1. Managing Conflict & Negotiation Skills
THERE ARE NOTES ATTACHED TO EACH SLIDE……PLEASE READ THEM
Drs. Ramesh Mehay & Nick Price
Programme Directors (Bradford VTS)

2. Aims the causal factors leading to conflict
systems and strategies that may prevent it
skills in managing conflict positively
to gain a deeper insight into the causal factors leading to conflict
to highlight systems and strategies that may prevent it
to gain some skills in managing conflict positively

3. Scenario
John is a 54 y old man you have been seeing for low back pain and has been getting repeat sick notes from you.
One day, on a home visit to someone else, you see him working in his garden.
You’ve asked him to come in.
Call him in…….
Role play
It’s okay if it all goes pear shaped
This is learning and fun at the end of the day
Three groups of 5-6
Fishbowl type thing?

4. What's all the Fuss? "An exhausting consultation
between a doctor and a patient which
often triggers off some powerful emotions either
in the doctor dealing with them, in the patient or both!”
Hooking the audience into this session

5. And it can affect the next consultation

6. AND

7. You might carry those feelings back home
stress, fear, anger, low morale, helplessness
The patient might feel and take them home too
……and that’s not fair nor good for either of you

8. Can you relate to any of this
Are you hooked?
From you experiences thus far?

9. So, What are we after? A (patient) lose – lose (doctor) aproach ?
A (patient) win – lose (doctor) aproach ?
A (patient) lose – win (doctor) aproach ?
A (patient) win – win (doctor) aproach ?
William Ury, Roger Fisher and Bruce Patton, Getting to Yes: Negotiating Agreement Without Giving in, Revised 2nd edition, Penguin USA, 1991,
The win/win approach demands two commitments:
To work towards better solutions that give everyone more of what they really need in the long term.
To engage in as much consultation and joint decision-making as the situation will allow.

10. The Session Plan from here
Causation
Strategies & Skills to Prevent It
Strategies & Skills to Halt Escalation
Recovery strategies when things go really belly up

11. Causation
Individually: take the next 5 minutes to reflect on a emotionally dysfunctional consultation and the factors you think led to it
In trios, pool together your thoughts and discuss new items (flip chart)
Team up with another trio and pool together your thoughts and discuss new items (flipchart)
Snowballing
Get them either to present the flip chart or shout them out and we list them on a flip chart
Exercise should take 15 minutes

12. Buckets of Shit: Causation
Failing to
ICE
illness vs disease
Missing cues
empathise
Personalities
Language
Egotism
Buckets of Shit: Causation
Unidirectional Consultations
patient
doctor
Before the consultation:
accessibility
conflict with others (other patients, reception)
Doctor running late
ORGANISATION
This slide is to help consolidate what they learned from the snowballing exercise they’ve just done.
Consultations are meant to be a two-way thing (bidirectional). Unidirectional ones can lead to dysfunctional ones.
Christie & Hofmaster (1986) “Ethical Issues in Family Medicine”, American Book
Suggested :
Patient behaviour that annoys the doctor:
Characteristics that violate a physicians personal values, even though they are unrelated to the medical condition or progress of therapy eg laziness, seductiveness, malingering, social bludgers – in other words, those that fail to abide by the “hard work ethic” including self sufficiency, achievement, stoicism and persistence in the face of adversity & exerting rational efforts to improve ones’s situation.
Characteristics that threaten or impede the course of therapy eg non-compliance
Characteristics that threaten a physician’s authority or prestige eg dr shopping
Characteristics that impede the dr-pt communication eg stupidity
Is the most common
The Type of Medical Illness
Conditions for which there is little hope of a cure
Conditions for which there is little hope for significant alleviation eg alcoholism
Conditions that doctors find too challenging eg TATT, headaches
Conditions which doctors feel it is the patients fault anyway eg syphilis, smoking related diseases, alcohol, ilicit drugs
And 2. are the most common
Pull Yourself Together Report (2000), Mental Health Foundation
Questionairre involving 550 patients suffering from mental illness
45% reported discrimination from the GP
Eg GP says “snap out of it” or “I can only help you if you are suicidal!”
Hence 1/5th of patients with mental illness feel they cannot talk to their GP
Request for more resources and funding into training GP’s.
PERSONALITIES
Different people have different personalities and characteristics
Mathers et al (1996) Sheffield Survey of GP’s
65% variance amongst GP’s in their selection of heart sink patients
You can please SOME people ALL of the time BUT
You can never please ALL of the people ALL of the time
What one may regard as difficult, another doctor may not!
Reported a 65% variance amongst a set of GP’s in their selection of heart sink patients.
Doctors who are more likely to label patients as difficult were those that had
Greater percieved workload
Low job satisfaction
A lack of counselling/communication skills
A lack of post graduate qualifications
Patient behaviour that annoys the doctor – Christie & Hofmaster (1986)
“Pull Yourself Together” report (2000), Mental Health Foundation)
Certain Medical Illnessses - Christie & Hofmaster (1986

