Conflict is an important aspect in the practice of emergency medicine. Successful conflict resolution in emergency medicine requires immediate intervention. As ethical issues are commonly integral to these conflicts, it is advisable to describe them in terms of rationality and to use a conventional, bioethical approach to resolution. This involves the case - study method, a well - known sociological research approach. The article provides examples of the application of this approach to emergency medicine.

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Conflict between emergency physicians and patients currently presents a growing problem. In the current political, economic and social climate, interpersonal conflict has become more intense, resulting in negative experiences and provoking aggression. Cases of assaults 49 and even murders of emergency physicians and other medical staff by patients with a mental disorder are quite common. The Chelyabinsk Department of Health Care reported 30 cases of assaults on emergency physicians in 2015 [1]. Taking into account a recent incident in Belgorod that resulted in the patient’s death, deputy minister of public health of the Russian Federation, I. Kagramanyan, addressed a letter to the St. Petersburg Committee of Health Care in which he called for putting greater emphasis on ethical and deontological standards and principles of behavior of health care professionals [2]. In accordance with applicable law, if a patient demonstrates aggressive behavior, the physician should promptly contact the police. Article 6 of the Constitution of the Russian Federation «Making the interests of patients the first priority when providing health care services» of the Law on «Comprehensive promotion of national heath» postulates « When providing health care services, the interests of patients are made the first priority by upholding ethical standards and moral principles and by the practice of respectful and humane behavior by the medical staff» [3]. However, recent studies which were conducted in clinical settings all around Russia have shown the highest percentage of patients’ complaints on lack of attention paid to the patient. A.A. Vodyakha demonstrated how often rudeness to patients and patient neglect occurred in health care settings, thus evolving a specific social phenomenon. Table 1 _Conflicts in medical practice [4]_ Potential causes of conflicts in medical practice Possible ways to resolve medical conflict 1. Lack of physician attention to the patient. 2. Failure to obtain informed consent from the patient. 3. Differences of opinion between colleagues from other areas of medicine. 4. Physician professional misconduct. 5. Lack of effective patient record keeping. 6. Personal characteristics of a physician and a patient. 7. Patient unawareness of their rights and obligations. 1. Teaching patient - centered communication skills to physicians. 2. Informing patients about the procedures performed, treatment options chosen, etc. 3. Making treatment decisions in collaboration with colleagues from other areas of medicine; documenting investigation findings to be shared with other physicians. 4. Following the standards for medical services. Encouraging physicians to improve their skills. 5. Control over the quality of medical documentation. 6. Testing for a patient’s psychological type. 7. Introducing an autonomous model; following the principle of informed consent. Other aspects that predispose to conflict between patients and providers of health care services include moral indifference which can be seen in a large proportion of health care professionals and underestimation of moral principles by them [5].Numerous studies have shown that emergency physicians infringe on such patients’ rights in the patients’ desire to be admitted to a particular hospital (in emergency situations), willingness/unwillingness to give informed consent, rude and abusive behavior of the medical staff. Reviewing medical encounters helps health care professionals make adequate choices in difficult situations and avoid interpersonal conflicts. An introduction of a case - study method, a well - known sociological research method, into a medical education program and post - graduate training is of great importance. The case - method was established at Harvard, where it continues to be used for teaching law and medicine. In western countries, the case method is widely used to teach medicine. This method allows us to review challenging situations by analyzing a specific case, applying logical thinking and searching for an adequate solution. A case - study method can also be referred to as: 1) a specific situation method; 2) method of reviewing a situation or a business situation; 3) case studies; 4) situational tasks. The case - study method is an integrated research approach which combines several qualitative techniques used to study a specific case, event, situation, or social/cultural community. This approach provides a comprehensive study of a social phenomenon based on exploring a specific/distinct case or situation, dividing it into its constituent parts and identifying the relationship between them. By doing so, one can analyze the factors that contribute to the situation and work out a solution. The case - study method helps the physician develop a committed responsibility for their actions, strive for the safety of patient life and health and the ability to avoid conflict by following ethical standards and deontology principles. We have applied the case - study method to review a number of conflict situations in emergency medicine. Case study № 1 Upon arrival at the airport, a female experienced severe pain in the heart. The emergency physicians who were on call declared relief of pain; however, they insisted on having an ECG done. The female had a business trip scheduled to another city and the plane was to take off in 45 minutes. She refused to let emergency physicians obtain an ECG. The refusal could result in unwanted sequelae and even death. The conflicting 50 dilemma presented paternalism versus autonomy. The emergency physician chose a paternalistic solution to the conflict. She informed the patient about the need for investigation emphasizing that her refusal