“Difficult” Clinician-Patient Encounters Monica Brewer March 2016 B Med Workshop

Objectives Discover the unique perceptual pattern that leads you to label the interaction as “difficult” Be able to apply practical different techniques for working with “difficult” interactions Describe four skills: two to acknowledge problems and discover meaning and two to show compassion and adjust boundaries

Materials Institute of Health Care Communications IHC Workshop CME : Patient Centered Communication series 2013 Supported by: CFPC Cancer Care Ontario Merk Frost Bayer Health Care Corporation Hamilton Community Foundation

“Difficult” Patient? Doctor? System? Illness? Subjective to the relationship Discomfort ? Happened ? What might happen

model Patient Clinician Illness SYSTEMS

Problems Three kinds of problems from the interactions of the Patient with doctor illness and the system SUCCESS is frustrated EXPECTATIONS are misaligned FLEXEBILITY is insufficient

Improve the Relationship ADOBE Acknowledge a problem Discover the meaning Opportunities for Compassion Boundaries Adjust Extend the system

Acknowledge Problem Sense your distress and say: “ I get the feeling that this visit is not going the way you hoped . “ “I am having trouble understanding how you would like me to help you.” “ I would really like to work with you even though we see some things differently. Can we plan some next steps together?”

Discover Meaning FIFE Consider meaning for you : Does this patient remind me of anyone or a certain situation? What are your HOT BUTTONS? Can you see the patient’s perspective?

Improve Relationships ADOBE Acknowledge a problem Discover MEANING Opportunities to show compassion Boundaries Adjust Extend the system

Opportunities for Empathy Start with being CURIOUS about the patient and their experience with the illness and with the system and with you Reflect the emotion: “Correct me if I am wrong but you seem to very frustrated by your experience” “From what you told me I think I would feel the same way if it had happened to me” Listen for repetition

Opportunities for Empathy OARS open ended questions; Affirmations; reflections; summaries Name the core emotion and thought Verify agreement with facts ,emotions and thoughts Legitamize thoughts and feelings Respect and encourage efforts to cope Offer support and partnership Build TRUST

Boundaries Adjustment A D O B E Boundaries : Time Roles Content Space and distance Is it you? HALT : Hungry Angry Late Tired How long has the patient waited?

Boundaries Adjustment Roles Clarification “What were you hoping I would be able to do for you today?” “you have quite a bit of experience with doctors, tell me what works best for you?”

Boundaries Adjustment Roles clarification Clinician role “ I know you want me to fill out your disability papers. My goal is to help you stay active despite your difficult condition. I could with your permission submit my chart notes to the disability people who will make that decision.” “For me to be effective I am going to need your help. Would you be willing to try ………”

Boundaries Adjustment Some boundaries need to be closed “Mrs Jones, I am not comfortable calling your daughter about your diet”

Extend the System Get Help Family members Friends and co workers Other Health Care Providers Spiritual advisors Support Groups