Mastering Difficult Conversations in Healthcare: Strategies and Insights

Continuing Medical Education of Southern Oregon

Conversations as

Medicine

(AKA Difficult

Conversations)

INTRO

Laura Heesacker, LCSW

May 20

th

, 2016

 I 

have nothing to declare in regards conflicts of interest

•

We all are rapidly using up our supply of pens and

cups

Laura’s 3 Truths

Clinicians:

“ I am concerned about you

and your medical conditions,

both for your pain control

but also for your safety.

Oxycodone is no longer a

good choice for either.”

When a

person’s

survival skills

are so fine

tuned it feels

like

manipulation

Reframe

Does it ever feel like you have stepped

into a trap?

General Objectives

Difficult Conversations Cycles

DIFFICULT DISCUSSIONS WITH

PATIENTS

:

How to Have a Positive Outcome

Lee S. Glass, MD

Associate Medical Director

Department of Labor & Industries

Disclosure #1

•

I have no financial conflicts of interest to

disclose

•

No relationships with any company or

organization, other than Washington State

Difficult Discussions

•

Some of the most important moments in medicine

involve communication

•

Some of the most important communications are

sometimes avoided

•

Discomfort, or fear of discomfort, is often the cause

of communication avoidance in medicine

•

We are likely to be more successful as physicians if we

can initiate difficult discussions in a manner that is

comfortable and effective  for all concerned

Definition

•

“Difficult Discussion”:

–

A conversation,

–

That involves content that may generate a negative

emotional response in or from one or more parties,

–

but which, if not conducted,

–

will have consequences that one or more parties

considers unfortunate or undesirable.

Goals

•

Understand the role that “difficult

discussions” may play in the practice of

medicine

•

Understand some ways in which one can

prepare for a difficult discussion

•

Learn techniques that maximize the likelihood

that a difficult discussion will have a mutually

satisfactory outcome.

Disclosure #2

•

Nobody’s perfect

•

What follows are concepts

•

Most of the concepts outlined below I learned

through mistakes

•

I made some mistakes more than once

•

Odds are great that some days we won’t do so

well implementing the concepts

•

Suggestion: Keep practicing!

Difficult Discussion

•

Condition: Inexplicable swelling of the non-

dominant hand, sharply demarcated at the

level of the wrist.

–

Followed early DIP then MCP amputations, 3

rd

digit, non-dominant hand

–

Patient sought amputation at level of wrist

•

Differential Diagnosis: CRPS vs. factitious

disorder

•

Options:

–

Medical: continue workup

–

Legal: litigate

Difficult Discussion

•

Option selected: Hospitalize and treat

•

Outcome: Treatment sabotaged

•

Noted in the chart: appearance of a band-like

constriction at the level of the wrist

–

Patient’s explanation: elastic cuff on jacket sleeve

–

Physician’s response: bilateral cuffs; unilateral

swelling

•

Final Diagnosis: CRPS

Difficult Discussion

•

Outcome (2 years later):

–

Per attorney:

•

“He hasn’t killed himself yet”

•

“Family is ruined”

•

“He hasn’t killed himself yet”

•

“The kids have problems”

•

“He hasn’t killed himself yet”

Difficult Discussion

•

Why this outcome:

–

Doctors involved were not trained in having

difficult discussions with patients

–

Hospital professional staff not trained in having

difficult discussions (with doctors or patients)

–

The system allowed all involved to ignore the

diagnosis of “factitious disorder” made by pain

clinic psychologist

Difficult Discussions

•

What are they?

–

Necessary verbal communications that are, or are

anticipated to be

–

Uncomfortable  or difficult for one or more

participants

•

Settings – anywhere

–

Exam room

–

Home

–

Work

–

Etc.

When They Don’t Happen

•

Opportunities are missed

•

Relationships suffer

–

Professional

–

Collegial

–

Familial

–

Supervisory

Why They Don’t Happen

•

Discomfort: One or more potential

participants fear discomfort:

–

Anger

–

Loss

–

Revenge

•

Physical

•

Economic

–

Embarrassment

–

Etc.

How We Avoid Them

•

Denial

–

There is no problem

–

Not my job

•

Avoidance

–

Don’t return phone calls or letters

–

Body English (e.g. stand in doorway)

•

Intimidation

–

Demeanor

–

Content of speech

Why They Don’t Happen

“There’s no problem::

•

One or more potential participants are blinded

as to the need for a discussion

–

“Pain” doctor prescribing 120 mg of morphine/day

for back pain not precipitated by an injury

–

Patient (28 y.o. F) lost custody of 8 y.o. son 2 yrs

before; on opioids last 1.5 years.

–

When doctor was asked why father has custody, he

answered: “Mother had a drug abuse problem.”

Why They Don’t Happen

•

One or more potential participants view

difficult discussions as “not my job”

–

Surgeon: will not delve into patient’s prior history

of sexual abuse

–

Surgeon: “not my job” to arrange for psychological

treatment for severely depressed “surgical

candidate”

–

“Pain doctor” will not call primary care physician

regarding psychological issues

Difficult Discussions: Goals

•

Build, strengthen, or repair a relationship

–

Professional

–

Family

–

Supervisory

•

Strategic

–

Achieve health care goal

•

e.g. assent for substance abuse treatment

•

e.g. discuss spousal abuse issues

•

Etc.

