Daniel O Connell, Ph.D.

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

2. 2 Managing Difficult Interactions with Patients and Families

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 The objectives for the workshop are pretty simple and straightforward. You�ll see these again in the workshop evaluation, so I�m going to leave them up for a minute or two. The first two are about really paying attention to what kinds of patient encounters and situations you personally find difficult, and what kinds you find rewarding. The last two are about learning some responses that can make these encounters and situations less difficult. In the evaluation section we�re going to ask you to choose a few of these procedures and practice them until they no longer feel awkward, and then to assess whether or not they are having a positive effect in your work with patients. The objectives for the workshop are pretty simple and straightforward. You�ll see these again in the workshop evaluation, so I�m going to leave them up for a minute or two. The first two are about really paying attention to what kinds of patient encounters and situations you personally find difficult, and what kinds you find rewarding. The last two are about learning some responses that can make these encounters and situations less difficult. In the evaluation section we�re going to ask you to choose a few of these procedures and practice them until they no longer feel awkward, and then to assess whether or not they are having a positive effect in your work with patients.

4. 4 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 So, our position is that �difficult� is a function of the relationship, or the way two people interact, rather than a property of either individual. The reason this distinction is important is that relationships can change, and that changes in behavior of one or both people can make the relationship more successful. This is good news. Otherwise we would always feel helpless and victimized by �those difficult patients.�So, our position is that �difficult� is a function of the relationship, or the way two people interact, rather than a property of either individual. The reason this distinction is important is that relationships can change, and that changes in behavior of one or both people can make the relationship more successful. This is good news. Otherwise we would always feel helpless and victimized by �those difficult patients.�

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�. Three different things can happen to create difficulty in the clinician-patient relationship. Once we recognize what the difficulty is, the model can tell us what is feeding it. First, success can be frustrated. The illness might be one that you and the patient both have difficulty finding success with, such as obesity. Or there might be social or cultural differences in the system making it hard for both of you to achieve success. Second, expectations can be misaligned. This means that you and the patient have different ideas about what is wrong, what needs to be done, and who should do it. For example, a patient might want you to sign for narcotics or disability for chronic pain, but you think the patient needs to enroll in a chronic pain program and continue working. Finally, difficult relationships can occur when flexibility is insufficient. For example, a patient might insist on getting test or x-ray results immediately, without waiting for results to be sent to the referring clinician. Or a clinician might have trouble working with patients who get competing advice from an alternative medicine practitioner. Three different things can happen to create difficulty in the clinician-patient relationship. Once we recognize what the difficulty is, the model can tell us what is feeding it. First, success can be frustrated. The illness might be one that you and the patient both have difficulty finding success with, such as obesity. Or there might be social or cultural differences in the system making it hard for both of you to achieve success. Second, expectations can be misaligned. This means that you and the patient have different ideas about what is wrong, what needs to be done, and who should do it. For example, a patient might want you to sign for narcotics or disability for chronic pain, but you think the patient needs to enroll in a chronic pain program and continue working. Finally, difficult relationships can occur when flexibility is insufficient. For example, a patient might insist on getting test or x-ray results immediately, without waiting for results to be sent to the referring clinician. Or a clinician might have trouble working with patients who get competing advice from an alternative medicine practitioner.

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. Acknowledge and Assess Problems Boundaries - Adjust Compassion � feel it and show it Discover Meaning � curious not furious Extend the System � to include others for help vs. send to�. Procedures to improve situations & relationships

9. 9 Pause to clarify thoughts and feelings If you start feeling uneasy with a patient, a common response is to �power through� the interaction, drive over the obstacles and hope the difficulty doesn�t stop you. This often increases the difficulty. Instead, step back or pause. You might even step out of the room for a moment to think carefully about what is going on. What is it about this situation that is difficult for you? As one person put it, �Don�t just do something, stand there!� Sometimes your feelings are clues to what is going on. If you�re feeling that things need to be taken care of right away or something awful will happen, chances are the patient feels anxious. If you�re feeling like time is dragging and you�re getting tired and bored, chances are the patient is depressed. If you�re feeling overwhelmed, or irritated, chances are the patient is too. These clues remind you to ask the patient how the visit is going for him/her so far. Commenting on the process of the visit like this can get right to the heart of the matter.If you start feeling uneasy with a patient, a common response is to �power through� the interaction, drive over the obstacles and hope the difficulty doesn�t stop you. This often increases the difficulty. Instead, step back or pause. You might even step out of the room for a moment to think carefully about what is going on. What is it about this situation that is difficult for you? As one person put it, �Don�t just do something, stand there!� Sometimes your feelings are clues to what is going on. If you�re feeling that things need to be taken care of right away or something awful will happen, chances are the patient feels anxious. If you�re feeling like time is dragging and you�re getting tired and bored, chances are the patient is depressed. If you�re feeling overwhelmed, or irritated, chances are the patient is too. These clues remind you to ask the patient how the visit is going for him/her so far. Commenting on the process of the visit like this can get right to the heart of the matter.

