Initial response to unexpected surgical outcomes is crucial

Five dispute resolution and conflict management techniques can help the doctor and staff effectively work with unhappy patients.

John W. Potter

One of the most intriguing aspects of what I have learned about the patient experience with unexpected results in refractive surgery has to do with how the person responds to emerging disputes and conflict.

What often happens is that the first response is problematic, which then leads to miscommunication and further misunderstanding, and by the time the doctor engages in the dispute it becomes more challenging in terms of how to help the patient. I spend nearly all of my professional time helping patients and their doctors with unexpected outcomes, and over the years I have developed an approach that may be helpful to your patients.

The rubric on negotiation from a classic book on dispute resolution and conflict management, Beyond Reason, (Fisher and Shapiro) can be used by a first responder following refractive surgery. Fundamentally, the emotion associated with unexpected outcomes can be applied in the same manner the authors define emotion in negotiation: “An experience to matters of personal significance, typically experienced in association with a distinct type of physical feeling, thought, physiology and action tendency.”

Negative emotions tend to create an obstacle in negotiation, while positive emotions may be supportive. Fisher and Shapiro suggested that emotions should not be suppressed or ignored. Instead, we should address what they call the five core concerns rather than the emotion specifically. This memorable list can easily be used by first responders; this interaction sets the tone and establishes the context in which the remainder of the patient experience will occur. These core concerns convey “human wants that are important to almost everyone in virtually every negotiation,” the authors said.

The five core concerns are appreciation, affiliation, autonomy, status and role.

Instill mutual feeling of appreciation

Appreciation is the desire to feel understood and honestly valued – a need common to the human condition. Cooperation increases with a mutual feeling of appreciation. Fisher and Shapiro describe three main obstacles to achieving mutual appreciation: failing to understand another point of view, criticizing the merit of another and failing to properly communicate your own merit.

To overcome these obstacles, we need to do the following: listen to words and recognize the emotional response of the patient; acknowledge the reasoning and beliefs behind their thoughts and feelings; disregard age or social position; shape your message so others correctly understand. By using these ideas, increasing appreciation and developing positive emotions will be easier to achieve.

Build affiliation

Building affiliation describes the sense of connection between you and your patient. Often we fail to recognize the commonality between us. Building affiliation bridges this gap among the patient, staff and doctor, while increasing the ability to work together.

Fisher and Shapiro distinguish between structural affiliation, which is the recognition of a common group membership, and personal connection. The purpose of recognizing affiliation is to humanize the other, but not make new friends. Friendship is not what the doctor-patient relationship is about in the normal sense, but building affiliation is.

Respect autonomy

It is vital to respect autonomy in modern health care, and this is certainly true in refractive surgery. When first engaging in a dispute or conflict with a patient, maintaining autonomy, or the “freedom to affect or make decisions without the imposition of other,” is essential to building a relationship with your patients that benefits them, according to Fisher and Shapiro. The difficult part is that we have to be careful not to impinge or interfere with the autonomy of the patient.

Fisher and Shapiro suggest using the inform, consent and negotiation system (ICN). A joint brainstorming session is an example of the inform step; it provides recommendations and options for you and your patient. Consulting others before deciding and looking for the best alternatives together are steps to ensure equality in representation. These steps help ensure the autonomy of each participating party.

As an example of respecting autonomy, consider the following. It is not a good idea to present the patient with unexpected outcomes who is now in conflict with his or her doctor only one alternative, as if you are the all-knowing authority. On the other hand, it is not a good idea to provide so many alternatives to the patient that he or she is bewildered and does not think of you as a knowledgeable and authoritative doctor.

Instead, offer two or three alternatives to your patient, but no more. If you do not know what alternatives are available, say so. Set up a time to follow up and do your own research to find out. Then allow your patient to participate in a meaningful and constructive discussion with you about which alternatives might be best to pursue.

Acknowledge status

Respecting autonomy ties itself directly to acknowledging status for your patient. According to Fisher and Shapiro, “Status refers to our standing in comparison to the standing of others.”

Positive emotions can be created when status increases self-esteem or the influence over others. Negative emotions arise out of the competition for status. The modern doctor-patient relationship requires a more level field for acknowledging status.

Sit at the same level as your patient and maintain eye contact. Ask questions and be engaged in conversation instead of dictating authoritative and directed imperatives for your patient to follow.

Acknowledging another’s status before acknowledging your own encourages positive emotions. Granted, you have status as an expert, but your patient also has status as a person who is engaged in a dispute or conflict with you because of their unexpected results from refractive surgery. It is important to recognize the limits of status; the opinions of a person with a higher status are not automatically correct. It may surprise you to learn that the most common cause of malpractice actions is not unexpected results from treatment, but dissatisfaction with communication and interpersonal skills (Studdert et al.).

Choose fulfilling role

The final step in this process is to choose a role that fulfills your needs and standards of appreciation, affiliation, autonomy and status. First, be aware of your conventional role and shape or expand that role to make it fulfilling.

Three important qualities of a fulfilling role are: a clear purpose, which provides an overarching framework to behavior; personally meaningful, which incorporates skills, interests, values and beliefs into a task; not a pretense – the role you are in is not who you pretend to be, but should define who you really are. It is important to note that not all roles are permanent; adopting temporary roles are helpful in fostering collaboration with your patient.

The extraordinary aspect of these five core concerns is that anyone can use them in your practice or group. Staff training can help those who are likely to be first responders to emerging disputes and conflict feel grounded in skills and techniques that can help your patients.

When you engage with your patient, and if you follow the rubric of the five core concerns, the dispute or conflict becomes more constructive and you can be more helpful to your patient. As a result, patients are more likely to collaborate with you, which benefits everyone.

References:

• Fisher R, Shapiro DL. Beyond Reason. New York, NY: Penguin Group USA; 2005.
• Studdert DM, Mello MM, Brennan TA. Medical malpractice. N Engl J Med. 2004;350(3):283-292.

• John W. Potter, OD, MA, is a lecturer in dispute resolution and conflict management at Southern Methodist University. He is also a Primary Care Optometry News Editorial Board Member. Dr. Potter can be reached at SMU, Dispute Resolution and Conflict Management, 5228 Tennyson Pkwy., Suite 118, Plano, TX 75024; (866) 768-1014; jwpotter@smu.edu.