Physicians encounter conflict all the time in medical practice, and they generally do their best to support and help patients when an argument strikes. What happens, however, when a patient’s agenda is to escalate and sustain the conflict versus attend to it constructively? This scenario is a paradox for most refractive surgery practices, but it happens. Conflict junkies engage in conflict for the sake of it. These individuals can be incredibly disruptive to a refractive surgery practice, but once you recognize the behaviors and know what to expect, you will be in a much better position to help these patients while protecting yourself and your practice. In my experience, nearly all conflict junkies will cycle through a pattern of behaviors to sustain conflict. The three hallmark behaviors are the trap, the attack, and the demand.
A 48-year-old man has a preoperative prescription for less than 2.00 D of correction for each eye. He is informed of the risks and benefits of refractive surgery with special attention to his need for reading glasses after surgery. The patient has been advised of his option for near vision correction, but he opts for distance BCVA with the understanding that he will need reading glasses for near vision. Does this scenario sound familiar?
At the first postoperative visit, the patient is agitated upon arrival. He loudly declares that having LASIK was the worst decision he ever made in his life. “I can’t see up close, and I can’t see my computer screen like I used to be able to do,” he reiterates over and over again. “I used to be able to read without my eyeglasses, and now I have to wear eyeglasses for reading! This is horrible.” This is the trap.
Negotiation theory clarifies the concept of the trap, which is characterized as the far side of reasonable. Let us say you want to buy something that costs $1. That price is more than you want to pay for the item, but you spend the dollar. If the item cost $2, you would not purchase the item, and if it were 50 cents, you would buy two of the items. In this situation, the far side of reasonable is that point where the price is enough to entice you to buy it but not so much that it turns you away. Applying this concept to the LASIK patient, what he said was not unreasonable, but on the other hand, he agreed to surgery with complete and more than adequately informed consent.
You begin the visit with this particular patient by making every effort to help him, and just when you think you have reached an understanding, he lashes out: “I know you told me about my near vision before surgery, but if I would have known it was going to be like this, I would never have had surgery in the first place. I want my money back. This is the worst thing that has ever happened to me.”
Next, comes the personal attack. “Several of my friends recommended this practice to me for surgery, and they were wrong,” he says. “I don’t think you care about your patients like you should. In fact, everyone here has an attitude that is unpleasant and offensive to people who have complications with their eyes.” Instead of a clinical problem, you are the problem. This is off-putting, which is why it works for the conflict junkie. You feel as if you are being punished for trying your best to help your patient.
The demand always escalates the conflict, which is the patient’s real goal. “I want my money back, and I want you to pay for my time off from work, my travel costs to the practice, and my babysitting costs, and I want you to continue my care,” he says. “You have to fix this now! I think I am losing my mind.”
The demand is always beyond the far side of reasonable. The conflict is what the patient needs and wants more than anything else, so what is uncomfortable for you is very comfortable for him or her.
Once you say no, your patient becomes contrite: “Look, I know I have been really upset with you, but I really need your help. I know you will understand. Can’t you make this just a little bit better for me?”
In fact, your patient will go to any length to keep you engaged in conflict, which is what he or she really wants. Before you know it, another trap is laid before you: “Won’t you at least buy me some reading glasses to help me out here?” If you say yes, the reading glasses will likely never be good enough. Soon, you will have purchased them over and over again, or the patient will select eyewear that is incredibly expensive. If you say no, then the patient will go on the attack immediately, continuing to engage in conflict no matter your answer, which is why it is a trap. The pattern continues.
In fairness, most conflict junkies are not completely aware of their behavior. They approach nearly every aspect of their lives in this manner. Calling them out and labeling them is rarely productive, so the question is what to do. Unfortunately, conflict junkies may follow this pattern of trap, attack, and demand for a few cycles before anyone recognizes it. Again, conflict junkies are well practiced in this behavior.
Here is my advice. First, recognize the trap. You may miss it a few times, but as soon as you see the pattern of entrapment, contrition, and entrapment at the far side of reasonable, stay alert.
Second, do not engage the attack. Conflict junkies are probably better at this sort of thing than you are. Do not interrupt or disagree with your patient. Give him or her time to say what he or she wants to say. Conflict junkies are used to people’s responding to their attack with interruptions and defensive language. Human behavior is greatly influenced by brain chemistry. We have enough neurochemicals to sustain an emotional cascade for approximately 90 seconds. My advice is therefore not to interrupt your patient. Let the cascade pass, and you will find that your patient will de-escalate. Once the patient is done, you can engage him or her constructively. If you interrupt and argue with your patient, the neurochemistry will recharge, and the cycle will begin again. Conflict junkies can escalate and maintain their practiced outrage well beyond 90 seconds. In fact, the conflict junkie is “addicted” to conflict.
Third, just say “no” to the demand. Be firm. Do not allow any room for movement. Do not explain yourself over and over. Be respectful and thoughtful, but be firm. “I am not going to buy you reading glasses.” This is not particularly easy to do for most of us, because we hope that placating the patient will lessen the conflict. Remember, the conflict junkie does not want the same things you do. Wait for the cycle to repeat itself, and maintain your posture until the conflict junkie realizes that he or she is not going to get the response needed to sustain the conflict. n
John Potter, OD, MA
• vice president of patient services, TLC Vision, Chesterfield, Missouri