10. 10 This model helps you think through what the sources of difficulty might be. First think about which areas might be involved - you, the patient, the illness, or a system that it occurs in. Often it�s more than one area, and not just �the patient�s problem.� Second think about what problems there might be. Is success being frustrated? What is success, anyway? For the �fat genes� patient it�s being able to eat, but for you it�s control of weight and blood pressure. Do you and the patient have the same expectations for care - what is the problem, what caused it, what should be done about it? You might want to recommend a chronic pain program for the patients with migraine or back pain, but they expect narcotics or disability. Finally are either of you being too inflexible? Can the woman who requests an employment physical get one without getting undressed? Maybe one or both of you refuses to take a detour, even though the road is closed. This model helps you think through what the sources of difficulty might be. First think about which areas might be involved - you, the patient, the illness, or a system that it occurs in. Often it�s more than one area, and not just �the patient�s problem.� Second think about what problems there might be. Is success being frustrated? What is success, anyway? For the �fat genes� patient it�s being able to eat, but for you it�s control of weight and blood pressure. Do you and the patient have the same expectations for care - what is the problem, what caused it, what should be done about it? You might want to recommend a chronic pain program for the patients with migraine or back pain, but they expect narcotics or disability. Finally are either of you being too inflexible? Can the woman who requests an employment physical get one without getting undressed? Maybe one or both of you refuses to take a detour, even though the road is closed.

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

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� Act to build a partnership This is where you want to get to, after you�ve become aware of a difficulty, assessed its sources, and agreed to take it on. The basic message is: Even though we are having some difficulty, I would still like to help, can we find some ways to work together? The example here is: �I�d like to work with you, even though we see some things differently.� �Can we plan some next steps together?�This is where you want to get to, after you�ve become aware of a difficulty, assessed its sources, and agreed to take it on. The basic message is: Even though we are having some difficulty, I would still like to help, can we find some ways to work together? The example here is: �I�d like to work with you, even though we see some things differently.� �Can we plan some next steps together?�

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�� Find Solid Ground Sometimes you as the clinician need to clarify the boundaries of your role. Here the clinician is talking with the �bad back� patient about his disability request. The clinician has several potential roles including documenter of clinical findings, health care provider, and adjudicator or certifier of disability. Some of these roles conflict with each other. For example, it�s hard to encourage a patient to reactivate and rehabilitate on the one hand, while signing for disability on the other. The clinician in this example is very clear that his role is to document findings, help the patient stay active, and discourage disability. Sometimes you as the clinician need to clarify the boundaries of your role. Here the clinician is talking with the �bad back� patient about his disability request. The clinician has several potential roles including documenter of clinical findings, health care provider, and adjudicator or certifier of disability. Some of these roles conflict with each other. For example, it�s hard to encourage a patient to reactivate and rehabilitate on the one hand, while signing for disability on the other. The clinician in this example is very clear that his role is to document findings, help the patient stay active, and discourage disability.

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�. Set limit on yourself, rather than the patient Sometimes you as the clinician need to clarify the boundaries of your role. Here the clinician is talking with the �bad back� patient about his disability request. The clinician has several potential roles including documenter of clinical findings, health care provider, and adjudicator or certifier of disability. Some of these roles conflict with each other. For example, it�s hard to encourage a patient to reactivate and rehabilitate on the one hand, while signing for disability on the other. The clinician in this example is very clear that his role is to document findings, help the patient stay active, and discourage disability. Sometimes you as the clinician need to clarify the boundaries of your role. Here the clinician is talking with the �bad back� patient about his disability request. The clinician has several potential roles including documenter of clinical findings, health care provider, and adjudicator or certifier of disability. Some of these roles conflict with each other. For example, it�s hard to encourage a patient to reactivate and rehabilitate on the one hand, while signing for disability on the other. The clinician in this example is very clear that his role is to document findings, help the patient stay active, and discourage disability.

