Transcript Difficult conversations with patients: How to Have a Positive Outcome

Continuing Medical Education of Southern Oregon
Conversations as
Medicine
(AKA Difficult
Conversations)
INTRO
Laura Heesacker, LCSW
May 20th, 2016
I have nothing to declare in regards conflicts of interest
• We all are rapidly using up our supply of pens and
cups
Laura’s 3 Truths
1. It is human nature to want to avoid
things that are difficult
2. When it comes to prescription
opioids for chronic non-cancer pain,
we can’t afford to avoid it anymore
3. It is possible to turn a difficult
conversation into medicine
Clinicians:
“ I am concerned about you
and your medical conditions,
both for your pain control
but also for your safety.
Oxycodone is no longer a
good choice for either.”
When a
person’s
survival skills
are so fine
tuned it feels
like
manipulation
Reframe
Does it ever feel like you have stepped
into a trap?
Patient: ”Do you want me
to suffer? Is that what
you want?”
(Compassion Trap)
“You’re cutting me off
and I have to live with my
pain?”
(All or Nothing Trap)
“Are you accusing me of
being an addict?”
Addiction Labeling Trap
“Don’t bother with any
other meds, I’ll just kill
myself.”
Desperate/Threatening
Trap
General Objectives
1) Increased confidence in managing patients
in challenging situations
2) Increased understanding that having “The
Difficult Conversation” will lead to both
patient and provider enhanced
satisfaction.
3) Increased awareness of patient’s issues
and agendas
4) Increased ability to engage the patient in a
plan that will have a measurably improved
functional outcome
Difficult Conversations Cycles
Learning
Objectives
(15 Min)
Patient/Provider
Demo
All Group
Process (10
Min.)
(poor)
(10 Min.)
Teamlette
Breakout
Practice
(10 min.)
All Group
Process
(10 Min.)
DIFFICULT DISCUSSIONS WITH
PATIENTS:
How to Have a Positive Outcome
Lee S. Glass, MD
Associate Medical Director
Department of Labor & Industries
Disclosure #1
• I have no financial conflicts of interest to
disclose
• No relationships with any company or
organization, other than Washington State
Difficult Discussions
• Some of the most important moments in medicine
involve communication
• Some of the most important communications are
sometimes avoided
• Discomfort, or fear of discomfort, is often the cause
of communication avoidance in medicine
• We are likely to be more successful as physicians if we
can initiate difficult discussions in a manner that is
comfortable and effective for all concerned
Definition
• “Difficult Discussion”:
– A conversation,
– That involves content that may generate a negative
emotional response in or from one or more parties,
– but which, if not conducted,
– will have consequences that one or more parties
considers unfortunate or undesirable.
Goals
• Understand the role that “difficult
discussions” may play in the practice of
medicine
• Understand some ways in which one can
prepare for a difficult discussion
• Learn techniques that maximize the likelihood
that a difficult discussion will have a mutually
satisfactory outcome.
Disclosure #2
• Nobody’s perfect
• What follows are concepts
• Most of the concepts outlined below I learned
through mistakes
• I made some mistakes more than once
• Odds are great that some days we won’t do so
well implementing the concepts
• Suggestion: Keep practicing!
Difficult Discussion
• Condition: Inexplicable swelling of the nondominant hand, sharply demarcated at the
level of the wrist.
– Followed early DIP then MCP amputations, 3rd
digit, non-dominant hand
– Patient sought amputation at level of wrist
• Differential Diagnosis: CRPS vs. factitious
disorder
• Options:
– Medical: continue workup
– Legal: litigate
Difficult Discussion
• Option selected: Hospitalize and treat
• Outcome: Treatment sabotaged
• Noted in the chart: appearance of a band-like
constriction at the level of the wrist
– Patient’s explanation: elastic cuff on jacket sleeve
– Physician’s response: bilateral cuffs; unilateral
swelling
• Final Diagnosis: CRPS
Difficult Discussion
• Outcome (2 years later):
– Per attorney:
•
•
•
•
•
“He hasn’t killed himself yet”
“Family is ruined”
“He hasn’t killed himself yet”
“The kids have problems”
“He hasn’t killed himself yet”
Difficult Discussion
• Why this outcome:
– Doctors involved were not trained in having
difficult discussions with patients
– Hospital professional staff not trained in having
difficult discussions (with doctors or patients)
– The system allowed all involved to ignore the
diagnosis of “factitious disorder” made by pain
clinic psychologist
Difficult Discussions
• What are they?
