1. Daniel O’Connell, Ph.D. 1816 1 st Ave. W. Seattle, WA 206 282-1007 danoconn@u.washington.edu 1

2. 2 Managing Difficult Interactions with Patients and Families Adopted with permission from Copyright 1996, rev. 2002, 2005 Institute for Healthcare Communication New Haven, Connecticut

3. 3 Objectives To recognize and diagnose the causes of difficult interactions To learn strategies for navigating difficult interactions more comfortably To choose 2-3 strategies to apply in the next month when sensing a difficult encounter is developing To recognize and diagnose the causes of difficult interactions To learn strategies for navigating difficult interactions more comfortably To choose 2-3 strategies to apply in the next month when sensing a difficult encounter is developing

4. 4 Two or more people How they interact?” What is the difficulty vs. why are you being so difficult? Two or more people How they interact?” What is the difficulty vs. why are you being so difficult? “Difficult” is a function of the interaction P R E M I S E S

5. The Mantra You are not the problem They are not the problem  Although it often seems that way The problem is the problem  So what is the problem? 5

6. 6 Relationship difficulties develop when…. Success is frustrated Success is frustrated Expectations are misaligned Expectations are misaligned Flexibility is insufficient Flexibility is insufficient A M O D E L

7. Questions for patient, family and yourselves Successful outcome:  “What is the outcome that you were hoping for?” Specific expectations:  “Was there something specific that your were hoping we would do now/today about this?” Flexibility:  “How open are you to considering a different approach?” 7

8. A cknowledge and Assess Problems B oundaries - Adjust Compassion – feel it and show it D iscover Meaning – curious not furious E xtend the System – to include others for help vs. send to…. A cknowledge and Assess Problems B oundaries - Adjust Compassion – feel it and show it D iscover Meaning – curious not furious E xtend the System – to include others for help vs. send to…. Procedures to improve situations & relationships

9. 9 Pause to clarify thoughts and feelings Recognize your thoughts, feelings, and their impact. Recognize your thoughts, feelings, and their impact. Acknowledge the difficulty and start to assess its cause and solutions Acknowledge the difficulty and start to assess its cause and solutions A C K N O W L E D G E

10. 10 Success is frustrated Success is frustrated Assess the difficulty Which area(s) What problem's) A C K N O W L E D G E Expectations are misaligned Expectations are misaligned Flexibility is insufficient Flexibility is insufficient

11. Acknowledge the Difficulty to the Patient “I can see that you are feeling frustrated.” “Maybe I haven’t understood you correctly. Let me summarize what I think you have told me and you can correct me when needed.” “I can see that you were hoping there might be a simpler way to address this.” “This is not going the way you expected.” 11 A C K N O W L E D G E

12. 12 Encourage joint problem solving: “I’d like to work with you on this, even though we see some things differently.” “What have other doctors told you about this in the past?” “We will try to make that happen. Let’s also talk about conditions that may call for a different approach” Encourage joint problem solving: “I’d like to work with you on this, even though we see some things differently.” “What have other doctors told you about this in the past?” “We will try to make that happen. Let’s also talk about conditions that may call for a different approach” A C K N O W L E D G E Act to build a partnership

13. 13 Is this a safe and effective way to approach the problem? Is it likely to cause more harm than good? Best practice rather than personal feeling “We have learned…” rather than "I am not comfortable with this…” Is this a safe and effective way to approach the problem? Is it likely to cause more harm than good? Best practice rather than personal feeling “We have learned…” rather than "I am not comfortable with this…” B O U N D A R I E S Find Solid Ground

14. 14 “Let’s think about this together for a moment. I’m open to any approach that has shown to be safe and effective. I just couldn’t allow myself to prescribe something that could cause more harm than good”. B O U N D A R I E S Set limit on yourself, rather than the patient

15. 15 “There are 4 criteria we use to determine if Percocet is the safest and most effective way to treat these problems” “The state wants physicians to use 3 criteria when deciding whether to approve a disability request.” “There are 4 criteria we use to determine if Percocet is the safest and most effective way to treat these problems” “The state wants physicians to use 3 criteria when deciding whether to approve a disability request.” B O U N D A R I E S Clarify your criteria for common requests

16. 16 “For me to be effective though I’m going to need your help. Would you be willing to ________?” “Please try to get here a few minutes before your appt time so we will not be so rushed during your next visit.” “Here in the office I go by Dr. O’Connell.” “For me to be effective though I’m going to need your help. Would you be willing to ________?” “Please try to get here a few minutes before your appt time so we will not be so rushed during your next visit.” “Here in the office I go by Dr. O’Connell.” B O U N D A R I E S Tell patients what you need from them:

