Faculty

Dan O’Connell, Ph.D.

To reach Dan:

danoconn@uw.edu

206 282-1007

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“Difficult” Clinician-Patient

Interactions

Copyright 1996, rev. 2002, 2005 Institute for Healthcare CommunicationNew Haven, Connecticut

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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

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Two people How they

interact

“Difficult” is a function of the relationship

P R

E M

I S

E S

P R

E M

I S

E S

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Relationship difficulties develop when….

• Success is frustrated

• Expectationsare misaligned

• Flexibilityis insufficientA

M

O D

E L

A

M O

D E

L

Pat

ient

Pat

ient

Clinician

Clinician

ClinicianIllnessIllness

SystemsSystems

““DD””

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Acknowledge and Assess

Discover Meaning

Opportunities for Compassion

Boundaries – Set/Adjust/Negotiate

Extend the System to include others

Use ADOBE to build cooperation

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, email) Explore flexibility: theirs and yours

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Ack

no

wle

dg

e &

Ass

ess

Ack

no

wle

dg

e &

Ass

ess

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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

D I

S C

O V

E R

Patient has self diagnosis and expectations

Ask about:

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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?”

Ask about:

D I

S C

O V

E R

D I

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O V

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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

D I

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O V

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Understand expectations and their origins

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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

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O V

E R

D I

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O V

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The illness and has meaning for the clinician

The illness and has meaning for the clinician

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.

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Op

po

rtu

nit

y fo

r C

om

pas

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nO

pp

ort

un

ity

for

Co

mp

assi

on

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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 bothfeel is safe and effective.”

B O

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B O

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Clinician’s perception of role

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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

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SB

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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

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SB

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B O

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D A

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E S

B O

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D A

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Yes/No

Responding to difficult requests

The clinician must reach conclusion

Safety Concerns?

Effectiveness?More harmthan good?

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Extend to include othersE

X

T

E

N

D

E

X

T

E

N

D

SHARED MEANINGWhat 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?What help is needed?

Including in vs. sending outIncluding in vs. sending out

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Family members

Friends and co-workers

Other health care professionals

Spiritual advisors

Support groups

E

X

T

E

N

DE

X

T

E

N

D

What are the sources of help?

What are the sources of help?

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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 helpExtend and get helpReferral or collaboration?

E

X

T

E

N

DE

X

T

E

N

D

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Relationship “difficulties” develop when...

S U

M M

A R

YS

U M

M A

R Y

Pat

ient

Pat

ient

Clinician

Clinician

Clinician

IllnessIllness

SystemsSystems

““DD””

• Success is frustrated

• Expectationsare misaligned

• Flexibilityis insufficient

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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.