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Faculty Dan O’Connell, Ph.D. To reach Dan: 206 282-1007 1.

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Presentation on theme: "Faculty Dan O’Connell, Ph.D. To reach Dan: 206 282-1007 1."— Presentation transcript:

1 Faculty Dan O’Connell, Ph.D. To reach Dan:

2 2 “Difficult” Clinician-Patient Interactions Copyright 1996, rev. 2002, 2005 Institute for Healthcare Communication New Haven, Connecticut

3 3 Objectives Extend the 4 Habits to address particularly challenging interactions To quickly diagnosis the causes of difficult interactions To learn and implement at least 2 strategies for turning around difficult interactions To practice a model for saying “no” when needed that reduces risk of conflict Extend the 4 Habits to address particularly challenging interactions To quickly diagnosis the causes of difficult interactions To learn and implement at least 2 strategies for turning around difficult interactions To practice a model for saying “no” when needed that reduces risk of conflict

4 4 Two people How they interact Two people How they interact “Difficult” is a function of the relationship P R E M I S E S

5 5 Relationship difficulties develop when…. Success is frustrated Success is frustrated Expectations are misaligned Expectations are misaligned Flexibility is insufficient Flexibility is insufficient A M O D E L

6 6 A cknowledge and Assess D iscover Meaning O pportunities for Compassion B oundaries – Set/Adjust/Negotiate E xtend the System to include others A cknowledge and Assess D iscover Meaning O pportunities for Compassion B oundaries – Set/Adjust/Negotiate E xtend the System to include others Use ADOBE to build cooperation

7 Techniques Acknowledge  “I can see this is frustrating.”  “I know we are seeing this differently.” Assess  What is each of your picture of success?  What are patient’s specific expectations for this interaction? (in person, on phone, )  Explore flexibility: theirs and yours 7 Acknowledge & Assess

8 8 Ideas “What do you think is going on?” -“I think I may have cancer.” Expectations “Did you have specific things you wanted me to consider doing about this today?” - “I was hoping for an antibiotic.” Ideas “What do you think is going on?” -“I think I may have cancer.” Expectations “Did you have specific things you wanted me to consider doing about this today?” - “I was hoping for an antibiotic.” D I S C O V E R Patient has self diagnosis and expectations Ask about:

9 9 The interaction has meaning for the patient and family Thoughts “What is going through your mind?” Feelings “You seem very discouraged. Tell me more. ” Impact on function “How has this affected your day to day life?”” Context of personal and family history “How is your family reacting to all this? ” Thoughts “What is going through your mind?” Feelings “You seem very discouraged. Tell me more. ” Impact on function “How has this affected your day to day life?”” Context of personal and family history “How is your family reacting to all this? ” Ask about: D I S C O V E R

10 10 What is behind the patient’s requests? “What is your understanding of how an MRI could help?” Why is the patient coming in now? Expectations? “How did you decide to come in to see me at this time?” Consider that the patient probably consulted others before the visit clinicians, family, friends, or the internet). “Tell me what you have heard from other clinicians and perhaps family and friends or the internet about this?” What is behind the patient’s requests? “What is your understanding of how an MRI could help?” Why is the patient coming in now? Expectations? “How did you decide to come in to see me at this time?” Consider that the patient probably consulted others before the visit clinicians, family, friends, or the internet). “Tell me what you have heard from other clinicians and perhaps family and friends or the internet about this?” D I S C O V E R Understand expectations and their origins

11 11 Attitudes depend on past experience and anticipations. They leak through. Notice what is going through your own mind? What impact is that having on how you are thinking and behaving? Attitudes depend on past experience and anticipations. They leak through. Notice what is going through your own mind? What impact is that having on how you are thinking and behaving? D I S C O V E R The illness and has meaning for the clinician