– Necessary verbal communications that are, or are
anticipated to be
– Uncomfortable or difficult for one or more
participants
• Settings – anywhere
–
–
–
–
Exam room
Home
Work
Etc.
When They Don’t Happen
• Opportunities are missed
• Relationships suffer
– Professional
– Collegial
– Familial
– Supervisory
Why They Don’t Happen
• Discomfort: One or more potential
participants fear discomfort:
– Anger
– Loss
– Revenge
• Physical
• Economic
– Embarrassment
– Etc.
How We Avoid Them
• Denial
– There is no problem
– Not my job
• Avoidance
– Don’t return phone calls or letters
– Body English (e.g. stand in doorway)
• Intimidation
– Demeanor
– Content of speech
Why They Don’t Happen
“There’s no problem::
• One or more potential participants are blinded
as to the need for a discussion
– “Pain” doctor prescribing 120 mg of morphine/day
for back pain not precipitated by an injury
– Patient (28 y.o. F) lost custody of 8 y.o. son 2 yrs
before; on opioids last 1.5 years.
– When doctor was asked why father has custody, he
answered: “Mother had a drug abuse problem.”
Why They Don’t Happen
• One or more potential participants view
difficult discussions as “not my job”
– Surgeon: will not delve into patient’s prior history
of sexual abuse
– Surgeon: “not my job” to arrange for psychological
treatment for severely depressed “surgical
candidate”
– “Pain doctor” will not call primary care physician
regarding psychological issues
Difficult Discussions: Goals
• Build, strengthen, or repair a relationship
– Professional
– Family
– Supervisory
• Strategic
– Achieve health care goal
• e.g. assent for substance abuse treatment
• e.g. discuss spousal abuse issues
• Etc.
Difficult Discussions: Goals
• Relationship is strengthened or advanced
• Strategic goal is achieved or agreeably modified
• Feel good when the discussion is over
– You feel good
– Others feel good
Difficult Discussions: Preparation
• What is the best time to prepare for the next
difficult discussion?
– Now
• Why “now”?
– Because there may be a lot to do
– Because nobody knows when the next difficult
discussion will arise
Difficult Discussions: Preparation
• Major categories of preparation:
– Self
– Expectations
– Logistics
Difficult Discussions: Preparation
• Self
– The most important, by far
– The only part of the process over which any of us
have complete control
– The part of the process most likely to produce – or
not produce! – comfort
Difficult Discussions: Preparation
• Self
– Who am I?
•
•
•
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Honesty – with self and others
Trust – of self and others
Commitment – What kind? How much? For how long?
Comfort – How comfortable are you?
– With yourself?
– With your patients?
– With their problems?
Difficult Discussions: Preparation
• Self
– Upon what foundation will you build the discussion?
• Scientific / professional
–
–
–
–
Knowledge
Training
Skill
Experience
• Personal
– Communication skills
– Value / belief system
– Resources (e.g. available time, etc.)
Difficult Discussions: Preparation
• Self
– Strategic analysis
• First have to have a clear understanding of goals:
– Question: “What am I really trying to achieve?”
• Flows from goals
– Question: “What is the best strategy to achieve my goals?”
