Engaging in difficult conversations around right care Auguste H. Fortin VI Yale School of Medicine Michael Wilkes University of California, Davis School of Medicine

What is patient centered care? Eliciting and understanding patient's perspective—concerns, ideas, expectations, needs, feelings, functioning. Understanding the patient within his or her unique biopsychosocial context. Reaching a shared understanding of the problem and its treatment with the patient that is concordant with the patient's values. Helping patients to share power and responsibility by involving them in choices to the degree that they wish.

Better outcomes through patient-centered communication Diabetes Pain management Adherence to medications Patient satisfaction with care experiences Clinician satisfaction Safran et al, J Fam Pract 1998; Stewart et al, J Fam Pract 2000; Levinson et al, Health Affairs 2010; Dwamena et al, Cochrane Database Syst Rev 2012; Hojat et al, Acad Med 2013; Kennedy et al, Pat Experience J 2014

Clinicians with more patient-centered skills order diagnostic tests less frequently Epstein RM et al. Am Fam Med. 2005;3:

Six steps to patient engagement around Right Care (1) Set agenda to understand patient’s concerns and expectations before addressing them (2) Elicit and validate the patient’s emotions using empathy (3) Inform patient about reassuring features of history and examination (4) Explain that you do not recommend test because risks outweigh benefits (or that you do recommend test because benefit outweighs risk) (5) Negotiate alternatives to testing (6) Explore residual concerns Modified from Fenton JJ et al. JAMA Intern Med. 2016;176:

Chief concern and agenda setting (1-2 min) Indicate time available Forecast what you would like to have happen in the interview Obtain list of all issues patient/parent wants to discuss; e.g., specific symptoms, requests, expectations, understanding Exhaustive “What else?” Summarize and finalize the agenda; negotiate specifics if too many agenda items From Fortin AH VI, Dwamena FC, Frankel RM, Smith RC. Smith’s Patient Centered Interviewing. 3rd ed. New York, McGraw-Hill, 2012.

Emotion-seeking skills: Direct-- Direct-- “How does that make you feel?” or, “How’s this been for you, emotionally?”Indirect: Impact— “How has this (symptom/illness) affected your life/things at home/work?” Belief— “What do you think is causing your problem?” Triggers— “What do you think made it begin when it did?” or “What made you decide to make an appointment/come to the emergency room now?” or “What else is going on in your life?” From Fortin AH VI, Dwamena FC, Frankel RM, Smith RC. Smith’s Patient Centered Interviewing. 3rd ed. New York, McGraw-Hill, 2012.

Empathically Address Emotion: NURS Name— Rename the feeling the patient stated: “Your worried.” Name the emotion you are reading: “You seem worried.” Understand— “I can see how you could be feeling this way. Many people who have headaches are worried that it could be due to something serious.” Respect— “This is a lot to go through.” or “You’ve really been through a lot.” or “I appreciate how you have hung in there with all this.” Support— “Let’s see what we can do together to get to the bottom of this”, or “I want to support you in any way I can.” From Fortin AH VI, Dwamena FC, Frankel RM, Smith RC. Smith’s Patient Centered Interviewing. 3rd ed. New York, McGraw-Hill, 2012.

Symptom Personal Emotional From Fortin AH VI, Dwamena FC, Frankel RM, Smith RC. Smith’s Patient Centered Interviewing. 3rd ed. New York, McGraw-Hill, 2012.

When the going gets tough…

Being Effective in the Face of Strong Emotion Don’t get defensive or retaliate Adapted from DocCom

Being Effective in the Face of Strong Emotion Recognize and Assess the Source of Tension, then: A cknowledge the Difficulty D iscover Meaning O pportunity for Empathy B oundary-setting E xtend the System Modified from Kemp White M, Keller V. JCOM.1998;5:5.

Being Effective in the Face of Strong Emotion A cknowledge the Emotion To Yourself Aloud This will not lead to escalation Not feeling heard arouses anger Adapted from DocCom Modified from Kemp White M, Keller V. JCOM.1998;5:5.

Being Effective in the Face of Strong Emotion D iscover the meaning Recognize anger as a secondary emotion Fear Hurt Disappointment Powerlessness Depression Other physical symptoms that are not obvious Nicotine withdrawal Hunger Pain Adapted from DocCom Modified from Kemp White M, Keller V. JCOM.1998;5:5.

Being Effective in the Face of Strong Emotion O pportunity for Empathy Especially when feeling attacked You can be empathic even if you disagree “I can understand that you would be upset with me for not prescribing the Vicodin, when that’s the main reason you came in today.” Adapted from DocCom Modified from Kemp White M, Keller V. JCOM.1998;5:5.

Being Effective in the Face of Strong Emotion B oundary Setting with Extremely Angry Patients “I’m willing to continue this conversation so long as you exhibit the same respect towards me that I am giving you.” “If you continue to disrupt our ability to conduct care safely in this clinic, I will need to call Security.” Adapted from DocCom Modified from Kemp White M, Keller V. JCOM.1998;5:5.

Being Effective in the Face of Strong Emotion E xtend the System Modified from Kemp White M, Keller V. JCOM.1998;5:5.

Recap Set agenda Listen to story Elicit emotion and NURS it Discuss risks and benefits of requested tests Use ADOBE when the going gets tough!

Bibliography American Academy on Communication in Healthcare (AACH): Egener B. Responding to Strong Emotions. in Novack, Clark and Saizow, eds. DocCom, Webtext Epstein RM et al. Am Fam Med. 2005;3: Fenton JJ et al. JAMA Intern Med. 2016;176: Fortin AH 6th, Dwamena FC Frankel RM, Smith RC. Smith’s Patient Centered Interviewing. 3rd ed. New York, McGraw-Hill, Jackson JL, Kroenke K. Arch Intern Med. 1999;159: White MK and Keller VF. Difficult Clinician-Patient Relationships. Journal of Clinical Outcomes Management.1998;5:32-36.