1. “Difficult” Clinician-Patient Encounters
Monica Brewer
March 2016
B Med Workshop

2. Objectives
Discover the unique perceptual pattern that leads you to label the interaction as “difficult”
Be able to apply practical different techniques for working with “difficult” interactions
Describe four skills: two to acknowledge problems and discover meaning and two to show compassion and adjust boundaries

3. Materials Institute of Health Care Communications IHC
Workshop CME : Patient Centered Communication series 2013
Supported by:
CFPC
Cancer Care Ontario
Merk Frost
Bayer Health Care Corporation
Hamilton Community Foundation

4. “Difficult” Patient? Doctor? System? Illness?
Subjective to the relationship
Discomfort ? Happened
? What might happen

5. model
Patient Clinician
Illness
SYSTEMS

6. Problems Three kinds of problems from the interactions of the
Patient with doctor illness and the system
SUCCESS is frustrated
EXPECTATIONS are misaligned
FLEXEBILITY is insufficient

7. Improve the Relationship ADOBE
Acknowledge a problem
Discover the meaning
Opportunities for Compassion
Boundaries Adjust
Extend the system

8. Acknowledge Problem Sense your distress and say:
“ I get the feeling that this visit is not going the way you hoped . “
“I am having trouble understanding how you would like me to help you.”
“ I would really like to work with you even though we see some things differently.
Can we plan some next steps together?”

9. Discover Meaning FIFE Consider meaning for you :
Does this patient remind me of anyone or a certain situation?
What are your HOT BUTTONS?
Can you see the patient’s perspective?

10. Improve Relationships ADOBE
Acknowledge a problem
Discover MEANING
Opportunities to show compassion
Boundaries Adjust
Extend the system

11. Opportunities for Empathy
Start with being CURIOUS about the patient and their experience with the illness and with the system and with you
Reflect the emotion:
“Correct me if I am wrong but you seem to very frustrated by your experience”
“From what you told me I think I would feel the same way if it had happened to me”
Listen for repetition

12. Opportunities for Empathy
OARS open ended questions; Affirmations; reflections; summaries
Name the core emotion and thought
Verify agreement with facts ,emotions and thoughts
Legitamize thoughts and feelings
Respect and encourage efforts to cope
Offer support and partnership
Build TRUST

13. Boundaries Adjustment
A D O B E
Boundaries : Time Roles Content Space and distance
Is it you?
HALT : Hungry Angry Late Tired
How long has the patient waited?

14. Boundaries Adjustment
Roles Clarification
“What were you hoping I would be able to do for you today?”
“you have quite a bit of experience with doctors, tell me what works best for you?”

15. Boundaries Adjustment
Roles clarification
Clinician role “ I know you want me to fill out your disability papers. My goal is to help you stay active despite your difficult condition.
I could with your permission submit my chart notes to the disability people who will make that decision.”
“For me to be effective I am going to need your help.
Would you be willing to try ………”

16. Boundaries Adjustment
Some boundaries need to be closed
“Mrs Jones, I am not comfortable calling your daughter about your diet”

17. Extend the System Get Help
Family members
Friends and co workers
Other Health Care Providers
Spiritual advisors
Support Groups