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.� Clarify your criteria for common requests Sometimes you as the clinician need to clarify the boundaries of your role. Here the clinician is talking with the �bad back� patient about his disability request. The clinician has several potential roles including documenter of clinical findings, health care provider, and adjudicator or certifier of disability. Some of these roles conflict with each other. For example, it�s hard to encourage a patient to reactivate and rehabilitate on the one hand, while signing for disability on the other. The clinician in this example is very clear that his role is to document findings, help the patient stay active, and discourage disability. Sometimes you as the clinician need to clarify the boundaries of your role. Here the clinician is talking with the �bad back� patient about his disability request. The clinician has several potential roles including documenter of clinical findings, health care provider, and adjudicator or certifier of disability. Some of these roles conflict with each other. For example, it�s hard to encourage a patient to reactivate and rehabilitate on the one hand, while signing for disability on the other. The clinician in this example is very clear that his role is to document findings, help the patient stay active, and discourage disability.

16. 16 �For me to be effective thoughI�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.� Sometimes you need to tell patients very explicitly what you need from them. Consider the patient who wants a physical for work but cries when asked to disrobe. Or the patient who wants to lose weight but won�t diet or exercise. The clinician needs some flexibility from the patient in order to accomplish the goals. In this example the clinician is clarifying boundaries, using compassion rather than threats: �I�d like to be your clinician and help you with this. For me to be effective, though, I�m going to need your help. Are you willing to �� Sometimes you need to tell patients very explicitly what you need from them. Consider the patient who wants a physical for work but cries when asked to disrobe. Or the patient who wants to lose weight but won�t diet or exercise. The clinician needs some flexibility from the patient in order to accomplish the goals. In this example the clinician is clarifying boundaries, using compassion rather than threats: �I�d like to be your clinician and help you with this. For me to be effective, though, I�m going to need your help. Are you willing to ��

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?� Sometimes you have heard the content before or you don�t feel it is pertinent to your work with the patient. If redirection doesn�t work, close the boundary more explicitly. Here�s one example from the �call my daughter� case, where the doctor makes it clear that he/she doesn�t think that calling the daughter to tell her to take better care of the patient, is something they should talk about further. Another example might be: �I want to discuss Polish specials with you sometime, Ms. X, but first we�d better focus on your heart.�Sometimes you have heard the content before or you don�t feel it is pertinent to your work with the patient. If redirection doesn�t work, close the boundary more explicitly. Here�s one example from the �call my daughter� case, where the doctor makes it clear that he/she doesn�t think that calling the daughter to tell her to take better care of the patient, is something they should talk about further. Another example might be: �I want to discuss Polish specials with you sometime, Ms. X, but first we�d better focus on your heart.�

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.� Occasionally, clinicians have to clarify boundaries very explicitly. One example is the patient whose behavior threatens the safety of himself or others. In the example here, the patient is expressing anger in a way that is personally upsetting to the doctor and perhaps makes him/her feel intimidated. Instead of reciprocal anger, the doctor sets a very clear limit, gives each of them some time to cool off, and describes what will happen if the boundary is crossed when care resumes. Occasionally, clinicians have to clarify boundaries very explicitly. One example is the patient whose behavior threatens the safety of himself or others. In the example here, the patient is expressing anger in a way that is personally upsetting to the doctor and perhaps makes him/her feel intimidated. Instead of reciprocal anger, the doctor sets a very clear limit, gives each of them some time to cool off, and describes what will happen if the boundary is crossed when care resumes.

