telephone number and web address of a medical society, or a hospital physician-referral service. A patient in the third trimester of pregnancy may be unable to find another physician to provide care, so terminating the relationship may be not feasible or appropriate. The physician may need to continue providing care for patients who are already in their third trimester until transfer of care is possible.

Legal counsel and state medical societies can be helpful in clarifying relevant local policies and state laws surrounding whether, when, and how to terminate the patient–physician relationship.

Practice and Institutional Policies

Practices and institutions should have policies that recognize the spectrum of potential conflict, help to ensure that conflict is managed in a nondiscriminatory manner, and balance institutional responsibilities to the patients they serve with their responsibilities to their physicians and other staff.

Such policies may range from provisions for expedited referral in the case of clinical conflict to ending the institutional relationship with the patient in cases of physical abuse by the patient, patient discrimination against the health care team, or other severely disruptive behavior. These policies should account for the effect of such conflict on the individual patient, the physician, other patients of the physician, and other physicians and staff in the practice or institution. Practice and institutional polices also should include measures to prevent bias and discrimination against patients and help to ensure that patient–physician conflict and termination of care is managed in an equitable manner. Medical practices and institutions have the responsibility to take precautions to help ensure the safety of their physicians and staff. Institutional support can help minimize the risk of physician burnout and, in turn, improve the clinical care physicians deliver to their patients.

CONCLUSION

Physicians have an ethical obligation to foster a therapeutic alliance with their patients. Maintaining an effective therapeutic alliance through the use of patient-centered care and communication strategies can improve clinical outcomes, patient satisfaction, and physician well-being. If the therapeutic relationship becomes strained, physicians should attempt to resolve the conflict, when possible, through intentional patient–physician discussion or through a third-party mediator. If return to a therapeutic relationship is not possible or mutually desirable, ending the patient–physician relationship may be the best option for the patient and the physician. The patient–physician relationship should be terminated in a manner that is ethical, legal, and consistent with local and institutional policies to help ensure continuity of care and maintain patient well-being and safety.

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All ACOG committee members and authors have submitted a conflict of interest disclosure statement related to this published product. Any potential conflicts have been considered and managed in accordance with ACOG’s Conflict of Interest Disclosure Policy. The ACOG policies can be found on acog.org. For products jointly developed with other organizations, conflict of interest disclosures by representatives of the other organizations are addressed by those organizations. The American College of Obstetricians and Gynecologists has neither solicited nor accepted any commercial involvement in the development of the content of this published product.