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

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

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
The objectives for the workshop are pretty simple and straightforward. You’ll see these again in the workshop evaluation, so I’m going to leave them up for a minute or two.
The first two are about really paying attention to what kinds of patient encounters and situations you personally find difficult, and what kinds you find rewarding. The last two are about learning some responses that can make these encounters and situations less difficult.
In the evaluation section we’re going to ask you to choose a few of these procedures and practice them until they no longer feel awkward, and then to assess whether or not they are having a positive effect in your work with patients.

4. “Difficult” is a function of the relationship
Two people
How they interact
P R E M I S E S
So, our position is that “difficult” is a function of the relationship, or the way two people interact, rather than a property of either individual.
The reason this distinction is important is that relationships can change, and that changes in behavior of one or both people can make the relationship more successful. This is good news. Otherwise we would always feel helpless and victimized by “those difficult patients.”

5. Relationship difficulties develop when….
Success is frustrated
Expectations are misaligned
Flexibility is insufficient
A M O D E L
Three different things can happen to create difficulty in the clinician-patient relationship.
Once we recognize what the difficulty is, the model can tell us what is feeding it.
First, success can be frustrated. The illness might be one that you and the patient both have difficulty finding success with, such as obesity. Or there might be social or cultural differences in the system making it hard for both of you to achieve success.
Second, expectations can be misaligned. This means that you and the patient have different ideas about what is wrong, what needs to be done, and who should do it. For example, a patient might want you to sign for narcotics or disability for chronic pain, but you think the patient needs to enroll in a chronic pain program and continue working.
Finally, difficult relationships can occur when flexibility is insufficient. For example, a patient might insist on getting test or x-ray results immediately, without waiting for results to be sent to the referring clinician. Or a clinician might have trouble working with patients who get competing advice from an alternative medicine practitioner.

6. Use ADOBE to build cooperation
Acknowledge and Assess
Discover Meaning
Opportunities for Compassion
Boundaries – Set/Adjust/Negotiate
Extend the System to include others
OK, let’s get started. The slides I’m using are under the Acknowledge / Discover tab in your workbooks.
The skills we are going to talk about to help difficult relationships be more successful are organized into 5 categories:
Acknowledge a relationship difficulty
Discover what the problem means to the patient
take Opportunities to show compassion
clarify or adjust Boundaries in the relationship, and
Extend the system, or reach outside of the relationship to get help.
Together these make up a mnemonic, ADOBE, to help us remember and implement them. The next 15 or so slides are on the first two, Acknowledge and Discover.

7. Techniques Acknowledge & Assess
“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
Acknowledge & Assess
“Acknowledge” means acknowledging a difficulty in the relationship - an experience you are both having. It’s different than acknowledging the medical problem (“I acknowledged he was dehydrated so I gave him fluids”) or the patient’s feelings (“I acknowledged he was angry so I empathized”). Instead, “acknowledge” means that one or both of you is finding that the relationship isn’t going the way you had hoped - that there are bumps and detours on this road.
Acknowledge has four steps:
First, being aware of cues and clues that a relationship difficulty exists
Second, assessing which parts of the model are contributing: success frustrated, expectations misaligned, flexibility lacking
Third, making a conscious decision to take on the relationship difficulty as well as other aspects of clinical care, and
Fourth, saying something to the patient about the difficulty and offering to help despite the difficulty.

8. Patient has self diagnosis and expectations
Ask about:
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
We know from research and our own experience that patients have already done some thinking or talking with others about what might be wrong, and what should be done about it. Asking patients about their ideas and expectations is a great way to discover meaning.
If you ask patients what they think is wrong, some will say “I don’t know, that’s why I’m here to see you.” I like to ask people what they have already learned about their problem, or what are they most concerned about.
It’s also very helpful to know what the patient expects you will do for them. It may not be something you want to hear - like “give me narcotics” or “give me disability” - but it gets the “cards on the table” so you and the patient know and agree on what needs to be addressed explicitly.

9. The interaction has meaning for the patient and family
Ask about:
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?”
D I S C O V E R
We think that meaning has four basic components: emotional, functional, symbolic, and contextual. Here are some examples, related to the woman who took a fertility drug and wound up needing a hysterectomy.
The emotional meaning is how she is feeling - furious.
The functional meaning is that she will never be able to have children. She also says “it’s impossible to have sex.”
The symbolic meaning is that she now feels totally worthless, without anything to live for. To her, inability to have a child is a symbol of personal failure.
The contextual meaning is that this affects her relationship with her husband.

10. Understand expectations and their origins
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
The visit itself can have meaning. Here’s an example. One of my patients was furious with me because I wouldn’t prescribe an antibiotic for a cold. He was verbally threatening and abusive. I tried acknowledging our difficulty, explaining that there was nothing to indicate a bacterial infection, and setting boundaries on what I was willing to do. He just kept escalating.
Finally I asked him what was it about the antibiotic that was so important to him. He told me about a time he was nearly put on a ventilator because he had pneumonia and waited too long to be seen. Then he said that his mother had died of pneumonia exactly one year ago that day and that he didn’t make it home in time to say goodbye to her. He left without the antibiotic, but we came to an understanding that day, and our relationship is much less difficult now.