Difficult Discussions: Goals

•

Relationship is strengthened or advanced

•

Strategic goal is achieved or agreeably modified

•

Feel good when the discussion is over

–

You feel good

–

Others feel good

Difficult Discussions: Preparation

•

What is the best time to prepare for the next

difficult discussion?

–

Now

•

Why “now”?

–

Because there may be a lot to do

–

Because nobody knows when the next difficult

discussion will arise

Difficult Discussions: Preparation

•

Major categories of preparation:

–

Self

–

Expectations

–

Logistics

Difficult Discussions: Preparation

•

Self

–

The most important, by far

–

The only part of the process over which any of us

have complete control

–

The part of the process most likely to produce – or

not produce! – comfort

Difficult Discussions: Preparation

•

Self

–

Who am I?

•

Honesty – with self and others

•

Trust – of self and others

•

Commitment – What kind? How much? For how long?

•

Comfort – How comfortable are you?

–

With yourself?

–

With your patients?

–

With their problems?

Difficult Discussions: Preparation

•

Self

–

Upon what foundation will you build the discussion?

•

Scientific / professional

–

Knowledge

–

Training

–

Skill

–

Experience

•

Personal

–

Communication skills

–

Value / belief system

–

Resources (e.g. available time, etc.)

Difficult Discussions: Preparation

•

Self

–

Strategic analysis

•

First have to have a clear understanding of goals:

–

Question: “What am I really trying to achieve?”

•

Flows from goals

–

Question: “What is the best strategy to achieve my goals?”

Difficult Discussions: Preparation

•

Patient

–

Start relationship on firm foundation

•

Only if it meets both parties’ needs will it last

•

Patient’s needs may not be fully understood initially

•

Patient’s needs may change over time

–

Expectation setting

•

First visit, whenever possible

•

Clear, unambiguous

•

Tied to the patient’s best interests

•

Consequences of unmet expectations are clear to patient

THE TAKE-HOME MESSAGE

•

If an industrial injury is involved, the most

important expectation is the role of the physician

–

Physician is patient advocate

•

Advocates for care that is necessary to treat the effects of the

industrial injury or occupational disease

–

What the patient needs and what the patient wants

may differ

•

Doctors advocate for medical needs

•

Lawyers advocate for patient wants

Difficult Discussions: Preparation

•

Logistics

–

Time

•

End of day versus during normal clinic day?

•

45 minutes versus 6 minutes?

–

Place

•

Exam room?

•

Office or conference room?

•

Teleconference?

–

Participants

•

Patient only?

•

Others: Spouse? Employer? Etc.

Process

•

Principal Considerations

–

Trust

–

Comfort

–

Clarity

–

Issue identification

Trust

•

Cornerstone of the relationship

–

Should be a two-way street

•

But patient MUST be able to trust the doctor

–

Should be established as quickly as possible

•

I tell injured workers: “There are only four rules to which I

have never found an exception, and the first is that

patients never look like their medical records suggest.”

–

Care should be taken to avoid ambiguities that might

detract from trust

Process

•

Comfort

–

Critical

•

Foundation for relationship

•

Maximizes chances for effective communication

•

Maximizes chances for maintaining a healthy

physician/patient relationship

•

Minimizes risk of harm

–

To physician by patient (e.g. litigation, negative publicity)

–

To patient by physician (e.g. damage to therapeutic

relationship)

Process

•

Comfort – Contributors

–

Setting

•

Respectful of patient? (e.g. exam room versus office)

•

Physically comfortable? (e.g. chair versus exam table)

•

Interruptions versus quietude

•

Support for patient (e.g. spouse or other advisor present?)

Process

•

Comfort – Contributors

–

Timing

•

Of the discussion

–

Beginning or middle of day?

–

Last appointment of day?

•

In relationship to the issue

–

A single event at issue?

–

An established pattern at issue?

–

Something in between?

Process

•

Comfort – Contributors

–

Mood

•

Patient’s mood

•

Your mood

Process

•

Comfort – Contributors

–

Your attitude

•

Is it what you want it to be?

•

Is it likely to be clear to the patient?

–

Difference between spoken words and body English?

–

Will you be perceived as truthful and fair?

–

Will you be perceived as trying to build a good relationship?

–

What tone are you communicating?

Process

•

Comfort – Contributors

–

Advanced notice

•

Can help reduce fear

•

Can set stage for a win-win discussion

•

Allows both patient and physician to prepare for discussion

•

To the alcoholic patient: “Let’s schedule you to come back

in a week to take out the stitches. Let’s also plan to talk

about why you fell. I promise you that you’ll feel a lot

better after we talk than you felt after your fall.”

Process

•

Clarity

–

The basis of effective communication

•

Often perceived as present when actually absent

–

“What you thought you heard me say is not what I had intended to

communicate.”