13. Doesn’t all this remind you of JoHari’s Window?
Things the patient knows
Things the patient don’t know
Things I know about the patient
Arena
Blind spot
Things I don’t know about the patient
Facade
Unknown

14. In trios, think about…….
Things you can do to prevent consultations from going bad
How you can recognise things are going bad
What can you now do to try and stop things getting worse
(15 minutes)

15. REDUCING THE CHANCES OF CONFLICT
CONFLICT PREVENTION
REDUCING THE CHANCES OF CONFLICT
Brainstorm what others had
No need to flip chart as the slides will hopefully pool things together

16. The Calgary Cambridge model
You can’t go wrong! Look…….

17. INITIATION Read the patient’s notes Acknowledge and apologise
for running late etc
“you told me to come in”
Any others?
Establish Rapport – and attend to patient’s comfort (physical, emotional)
Figure out their agenda
Neutralise YOUR feelings
Be aware of your own negative verbal/non verbal cues

18. GATHERING INFORMATION
Explore ICE properly
Figure out the ILLNESS vs disease
Really show EMPATHY
Figure out the patient’s agenda, Identify your agenda, and BLEND the two….(SHARED AGENDA SETTING)

19. EXPLANATION & PLANNING
AVOID PREMATURE REASSURANCE
PITCHING explanation
SHARED planning WITH the patient
CHECK understanding and acceptability (seeking agreement before moving on)
PREMATURE REASSURANCE This is when reassurance is given before adequate information has been obtained, before patients’ concerns have been discovered and before rapport has been developed. Unless we obtain sufficient information first, reassurance may sound false. Unless we understand our patients’ fears, we may be addressing the wrong concern. Unless we have developed rapport with the patient, reassurance may well be interpreted as indifference or as being dismissive. And lastly, unless appropriate and relevant information is provided to back up our reassurance, patients will not understand the basis for our assertions (Kessel 1979).
Reassurance should be
appropriately timed ie not before you’ve done enough information gathering (clinical history + ICE) and examination
properly explained (why you think it so) and
matched to the patient’s concerns. 
Sometimes, without further investigation, it is difficult to reassure the patient about a specific disease. However, we should still be able to reassure that we will give careful attention to their concerns.

20. Paying attention to your language
Prefacing your remarks
“Sounds like…", "So,…", "In other Words…", "You’re saying…"
Avoiding absolute words such as "always" and "never"
Replacing "loaded" words with neutral words.
"wastes time"  "takes time to…"
Using words/phrases that have positive connotations
"She always wastes time"  "You want to work more efficiently.“
Reflecting the emotional tone of the message as well as the words
eg sound like you feel xxx because of yyyy”
Prefacing your remarks with "Sounds like…", "So,…", "In other Words…", "You’re saying…"
Avoiding absolute words such as "always" and "never"
Replacing "loaded" words that carry emotional messages with neutral words. For example "wastes time" could be rephrased as "takes time to…"
Using words and phrases that have positive connotation in the paraphrase. For example "She always wastes time" could be reflected as "You want to work more efficiently."
Reflecting the emotional tone of the message as well as the words. A suggested sentence frame to use in reflective listening is: "Sounds like you feel _______ because ______".