could lead to serious health complications and even death and deprive her two children of their mother. In the end, the female agreed to have a complete physical examination and had to cancel her business trip [6]. Comments. An adequate choice for the solution to the conflict, obtaining the patient’s informed consent for the treatment proposed, saved her life and prevented potential irreversible complications. In a while, the female wrote a letter in which she thanked the physician for her tremendous ability to persuade and uphold the ethical obligations [6]. The analysis of this case suggests that physicians should behave similarly in such conflict situations and make competency - based decisions. Case study № 2. February 4th, 2016, Tolyatti, Russia. At 10 p.m. an emergency service manager received a call regarding an incident involving a 33 - year - old male with a head injury. The male sought emergency care. Upon arrival, the emergency physicians found that the victim’s brother was drunk and demanded them to provide care first to him rather than to his brother. On examination the physicians found no signs of damage to him and insisted that emergency treatment was needed to preserve his brother’s life. However, the drunken brother did not respond adequately and hit the nurse who fell and lost consciousness. The emergency physician contacted the police as the drunken brother attacked her, too. The emergency physicians asked the neighbors for help. However, nobody helped them. The emergency physicians had to leave the house. The police arrived after a few minutes. The injured brother was admitted to the hospital and diagnosed with a brain concussion. A brain concussion was also diagnosed in the nurse whose duty is to save patients’ lives [7]. Comments The issue we address here is failure to provide prompt medical care. The emergency physicians failed to do so because of independent risk factors. To minimize such risk factors, it is necessary to involve social agents whose duty is to handle such situations. In this case, the police played the role of the social agent obliged to resolve such conflicts. The emergency physicians were found to respond appropriately to this conflicting situation. Case study № 3. February 18th, 2016, Moscow, Russia. At night, at the 68th km of the Moscow ring highway a female was run down by a car. The female was crossing the road at the wrong place. The female was declared dead by the emergency physicians. The dead body was covered with a thick polyethylene bag and left for an hour on the road. One hour later, the female was found moving. She was admitted to the resuscitation room in an extremely critical condition [8]. The Moscow Department of Health Care reported that the emergency physicians who arrived at the scene were fired for incompetence. Comments. The conflict arose due to professional incompetence and carelessness of health care professionals which resulted in harm to the injured female. The wrong diagnosis made by the emergency physicians and delay in admitting to the resuscitation room were erroneous actions of health care providers. A list of case - studies involving most common conflict situations which embed ethical issues is presented in special journals including Medical Ethics Journal 2013. Case study № 4. An accident occurred on an inter - city road. A person was injured. He experienced severe pain in the stomach and in the back. The emergency physician suspected internal hemorrhage which required the administration of the serum. The victim who had been informed about the severity of the injuries refused immediate medical treatment because of his religious beliefs. He said that he was prepared to go before God during Ramadan fasting. Does the emergency physician, who is aware of the severity of the injuries and religious beliefs of the victim, have the right to leave the injured without providing medical care to him? [9]. Comments. Medical conflicts, which are the result of differences in professional opinion and the value system of a patient, are the greatest challenge in emergency medicine. Emergency physicians must provide immediate medical care rather than deliver a psychotherapy session to a patient. Ethical issues embedded in medical conflicts require an individually - tailored approach to their resolution. Therefore, it is difficult to develop general guidelines which can be applied in a variety of conflict situations. In this particular case the situation can be defined as life - threatening. Taking into account the injuries the patient had received, he was unable to make any decisions at that moment. In such situations, medical care must be provided without obtaining patient’s informed 51 consent; however, permission must be received from a responsible clinical administrator. If the patient’s condition was not life - threatening, the emergency physician could offer the patient admission to a hospital where a priest could be invited to discuss the patient’s decision. In conflict situations between a physician and a patient, the life of the latter depends on the ability of the physician to reinforce the need for medical intervention, the ability to avoid conflict situations, as well as the ability to obtain an informed consent from the patient or relatives for authorization of a medical intervention. The Ministry of Public Health of the Russian Federation has developed guidelines for providing medical care, formulated the standards of emergency care to children and adults in a variety of situations. They serve as a physician’s practical guide. However, when fulfilling their duties, physicians must uphold ethical standards. The case - study method contributes to the improvement of professional competency, and the enhancement of responsibility of emergency physicians for the care provided, health and life of patients.

About the authors

E. N Grebennikova

Volgograd state medical University

400131, Volgograd
Assistant Lecturer, PhD (Medicine), Department of Emergency and Ambulatory Care

S. H Ayvazyan

Rostov State Medical University

Rostov - on - Don, Russia
Post - graduate student at the Department of Public health and Health Care № 1 with the course of history of medicine


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