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?� Compassion is Empathy + Empathy means truly understanding what someone else is feeling. That is different than sympathy, which is what you feel about somebody else (eg, sadness or pity). Usually the first step is simply being curious about the other person�s experience with illness or health care. Emotional moments aren�t hard to recognize. Patients change their facial expression or posture when they feel angry, sad, or frightened. Sometimes there is a mismatch between what their words and their body language. We said before that patients tend to repeat themselves until they�ve been heard. Sometimes anger, fear, or sadness drive these repetitions. We also said that your own feelings can be clues to how the patient is feeling, and remind you to use empathy and compassion. Empathy means truly understanding what someone else is feeling. That is different than sympathy, which is what you feel about somebody else (eg, sadness or pity). Usually the first step is simply being curious about the other person�s experience with illness or health care. Emotional moments aren�t hard to recognize. Patients change their facial expression or posture when they feel angry, sad, or frightened. Sometimes there is a mismatch between what their words and their body language. We said before that patients tend to repeat themselves until they�ve been heard. Sometimes anger, fear, or sadness drive these repetitions. We also said that your own feelings can be clues to how the patient is feeling, and remind you to use empathy and 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? Compassion is Empathy + Empathy means truly understanding what someone else is feeling. That is different than sympathy, which is what you feel about somebody else (eg, sadness or pity). Usually the first step is simply being curious about the other person�s experience with illness or health care. Emotional moments aren�t hard to recognize. Patients change their facial expression or posture when they feel angry, sad, or frightened. Sometimes there is a mismatch between what their words and their body language. We said before that patients tend to repeat themselves until they�ve been heard. Sometimes anger, fear, or sadness drive these repetitions. We also said that your own feelings can be clues to how the patient is feeling, and remind you to use empathy and compassion. Empathy means truly understanding what someone else is feeling. That is different than sympathy, which is what you feel about somebody else (eg, sadness or pity). Usually the first step is simply being curious about the other person�s experience with illness or health care. Emotional moments aren�t hard to recognize. Patients change their facial expression or posture when they feel angry, sad, or frightened. Sometimes there is a mismatch between what their words and their body language. We said before that patients tend to repeat themselves until they�ve been heard. Sometimes anger, fear, or sadness drive these repetitions. We also said that your own feelings can be clues to how the patient is feeling, and remind you to use empathy and 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.� The patient/family has expectations for the visit We know from research and our own experience that patients have already done some thinking or talking with others about what might be wrong, and what should be done about it. Asking patients about their ideas and expectations is a great way to discover meaning. If you ask patients what they think is wrong, some will say �I don�t know, that�s why I�m here to see you.� I like to ask people what they have already learned about their problem, or what are they most concerned about. It�s also very helpful to know what the patient expects you will do for them. It may not be something you want to hear - like �give me narcotics� or �give me disability� - but it gets the �cards on the table� so you and the patient know and agree on what needs to be addressed explicitly. We know from research and our own experience that patients have already done some thinking or talking with others about what might be wrong, and what should be done about it. Asking patients about their ideas and expectations is a great way to discover meaning. If you ask patients what they think is wrong, some will say �I don�t know, that�s why I�m here to see you.� I like to ask people what they have already learned about their problem, or what are they most concerned about. It�s also very helpful to know what the patient expects you will do for them. It may not be something you want to hear - like �give me narcotics� or �give me disability� - but it gets the �cards on the table� so you and the patient know and agree on what needs to be addressed explicitly.

22. 22 The illness has meaning for the patient Feelings Impact on function Personal meaning Context of personal and family history We think that meaning has four basic components: emotional, functional, symbolic, and contextual. Here are some examples, related to the woman who took a fertility drug and wound up needing a hysterectomy. The emotional meaning is how she is feeling - furious. The functional meaning is that she will never be able to have children. She also says �it�s impossible to have sex.� The symbolic meaning is that she now feels totally worthless, without anything to live for. To her, inability to have a child is a symbol of personal failure. The contextual meaning is that this affects her relationship with her husband. We think that meaning has four basic components: emotional, functional, symbolic, and contextual. Here are some examples, related to the woman who took a fertility drug and wound up needing a hysterectomy. The emotional meaning is how she is feeling - furious. The functional meaning is that she will never be able to have children. She also says �it�s impossible to have sex.� The symbolic meaning is that she now feels totally worthless, without anything to live for. To her, inability to have a child is a symbol of personal failure. The contextual meaning is that this affects her relationship with her husband.