21. Responding to Cues Verbal/Non-verbal
Suchman 1997: patients seldom verbalise their emotions directly and spontaneously, but tend to offer cues instead
Skills to Consider: Encouragement, Silence, Repetition (echoing), Paraphrasing
However, in most of the consultations, the physicians allowed both cues and direct expressions of affect to pass without acknowledgement, returning instead to the preceding topic, usually the direct exploration of symptoms.  
With emotional expressions so terminated, some patients attempted to raise the topic again, sometimes repeatedly and with escalating intensity. 
Conclusion:      We need to be able to recognise when emotions may be present but not directly expressed, invite exploration of these unexpressed feelings and effectively acknowledge these feelings so that the patient feels understood. The frequent lack of acknowledgement by doctors of both direct and indirect expressions of affect poses a threat to the doctor-patient relationship.

22. Following the helical model
ie what I say influences what you say in a spiral fashion (ie what you then say influences whay I say next)
reiteration and repetition
coming back around the spiral of communication at a little different level each time are essential

23. RECOGNISING THE PATIENT WHO’S GOING OFF ON ONE

24. Read the patient continuously
Verbal (HEAR) – tone, pitch, rate, content
I sense that you're not quite happy with the explanations you've been given in the past. Is that right?'
Non-Verbal (SEE) – facial expressions, posture, agitation
'Am I right in thinking you're quite upset about your daughter's illness?‘
Check how you are feeling

25. DE-ESCALATING CONFLICT
BRINGING A STOP TO ESCALATION

26. Principles Take a deep breath, stay calm. Neutralise YOUR feelings
Be aware of you own negative verbal/non verbal cues
Don’t fight anger with anger, Don’t be defensive
Look for the reason for the reaction, remember, it’s often not personal
Recognise and accept the feelings as natural and reasonable
Remember that the irrational component of anger may have it origins from previous experiences and you may need to explore this (with care)

27. Specific Communication Skills
Get down physically to the patient’s level
Feedback what you see or hear
Go back and revisit the patient’s framework + other contributory reasons for the anger (INFO GATHERING)
Listen to the patient’s distress
Express empathy, concern and support
Apologise that they feel upset (and mean it!)
Reformulate the main problems for the patient (INFO GATHERING)
Move on with the patient re: possible solutions, ways forward (JOINTLY) = PLANNING
Offer realistic and achievable help (PLANNING)

28. Try it again………
John is a 54 y old man you have been seeing for low back pain and has been getting repeat sick notes from you.
One day, on a home visit to someone else, you see him working in his garden.
You’ve asked him to come in.
Call him in…….

29. Confrontation with a little C
Sometimes, a little bit of confrontation can be good
eg challenging an attitude, belief or behaviour, to bring something to someone’s attention, an uncomfortable truth
Your aims in this case would be to
Allow the pt to hear and acknowledge you without destroying to Dr-Pt relationship
To address behaviour whilst affirming the patient’s worth as a person
BUT: our own anxiety gets in the way: our past experiences of confrontation (personal and professional) and the present situation lead us to either to sledgehammer or pussyfoot or avoid
Role Play – Fish bowl type thing
Doctor Instructions
Scenario : Sarah Nopes, age 51, morbidly obese
Known COPD 10 years, still smokes 40 per day – smells of fag ash
Getting worse again
Also has arthritis – again worsening
Call her in
PMH : COPD, Arthritis, Morbid Obesity, non exerciser
Call her in……………..
(NB You are allowed to offer her any medication you feel fit – antibiotics, already on inhalers)
Encourage self help – eg stop smoking, exercise
Patient Instructions
Doctor will ask you “How are You” .
Response : In an mellow tone : - “As you can see, I’m out of breath doctor. I think I need some more steroids and antibiotics. I’m also a bit fed up of these pains my legs….they’ve been going on for a while and nothing seems to have worked so far”
“I need you help doctor to sort it out for me”
If depressive symptoms enquired about – respond negatively ie NO to not sleeping, low moods, anhedonia etc etc
Only offer the following information if asked: (again in a MELLOW TONE)
Accept any antibiotics, steroids or incrementation of inhalers.
If smoking advice offered – “I’ve smoked for years and it aint done me any harm. My grandmother lived til 92 and she smoked all of her life…..so I can’t see that smoking is bad. And there was my aunt and friend too…so I really don’t think that will do anything…..and I gave up for 6 months and it didn’t help then either!”
Same for exercise – “ I really don’t feel it would help doctor. Besides, I find it very difficult to exercise now and the local gym charges a fortune..I can’t afford it”
If the doctor asks what you want – suggest antibiotics and steroids.
You worries: just worried that your chest will get bad if you don’t get antibiotics and steroids….they’ve worked before.
PMH : bronchitis, arthtritis ……but you don’t know the specific terms
When doctor offers a treatment….accept any drug treatment. Reject self help measures……show you are not keen on them. Instead of exercise ask for slimming pills. Keep asking “Can You sort this out”.
On Leaving (non-aggressive tone) – “What ever would I do without you doctors to sort my body out”
Facilitator Instructions
Chest – infective exacerbation of COPD signs. Walks without aid, despite morbid obsesity. Pain control – cocodamol 30/500 qds
PMH COPD, Arthritis, morbid obesity
After Role Play :
What sort of patient is this according to Groves? (discuss definition of Self Help Rejector). Why…what sort of characteristics helped you in your classification?
How did she make the doctor feel, can others identify the scenario with their experiences?
What factors before the consultation could you identify that might have led to the dysfunctional consultation.
What bits of the consultation led to doctor feelings
Whose fault – doctor or patient? Why do they behave the way they do?
What good methods did the doctor use to tackle the situation? Any methods of controlling behaviour? Any unhelpful doctor behaviour?
Any other methods the audience can suggest of controlling patient behaviour?