17. 17 “ Let me interrupt for a moment to see if I am understanding this correctly.” “Let’s first make a list of your concerns and then we can take then one at a time. OK?” “Maybe you can appoint a spokesperson who can stay with Brenda in the exam room to support her and keep the family up to date. Would that be OK?” “ Let me interrupt for a moment to see if I am understanding this correctly.” “Let’s first make a list of your concerns and then we can take then one at a time. OK?” “Maybe you can appoint a spokesperson who can stay with Brenda in the exam room to support her and keep the family up to date. Would that be OK?” B O U N D A R I E S Interrupt and structure to establish focus if needed

18. 18 Note and manage time proactively “I can see that I am running short of time and wanted to be sure we have a plan in place for the issues we discussed before I have to step out to see another patient.” “I just have a moment now but you have my undivided attention.” Note and manage time proactively “I can see that I am running short of time and wanted to be sure we have a plan in place for the issues we discussed before I have to step out to see another patient.” “I just have a moment now but you have my undivided attention.” B O U N D A R I E S Close boundaries around time

19. 19 Recognize emotional moments “I see you’re upset. Can you tell me what is going through your mind.” Seeing it through the patient’s eyes “It is natural to feel upset at times like these.” Short summaries show understanding “So It seems that this has been getting worse rather than better and you are losing hope for improvement?” Recognize emotional moments “I see you’re upset. Can you tell me what is going through your mind.” Seeing it through the patient’s eyes “It is natural to feel upset at times like these.” Short summaries show understanding “So It seems that this has been getting worse rather than better and you are losing hope for improvement?” Compassion is Empathy + COMPASSION

20. 20 Notice the story you are telling yourself that is upsetting you  Can you be absolutely certain that is true?  How do you feel and act when you tell yourself that story?  How would you be feeling and acting if you told yourself the most compassionate story you could think of consistent with reality? Notice the story you are telling yourself that is upsetting you  Can you be absolutely certain that is true?  How do you feel and act when you tell yourself that story?  How would you be feeling and acting if you told yourself the most compassionate story you could think of consistent with reality? Compassion is Empathy + COMPASSION

21. 21 Ideas, Self Diagnoses, Concerns “What do you think is causing this/making it worse?” -“I think I may have cancer.” Expectations “Was there something specific that you were expecting we would do today for that?” - “I was hoping you’d give me an antibiotic.” Ideas, Self Diagnoses, Concerns “What do you think is causing this/making it worse?” -“I think I may have cancer.” Expectations “Was there something specific that you were expecting we would do today for that?” - “I was hoping you’d give me an antibiotic.” D I S C O V E R The patient/family has expectations for the visit

22. 22 The illness has meaning for the patient Feelings Impact on function Personal meaning Context of personal and family history Feelings Impact on function Personal meaning Context of personal and family history Ask about/pay attention for: D I S C O V E R

23. 23 What is the meaning of the patient’s request? “What were you thinking an MRI scan might reveal?” Why is the patient coming in now? “How did you decide to come in to see me at this time?” Consider that the patient probably consulted others before the visit (family, friends, co-workers, or the internet). “Are there people at home who have an opinion about what is going on here or what we should do next?” What is the meaning of the patient’s request? “What were you thinking an MRI scan might reveal?” Why is the patient coming in now? “How did you decide to come in to see me at this time?” Consider that the patient probably consulted others before the visit (family, friends, co-workers, or the internet). “Are there people at home who have an opinion about what is going on here or what we should do next?” D I S C O V E R The visit has meaning for the patient

24. 24 Attitudes depend on past experience and get projected onto the current visit We tell ourselves a story and that story shapes our emotions and our behavior “They are challenging my expertise.” “They refuse to be responsible.” “They just want to make trouble.” Attitudes depend on past experience and get projected onto the current visit We tell ourselves a story and that story shapes our emotions and our behavior “They are challenging my expertise.” “They refuse to be responsible.” “They just want to make trouble.” D I S C O V E R Clinicians have “hot buttons” -Recognize and own yours- Clinicians have “hot buttons” -Recognize and own yours-

25. 25 Family members Friends and co-workers Other health care professionals Spiritual advisors Support groups Family members Friends and co-workers Other health care professionals Spiritual advisors Support groups E X T E N D Extend the system -When you are not enough-

26. 26 “I think we could use the help of a ____________ to figure this out/better solve this problem” “I would like to get the thoughts of a psychiatrist/psychologist about how we can better help you cope with this. What do you think?” “Perhaps your mother/husband/boyfriend could come to the next visit and we could think this through together. Does that make sense?” “I think we could use the help of a ____________ to figure this out/better solve this problem” “I would like to get the thoughts of a psychiatrist/psychologist about how we can better help you cope with this. What do you think?” “Perhaps your mother/husband/boyfriend could come to the next visit and we could think this through together. Does that make sense?” “Including in” rather than “referring out” E X T E N D

27. 27 Relationship “difficulties” develop when... S U M M A R Y Success is frustrated Success is frustrated Expectations are misaligned Expectations are misaligned Flexibility is insufficient Flexibility is insufficient