1. Difficult Areas in the Consultation Dr Andrew Ashford

2. Aims of session  To IDENTIFY problem areas  To improve our UNDERSTANDING of why they may be difficult  To generate / improve strategies that can –Achieve better outcomes for the patient –Minimise stress for the doctor!

3. Brainstorm!  Flipchart!

4. My list!  Patients with long “lists”  Managing dissatisfaction / anger  The acutely distressed patient  Patients who seem unhelpable!  Demands for specific Rx or management from the outset: “Just refer me to Dr X!”  Rescuing consultations that have become dysfunctional

5. (continued)  Breaking bad news –Awareness of skills –Awareness of what constitutes “bad news”?  How to say “sorry” when things have gone wrong  Managing important problems that emerge late

6. Your list!

7. Doctors and Stress I don’t have all the answers! We probably need to ACCEPT that a certain amount of emotional discomfort & stress is:-  Inevitable  Inherent to our professional role

8. Levels of stress Stress can be understood at different levels:  EXTERNAL –Hours worked, conditions –The boss!  INTERNAL - Our innate qualities that make us –stressed / driven –dependent on continuing relationship with the patient –unable to say “No!”

9. Recognising projection & stress  Weariness  Hopelessness  Tired & irritable  No sense of humour  Inadequacy  Feelings of distress  Growing inefficiency  Sense of drudgery  Depression  Alcohol  Drug abuse  Suicide

10. Innate conflicts for doctors  Wish to be a good considerate doctor v. wish to be considerate to self  Need to care for patients v. need to care for family  Political scene

11. DEFENCE – finding the balance Issues include:-  Dilemma of personal involvement v. draining of own resources  Being over-stressed v. over-defended (“high walls”)  Taking responsibility from patients and carrying it  Overload – shut-off – defensiveness – insensitivity to own / others feelings

12. Defence (2) – self preservation Accept the necessity of SOME defence! -  Appalling injuries  Ill and dying patients (esp. children)  ? Perpetually demanding patients (talk to a policeman!)

13. Hiding our distress  Breaking bad news abruptly / insensitively can be devastating & long-lasting (Finlay & Dallimore 1991)  Patients can be upset by doctors being unmoved by their distress when bad news imparted (Wooley et al 1989) So…  Doctors should not fear displaying emotion (Fallowfield 1993) –How much to share is a difficult judgement –Not the patient’s job to deal with your distress!

14. Problem ownership We are (should be?!) a self-selected group with an inner need to take care of people. NEEDY PEOPLE SENSE THIS - and may therefore wish to transfer responsibility to us whenever possible

15. Avoiding responsibility Patients may fear to take responsibility for their problems because of  The effort involved  Fear!  Relinquishing dependency  “You are supposed to make me better”  Being responsible for consequences of subsequent actions

16. Whose responsibility? If you take inappropriate responsibility for a problem & sort it for the patient… They become stuck with the next one! (Monkey management in business)

17. Shift of emphasis Solving immediate problem for the patient Supporting patient as he discovers why he is not doing his own problem solving

18. The “regular attender” – moving to a new level  Observing the pattern of behaviour –Yours and theirs! –How the consultations run –How they make you feel (projection?) –Patterns of health-seeking behaviour  Reflecting your perceptions back to the patient

19. Common traps! Be clear about the difference between:-  Acceptance & Agreement  Empathy & Sympathy  Saying sorry about & sorry for

20. References  “The One Minute Manager meets the Monkey” – Ken Blanchard  “A Doctor’s Dilemma – stress and the role of the carer” John Holland (ISBN 1-85343-306-3)  “Skills for communicating with patients” (2 nd Edn) Silverman et al  “The doctor, the patient & the illness” Balint  “Games people play” – Byrne & Long  “I Don’t Know What to Say” Dr Robert Buckman