Difficult Discussions: Preparation
• Patient
– Start relationship on firm foundation
• Only if it meets both parties’ needs will it last
• Patient’s needs may not be fully understood initially
• Patient’s needs may change over time
– Expectation setting
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•
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First visit, whenever possible
Clear, unambiguous
Tied to the patient’s best interests
Consequences of unmet expectations are clear to patient
THE TAKE-HOME MESSAGE
• If an industrial injury is involved, the most
important expectation is the role of the physician
– Physician is patient advocate
• Advocates for care that is necessary to treat the effects of the
industrial injury or occupational disease
– What the patient needs and what the patient wants
may differ
• Doctors advocate for medical needs
• Lawyers advocate for patient wants
Difficult Discussions: Preparation
• Logistics
– Time
• End of day versus during normal clinic day?
• 45 minutes versus 6 minutes?
– Place
• Exam room?
• Office or conference room?
• Teleconference?
– Participants
• Patient only?
• Others: Spouse? Employer? Etc.
Process
• Principal Considerations
– Trust
– Comfort
– Clarity
– Issue identification
Trust
• Cornerstone of the relationship
– Should be a two-way street
• But patient MUST be able to trust the doctor
– Should be established as quickly as possible
• I tell injured workers: “There are only four rules to which I
have never found an exception, and the first is that
patients never look like their medical records suggest.”
– Care should be taken to avoid ambiguities that might
detract from trust
Process
• Comfort
– Critical
• Foundation for relationship
• Maximizes chances for effective communication
• Maximizes chances for maintaining a healthy
physician/patient relationship
• Minimizes risk of harm
– To physician by patient (e.g. litigation, negative publicity)
– To patient by physician (e.g. damage to therapeutic
relationship)
Process
• Comfort – Contributors
– Setting
•
•
•
•
Respectful of patient? (e.g. exam room versus office)
Physically comfortable? (e.g. chair versus exam table)
Interruptions versus quietude
Support for patient (e.g. spouse or other advisor present?)
Process
• Comfort – Contributors
– Timing
• Of the discussion
– Beginning or middle of day?
– Last appointment of day?
• In relationship to the issue
– A single event at issue?
– An established pattern at issue?
– Something in between?
Process
• Comfort – Contributors
– Mood
• Patient’s mood
• Your mood
Process
• Comfort – Contributors
– Your attitude
• Is it what you want it to be?
• Is it likely to be clear to the patient?
–
–
–
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Difference between spoken words and body English?
Will you be perceived as truthful and fair?
Will you be perceived as trying to build a good relationship?
What tone are you communicating?
Process
• Comfort – Contributors
– Advanced notice
•
•
•
•
Can help reduce fear
Can set stage for a win-win discussion
Allows both patient and physician to prepare for discussion
To the alcoholic patient: “Let’s schedule you to come back
in a week to take out the stitches. Let’s also plan to talk
about why you fell. I promise you that you’ll feel a lot
better after we talk than you felt after your fall.”
Process
• Clarity
– The basis of effective communication
• Often perceived as present when actually absent
– “What you thought you heard me say is not what I had intended to
communicate.”
• Three critical elements:
– Words that were spoken
– Words that were heard
– Meaning that was given by patient to words that were heard
Process
• Clarity
– Words that are spoken
• Come from our background of knowledge – not shared by
most patients
• May have cultural connotations that may or may not shared
by the patient
• May contain vocabulary not understood by the patient
Process
• Clarity
– Words that are heard
• What is being said?
– Patient may not hear the words – e.g. what is heard following the
word “cancer” may not be all that was said
– Words will be processed – processing speed may be much slower
than the flow of the spoken words
• Why is it being said?
– Motivation may be misunderstood – e.g. previously abused patient
may feel that words are hurtful
• Who is listening?