•

Three critical elements:

–

Words that were spoken

–

Words that were heard

–

Meaning that was given by patient to words that were heard

Process

•

Clarity

–

Words that are spoken

•

Come from our background of knowledge – not shared by

most patients

•

May have cultural connotations that may or may not shared

by the patient

•

May contain vocabulary not understood by the patient

Process

•

Clarity

–

Words that are heard

•

What is being said?

–

Patient may not hear the words – e.g. what is heard following the

word “cancer” may not be all that was said

–

Words will be processed – processing speed may be much slower

than the flow of the spoken words

•

Why is it being said?

–

Motivation may be misunderstood – e.g. previously abused patient

may feel that words are hurtful

•

Who is listening?

–

For the words to be truly understood, the patient may need others

(e.g. spouse, adult child) to hear what is being said

Process

•

Clarity

–

Meaning will be given to the words that were heard

•

The meaning will be created by the listener(s)

•

This is the meaning that will be the basis for the listener’s

decision-making

•

Correlation with intended meaning may be poor

Process

•

Clarity

–

Need for clarity cannot be over-emphasized

–

Tools

•

Try to use the patient’s vocabulary

–

Consider the patient’s trade or profession and create analogies

–

Consider the patient’s level of education

•

Try to test patient’s level of understanding

–

Ask questions that will provide feedback regarding understanding

–

Repetition of fundamental points may be helpful

•

Try to have all necessary listeners present

Content

•

Infinite variation in discussion content, but

•

Two important themes are invariant:

–

1) Trust, always

–

2) Comfort, to the greatest extent possible

•

Content should be reflective of the above themes

–

How can my words and actions most build trust?

–

How can my words and actions help create comfort?

Content

•

Motive identification

–

Best to verbalize motivation at the outset

•

Example: Patient seeks surgery that doctor feels is unlikely

to relieve patient’s chronic back pain

•

Scenario 1: “I wouldn’t be doing my job as a doctor if I

didn’t raise some pretty challenging issues regarding future

treatment. Shall we explore them?”

–

Motive – clearly stated – “I want to be a good doctor”

Content

•

Motive identification

–

Best to verbalize motivation at the outset

•

Scenario 2: “I realize this might be upsetting to you, but I

really don’t think you will be benefited by surgery, and I am

not prepared to schedule back surgery for you.”

–

Motive – unstated. Patient may conjure up any motivation to apply

to the doctor’s message.

»

You don’t like me…

»

You’re just trying to save money for the insurance company…

»

Etc.

Content

•

Issue Identification

–

Agreement on issue identification is critical

•

e.g. Patient focus on falls, physician focus on alcoholism

–

May need to connect falls to alcoholism as first step

•

e.g. High-dose opioid prescriber may cite standard of

practice as explanation for prescribing problem

–

Issues of safety and effectiveness may have to be discussed first

•

Issue clarification

–

Single event?

–

Pattern of behavior?

–

Involve honesty or trust?

•

Type of response will differ with types of issues

Content

•

Content: establishing issues should be factual

–

Facts can be powerful; you can harness that power

–

If accurately stated, facts can usually be accepted

•

Contrast:

–

If I have heard you correctly, you have had three convictions for

DWI, and you spent 10 days in jail

–

You have simply got to stop drinking and driving

TAKE-HOME MESSAGE

•

Delivery should usually be unemotional and non-

judgmental

–

Goal: 

Decision-making by cortex, not amygdala

–

Contrast:

–

Once the newspaper printed the story that you had been charged

with child molestation, your daughter has found it difficult to

maintain her friendships at her school.

–

What you did was a matter of choice, but you know that you made

a very bad choice when you did it.

Content

•

Tentative delivery 

can help minimize negative

reactions

–

Goal: Decision-making by cortex, not amygdala

–

Contrast:

•

I am wondering if one possible solution might be ….

•

What you need to do is ….

Content

•

Questions

 can help patients verbalize difficult

realizations

–

Looking back on it all now, when do you think you

first saw signs that your son was using drugs?

–

Knowing what you know now, what would you tell

another father to look out for, in raising a teenager?

Content

•

A focus on the 

patient’s interests 

may facilitate

acceptance of your thoughts:

–

Let’s consider the pluses of your not having the test,

on the one hand, to the minuses on the other…

–

It’s hard to have to start making decisions for a

partner you have shared a lifetime with. Would it

help to talk about what your wife might say, if we

could ask her?

Listening

•

We all want to be heard and understood.

•

Clarifying strategies can be very helpful:

–

Help me understand why that is important to you…

–

I heard you say …. – did I get that right?

–

You seem a bit uncomfortable – was my question

upsetting to you?

When our buttons are pushed

•

Patients with personality disorders many seek

control through putting others on the defensive.

Reduce the risk of being defensive by:

–

Considering why the patient is adopting such a tactic

•

Fear that needs won’t be met? Concern that interests

won’t be understood?

–

Asking ourselves if we have anything about which to

feel defensive

•

If so, perhaps that could be put on the table for discussion

Summary

•

Know who you are

•

Know exactly what you want to achieve

•

Utilize a process that develops trust and comfort

•

Listen carefully and actively

•

Content should be responsive to motivation

•

Remember: It is often easier to be right than to

do the right thing