11. D I S C O V E R The illness and has meaning for the clinician
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 has meaning for the clinician, too. Our attitudes depend on our past experience. If your only experience with alcoholic patients has been taking care of GI bleeding in refractory alcoholic liver disease, you will be pessimistic about treating alcoholic patients.
Similarly, you as a clinician may be challenged or bored with the disease. You can get very tired if you are a pediatrician seeing your millionth sore throat, or very challenged if you find the sore throat is because of a leukemia or HIV.
Finally the disease may have a personal meaning for the clinician. When I was a medical intern and my grandmother was at home with congestive heart failure and refusing to go to the hospital, I was admitting little old ladies from the emergency room just to make sure they would do OK. Some got worried or perturbed when I tried to admit them. Only years later did I see that it was my way of trying to take care of my grandmother.

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.
Opportunity for Compassion
Empathy means truly understanding what someone else is feeling. That is different than sympathy, which is what you feel about somebody else (eg, sadness or pity). Usually the first step is simply being curious about the other person’s experience with illness or health care.
Emotional moments aren’t hard to recognize. Patients change their facial expression or posture when they feel angry, sad, or frightened. Sometimes there is a mismatch between what their words and their body language.
We said before that patients tend to repeat themselves until they’ve been heard. Sometimes anger, fear, or sadness drive these repetitions.
We also said that your own feelings can be clues to how the patient is feeling, and remind you to use empathy and compassion.

13. Clinician’s perception of role
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
Sometimes you as the clinician need to clarify the boundaries of your role.
Here the clinician is talking with the “bad back” patient about his disability request. The clinician has several potential roles including documenter of clinical findings, health care provider, and adjudicator or certifier of disability. Some of these roles conflict with each other. For example, it’s hard to encourage a patient to reactivate and rehabilitate on the one hand, while signing for disability on the other. The clinician in this example is very clear that his role is to document findings, help the patient stay active, and discourage disability.

14. B O U N D A R I E S Time Advocacy Goals/Objectives/Recommendations
“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
The second category under “Boundaries” is roles, or who is responsible for what. For example, patients look to their clinicians for help in three general areas: symptoms, goals, and requests. Knowing these categories can help us anticipate and recognize the boundaries of our roles.

15. B O U N D A R I E S Personal Patient Deportment/
“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
The second category under “Boundaries” is roles, or who is responsible for what. For example, patients look to their clinicians for help in three general areas: symptoms, goals, and requests. Knowing these categories can help us anticipate and recognize the boundaries of our roles.

16. B O U N D A R I E S Responding to difficult requests
The clinician must reach conclusion
Safety Concerns?
Yes/No
B O U N D A R I E S
More harm than good?
Effectiveness?

17. Extend to include others
SHARED MEANING
What are the
sources of help?
Involve the patient in
getting the help
What help is needed?
E X T E N D
Usually we send a referral, or send a patient, for help without giving it a second thought. We’d like to challenge that practice, especially for your “difficult relationships” patients. Instead of sending the patient or the referral elsewhere, we’d like you to think of it as inviting someone else into the relationship temporarily. The implications are that you aren’t abandoning the patient or the problem, and that both of you are seeking help for the problem.
There are three questions to consider, before reaching outside of the relationship for help:
What help is needed?
Who can help - what are the sources? And
How will the patient be involved in decisions to get help?
Let’s think about the case of the battered woman on the video. What help would you need as a clinician to work with this woman? What are the sources of help? And how would you include her in getting help?
Including in vs. sending out

18. What are the sources of help?
Family members
Friends and co-workers
Other health care professionals
Spiritual advisors
Support groups
E X T E N D
Here is a list of possible sources of help. Any of these could be potential sources of help for this woman and her clinician. She might have a best friend, a spiritual advisor, a co-worker or family member who is ready to help. Or she might be willing to talk to another woman who has lived through and survived what she is going through now.
How can you begin to involve these people? What is the patient’s role in deciding who should be sources of help, and how they should be involved?

19. E X T E N D Extend and get help Referral or collaboration?
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?
E X T E N D
Since the goal is inclusion of others in the relationship, the agreement should address what will happen to in the relationship itself. When will the clinician and patient talk again? If there is no plan to do so, the clinician needs to insure that Mrs. Z has adequate follow-up for her medical and other care.

20. Relationship “difficulties” develop when...
Success is frustrated
S U M M A R Y
Expectations are misaligned
Flexibility is insufficient
To finish up, I want to review the two of the models we discussed earlier. These are on page 60 of the workbook.
We presented a model of “difficult” clinician-patient relationships. Relationship difficulties can develop around the clinician, the patient, the illness, or a combination, and these difficulties take place in the contexts such as healthcare, home and family, work, and social systems. In particular, we believe the label “difficult” is applied when success is frustrated, expectations are misaligned, or 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.