12 Compassion is Empathy + It allows care with kindness Patient and family often have a real dilemma  Drug addiction is a tough but solvable problem  Making decisions in the face of uncertainty  Cost of care can be daunting  Hearing different opinions shakes confidence  Lifestyle change is hard (e.g.., weight loss)  A chaotic life makes adherence difficult  Enduring aspects of patient’s lives can make participating in healthcare complicated Personality, culture, disability, psychiatric issues etc. Patient and family often have a real dilemma  Drug addiction is a tough but solvable problem  Making decisions in the face of uncertainty  Cost of care can be daunting  Hearing different opinions shakes confidence  Lifestyle change is hard (e.g.., weight loss)  A chaotic life makes adherence difficult  Enduring aspects of patient’s lives can make participating in healthcare complicated Personality, culture, disability, psychiatric issues etc. 12 Opportunity for Compassion

13 13 Clarify your roles and preferences: “I see myself working with you to make a diagnosis and lay out treatment options. My goal is to agree on a plan that we both feel is safe and effective.” Clarify your roles and preferences: “I see myself working with you to make a diagnosis and lay out treatment options. My goal is to agree on a plan that we both feel is safe and effective.” B O U N D A R I E S Clinician’s perception of role

14 14 Time  “We are out of time for today so let’s summarize what we have agreed upon and be sure we are clear about next steps.” Advocacy  “I will put in that referral for you because I can see that you are still quite worried. The referral may be rejected since they will use the same criteria that I described, but let’s try. OK?” Goals/Objectives/Recommendations  “Tell me what is most important to you and I will be able to give you a clearer picture of what we are usually able to accomplish in difficult situations like this.” Time  “We are out of time for today so let’s summarize what we have agreed upon and be sure we are clear about next steps.” Advocacy  “I will put in that referral for you because I can see that you are still quite worried. The referral may be rejected since they will use the same criteria that I described, but let’s try. OK?” Goals/Objectives/Recommendations  “Tell me what is most important to you and I will be able to give you a clearer picture of what we are usually able to accomplish in difficult situations like this.” B O U N D A R I E S

15 15 Personal  “Here in the office it works best if you call me Dr. O’Connell, since that is the staff and other doctors refer to each other.” Patient Deportment/  “The staff have told me that they sometimes feel disrespected and even threatened when you call or come to the desk very upset. I hope we can agree that we don’t want that, can’t we?” Re-assessing the relationship  “You deserve a doctor with whom you feel comfortable and whose advice you are willing to follow and I am wondering if we are just not a good fit. Can we talk about that?” Personal  “Here in the office it works best if you call me Dr. O’Connell, since that is the staff and other doctors refer to each other.” Patient Deportment/  “The staff have told me that they sometimes feel disrespected and even threatened when you call or come to the desk very upset. I hope we can agree that we don’t want that, can’t we?” Re-assessing the relationship  “You deserve a doctor with whom you feel comfortable and whose advice you are willing to follow and I am wondering if we are just not a good fit. Can we talk about that?” B O U N D A R I E S

16 16 B O U N D A R I E S Responding to difficult requests The clinician must reach conclusion Safety Concerns? Effectiveness ? More harm than good?

17 17 Extend to include others E X T E N D SHARED MEANING What are the sources of help? What are the sources of help? Involve the patient in getting the help Involve the patient in getting the help What help is needed? Including in vs. sending out

18 18 Family members Friends and co-workers Other health care professionals Spiritual advisors Support groups Family members Friends and co-workers Other health care professionals Spiritual advisors Support groups E X T E N D What are the sources of help?

19 19 When will the patient hear from or see you again? Are you including others in your care of the patient or sending the patient out for others to care for? What can patients expect from you now? When will the patient hear from or see you again? Are you including others in your care of the patient or sending the patient out for others to care for? What can patients expect from you now? Extend and get help Referral or collaboration? E X T E N D

20 20 Relationship “difficulties” develop when... S U M M A R Y Success is frustrated Success is frustrated Expectations are misaligned Expectations are misaligned Flexibility is insufficient Flexibility is insufficient

21 Quick Reads Sherri A. Hinchey s and Jackson J. (2011) A Cohort Study Assessing Difficult Patient Encounters in a Walk-In Primary Care Clinic, Predictors and Outcomes. J Gen Intern Med 26(6):588–94 Platt FW and Gordon GH (1999) Field guide to the difficult patient interview. Lippincott: Balt, MD O’Connell, D. (2008 3rd ed.). Behavior Change. In Feldman, M.D. and Christensen, J.F., (eds.), Behavioral Medicine: A guide for clinical practice. 21


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