30. How DO You Do IT Then? Be honest, be supportive
Feedback what you have seen or heard directly from the patient – it’s hard to argue with the evidence
BUT
Do this sympathetically…. Heron shows you how…..

31. Heron (1975) says… Signpost your intent
State what the problem is & the effect it has
effect on U and patient, use I statements
State what you would like to happen
and why (eg the benefits for both of you)
Make a valueing statement about the person
separate the pt’s behaviour from them as a person
Overtly demonstrate your care/empathy
Then give plenty of time, ask about feelings, explain difficulty fo u too, negotiate how to move on (planning)
Abnormal consultation
Multiple complaints requiring regular reassurance over minor problems
Abnormal illness behaviour, Abnormal language eg excruciating, violent
Doctor shopping
Hostility
Strong Beliefs
That something is wrong – “you just haven’t found it!”
Demand more services eg referrals and often complain about existing ones
Frequent Ix which are negative
Social Difficulties
Job, home relationships
Chronic Depression
Nothing Works
High level of denial
DR: “Have you tried xxxx” ; PATIENT : “Oh yeah, and it was crap”
Refuses to accept behaviour affects illness and not willing to alter such habits

32. HOW TO RECOVER A STITUATION THAT’S GONE REALLY BAD
CONFLICT RESOLUTION
HOW TO RECOVER A STITUATION THAT’S GONE REALLY BAD

33. Why recover? Let it go??? It is cost saving
Avoids polarization of parties
It is educative thru understanding
Probes wider issues
It promotes fairness
Gives disputants more control over the dispute process

34. Principles You may need a “cooling off” period before engaging
Both parties (Dr and Pt) must be willing to participate
Establish ground rules
Ensure both you and patient understand win =win aim;
own volition into engaging, not enforced
No interrruptions whilst other is talking

36. How to Do IT An agreement to talk about a set agenda
One party speaks without other interrupting
healthy venting of emotions, what the problem is for them
Other party paraphrases what they heard
First party corrects any miscommunication
Process repeats the other way round
What does each party need or want to happen…..in light of what’s been said
Boulle, L (2005) Mediation: Principles Processes Practice, Australia, LexisNexis Butterworths
Get agreement from both people about a basic willingness to fix the problem.
Let each person say what the problem is for them. Check back that the other person has actually understood them.
Guide the conversation towards a joint problem solving approach and away from personal attack.
Encourage them to look for answers where everybody gets what they need.
Redirect "Fouls" (Name Calling, Put Downs, Sneering, Blaming, Threats, Bringing up the Past, Making Excuses, Not Listening, Getting Even)
Where possible you reframe the negative statement into a neutral description of a legitimate present time concern.

37. Key Message
if you resolve conflict positively you can really build upon a foundation of loyalty and trust in the relationship