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?� The visit has meaning for the patient The visit itself can have meaning. Here�s an example. One of my patients was furious with me because I wouldn�t prescribe an antibiotic for a cold. He was verbally threatening and abusive. I tried acknowledging our difficulty, explaining that there was nothing to indicate a bacterial infection, and setting boundaries on what I was willing to do. He just kept escalating. Finally I asked him what was it about the antibiotic that was so important to him. He told me about a time he was nearly put on a ventilator because he had pneumonia and waited too long to be seen. Then he said that his mother had died of pneumonia exactly one year ago that day and that he didn�t make it home in time to say goodbye to her. He left without the antibiotic, but we came to an understanding that day, and our relationship is much less difficult now. The visit itself can have meaning. Here�s an example. One of my patients was furious with me because I wouldn�t prescribe an antibiotic for a cold. He was verbally threatening and abusive. I tried acknowledging our difficulty, explaining that there was nothing to indicate a bacterial infection, and setting boundaries on what I was willing to do. He just kept escalating. Finally I asked him what was it about the antibiotic that was so important to him. He told me about a time he was nearly put on a ventilator because he had pneumonia and waited too long to be seen. Then he said that his mother had died of pneumonia exactly one year ago that day and that he didn�t make it home in time to say goodbye to her. He left without the antibiotic, but we came to an understanding that day, and our relationship is much less difficult now.

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.� The illness has meaning for the clinician, too. Our attitudes depend on our past experience. If your only experience with alcoholic patients has been taking care of GI bleeding in refractory alcoholic liver disease, you will be pessimistic about treating alcoholic patients. Similarly, you as a clinician may be challenged or bored with the disease. You can get very tired if you are a pediatrician seeing your millionth sore throat, or very challenged if you find the sore throat is because of a leukemia or HIV. Finally the disease may have a personal meaning for the clinician. When I was a medical intern and my grandmother was at home with congestive heart failure and refusing to go to the hospital, I was admitting little old ladies from the emergency room just to make sure they would do OK. Some got worried or perturbed when I tried to admit them. Only years later did I see that it was my way of trying to take care of my grandmother. The illness has meaning for the clinician, too. Our attitudes depend on our past experience. If your only experience with alcoholic patients has been taking care of GI bleeding in refractory alcoholic liver disease, you will be pessimistic about treating alcoholic patients. Similarly, you as a clinician may be challenged or bored with the disease. You can get very tired if you are a pediatrician seeing your millionth sore throat, or very challenged if you find the sore throat is because of a leukemia or HIV. Finally the disease may have a personal meaning for the clinician. When I was a medical intern and my grandmother was at home with congestive heart failure and refusing to go to the hospital, I was admitting little old ladies from the emergency room just to make sure they would do OK. Some got worried or perturbed when I tried to admit them. Only years later did I see that it was my way of trying to take care of my grandmother.

25. 25 Family members Friends and co-workers Other health care professionals Spiritual advisors Support groups Here is a list of possible sources of help. Any of these could be potential sources of help for this woman and her clinician. She might have a best friend, a spiritual advisor, a co-worker or family member who is ready to help. Or she might be willing to talk to another woman who has lived through and survived what she is going through now. How can you begin to involve these people? What is the patient�s role in deciding who should be sources of help, and how they should be involved? Here is a list of possible sources of help. Any of these could be potential sources of help for this woman and her clinician. She might have a best friend, a spiritual advisor, a co-worker or family member who is ready to help. Or she might be willing to talk to another woman who has lived through and survived what she is going through now. How can you begin to involve these people? What is the patient�s role in deciding who should be sources of help, and how they should be involved?

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?� Since the goal is inclusion of others in the relationship, the agreement should address what will happen to in the relationship itself. When will the clinician and patient talk again? If there is no plan to do so, the clinician needs to insure that Mrs. Z has adequate follow-up for her medical and other care. Since the goal is inclusion of others in the relationship, the agreement should address what will happen to in the relationship itself. When will the clinician and patient talk again? If there is no plan to do so, the clinician needs to insure that Mrs. Z has adequate follow-up for her medical and other care.

27. 27 Relationship �difficulties� develop when... To finish up, I want to review the two of the models we discussed earlier. These are on page 60 of the workbook. We presented a model of �difficult� clinician-patient relationships. Relationship difficulties can develop around the clinician, the patient, the illness, or a combination, and these difficulties take place in the contexts such as healthcare, home and family, work, and social systems. In particular, we believe the label �difficult� is applied when success is frustrated, expectations are misaligned, or flexibility is insufficient. To finish up, I want to review the two of the models we discussed earlier. These are on page 60 of the workbook. We presented a model of �difficult� clinician-patient relationships. Relationship difficulties can develop around the clinician, the patient, the illness, or a combination, and these difficulties take place in the contexts such as healthcare, home and family, work, and social systems. In particular, we believe the label �difficult� is applied when success is frustrated, expectations are misaligned, or flexibility is insufficient.