– For the words to be truly understood, the patient may need others
(e.g. spouse, adult child) to hear what is being said
Process
• Clarity
– Meaning will be given to the words that were heard
• The meaning will be created by the listener(s)
• This is the meaning that will be the basis for the listener’s
decision-making
• Correlation with intended meaning may be poor
Process
• Clarity
– Need for clarity cannot be over-emphasized
– Tools
• Try to use the patient’s vocabulary
– Consider the patient’s trade or profession and create analogies
– Consider the patient’s level of education
• Try to test patient’s level of understanding
– Ask questions that will provide feedback regarding understanding
– Repetition of fundamental points may be helpful
• Try to have all necessary listeners present
Content
• Infinite variation in discussion content, but
• Two important themes are invariant:
– 1) Trust, always
– 2) Comfort, to the greatest extent possible
• Content should be reflective of the above themes
– How can my words and actions most build trust?
– How can my words and actions help create comfort?
Content
• Motive identification
– Best to verbalize motivation at the outset
• Example: Patient seeks surgery that doctor feels is unlikely
to relieve patient’s chronic back pain
• Scenario 1: “I wouldn’t be doing my job as a doctor if I
didn’t raise some pretty challenging issues regarding future
treatment. Shall we explore them?”
– Motive – clearly stated – “I want to be a good doctor”
Content
• Motive identification
– Best to verbalize motivation at the outset
• Scenario 2: “I realize this might be upsetting to you, but I
really don’t think you will be benefited by surgery, and I am
not prepared to schedule back surgery for you.”
– Motive – unstated. Patient may conjure up any motivation to apply
to the doctor’s message.
» You don’t like me…
» You’re just trying to save money for the insurance company…
» Etc.
Content
• Issue Identification
– Agreement on issue identification is critical
• e.g. Patient focus on falls, physician focus on alcoholism
– May need to connect falls to alcoholism as first step
• e.g. High-dose opioid prescriber may cite standard of
practice as explanation for prescribing problem
– Issues of safety and effectiveness may have to be discussed first
• Issue clarification
– Single event?
– Pattern of behavior?
– Involve honesty or trust?
• Type of response will differ with types of issues
Content
• Content: establishing issues should be factual
– Facts can be powerful; you can harness that power
– If accurately stated, facts can usually be accepted
• Contrast:
– If I have heard you correctly, you have had three convictions for
DWI, and you spent 10 days in jail
– You have simply got to stop drinking and driving
TAKE-HOME MESSAGE
• Delivery should usually be unemotional and nonjudgmental
– Goal: Decision-making by cortex, not amygdala
– Contrast:
– Once the newspaper printed the story that you had been charged
with child molestation, your daughter has found it difficult to
maintain her friendships at her school.
– What you did was a matter of choice, but you know that you made
a very bad choice when you did it.
Content
• Tentative delivery can help minimize negative
reactions
– Goal: Decision-making by cortex, not amygdala
– Contrast:
• I am wondering if one possible solution might be ….
• What you need to do is ….
Content
• Questions can help patients verbalize difficult
realizations
– Looking back on it all now, when do you think you
first saw signs that your son was using drugs?
– Knowing what you know now, what would you tell
another father to look out for, in raising a teenager?
Content
• A focus on the patient’s interests may facilitate
acceptance of your thoughts:
– Let’s consider the pluses of your not having the test,
on the one hand, to the minuses on the other…
– It’s hard to have to start making decisions for a
partner you have shared a lifetime with. Would it
help to talk about what your wife might say, if we
could ask her?
Listening
• We all want to be heard and understood.
• Clarifying strategies can be very helpful:
– Help me understand why that is important to you…
– I heard you say …. – did I get that right?
– You seem a bit uncomfortable – was my question
upsetting to you?
When our buttons are pushed
• Patients with personality disorders many seek
control through putting others on the defensive.
Reduce the risk of being defensive by:
– Considering why the patient is adopting such a tactic
• Fear that needs won’t be met? Concern that interests
won’t be understood?
– Asking ourselves if we have anything about which to
feel defensive
• If so, perhaps that could be put on the table for discussion
Summary
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•
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Know who you are
Know exactly what you want to achieve
Utilize a process that develops trust and comfort
Listen carefully and actively
Content should be responsive to motivation
Remember: It is often easier to be right than to
do the right thing