Department of Medicine Hartford Hospital

1. Department of Medicine Hartford Hospital Quality Program Morbidity & Mortality Conference January 17th, 2013 This material is confidential and is utilized as defined in Connecticut State statute 19a-17b Section(4) for evaluating and improving the quality of health care rendered

2. Morbidity & Mortality Conference It is for the department faculty and residents to peer review case(s) from the inpatient service. The primary objective is to improve overall patient care focusing on quality of care delivered, performance improvement, patient safety and risk management. This material is confidential and is utilized as defined in Connecticut State statute 19a-17b Section(4) for evaluating and improving the quality of health care rendered

3. Morbidity & Mortality Conference Goals: To review recent cases and identify areas for improvement for (all) clinicians involved Patient complications & deaths are reviewed with the purpose of educating staff, residents and medical students. To identify ‘system issues’, which negatively affect patient care To modify behavior and judgment and to prevent repetition of errors leading to complications. To assess all six ACGME competencies and Institute of Medicine (IOM) Values in the quality of care delivered Conferences are non punitive and focus on the goal of improved and safer patient care This material is confidential and is utilized as defined in Connecticut State statute 19a-17b Section(4) for evaluating and improving the quality of health care rendered

4. Morbidity & Mortality Conference Every Defect is a Treasure This material is confidential and is utilized as defined in Connecticut State statute 19a-17b Section(4) for evaluating and improving the quality of health care rendered

5. Every Defect is a Treasure Errors are due to: Processes – 80% Individuals – 20% Translate all error into education This material is confidential and is utilized as defined in Connecticut State statute 19a-17b Section(4) for evaluating and improving the quality of health care rendered

6. Every Defect is a Treasure I request those that may recognize and may have been involved in the care of patients’ being presented not to take the discussion personally… This material is confidential and is utilized as defined in Connecticut State statute 19a-17b Section(4) for evaluating and improving the quality of health care rendered

7. managing the Difficult Patient Encounter

8. Learning Objectives Identify common characteristics of difficult patients Identifying unconscious physican physician responses to difficult patients and encounters Learn coping strategies for physicians Learn behavioral strategies to cope with difficult patients and encounters

9. Definition The "difficult" medical patient experiences emotions and demonstrates behaviors that interfere with effective medical care. These emotions and behaviors typically evoke negative feelings in caregivers, and this aversive reaction leads to the designation of such patients as "difficult."

10. Who are “difficult” patients? What characteristics make a patient “difficult”? • Mental health disorders • Multiple symptoms or comorbidities • Chronic pain • Functional impairment • Unmet expectations • Lower satisfaction with care • High users of health care services – “frequent fliers” Dr. Tom O’Dowd coined the term “heartsink patient” BMJ, 1988

11. Components of a Difficult Patient Encounter

12. Physician Emotions • Transference v. Countertransference • Hatred of Patients • Typing of Patients

13. Transference vs. Countertransference • Transference=feelings experienced by the patient toward the physician that recapitulate other important relationships within the patient’s life • Countertransference=the analogous emotions experienced by the physician in this relation with the patient

14. Typing of Patients - Grove’s Classification • Dependent clingers • Entitled demanders • Manipulative help-rejecters • Self-destructive deniers Groves, 1978 NEJM

15. Grove’s Classification Sohr, 1996

16. Grove’s Classification Sohr, 1996

17. The CALMER Approach • Physicians must understand how their own attitudes and behavior may contribute. • The CALMER approach assists physicians in reducing distress associated with interactions with problem patients.

18. CALMER C=catalyst for change A=alter thoughts to change feelings L=listen and then make a diagnosis M=make an agreement E=education and follow-up R=reach out and discuss feelings

19. CALMER • Catalyst for Change • See Physicians should remind themselves of what they can and cannot control about the situation. • Physicians cannot control the patient’s behavior, but they can control their own reaction and try to be helpful by offering practical advice. • Alter thoughts (changes feelings) • Discuss patient's specific negative feelings and their impact on the encounter • Providers should also identify their own negative feelings • Listen first (then diagnose) • Eliminate barriers to communication and find ways to improve doctor-patient relationship • Make Agreement • Co-author a health improvement plan with the patient • Education • Set reasonable goals for the next appointment/interaction/day/week. • Reach out • Establish self-care strategy

20. Catalyst for Change The patient needs to go through the cycle of change. Assess what stage they are at and help them get to the next stage.

21. CALMER • Catalyst for Change • See Physicians should remind themselves of what they can and cannot control about the situation. • Physicians cannot control the patient’s behavior, but they can control their own reaction and try to be helpful by offering practical advice. • Alter thoughts (changes feelings) • Discuss patient's specific negative feelings and their impact on the encounter • Providers should also identify their own negative feelings • Listen first (then diagnose) • Eliminate barriers to communication and find ways to improve doctor-patient relationship • Make Agreement • Co-author a health improvement plan with the patient • Education • Set reasonable goals for the next appointment/interaction/day/week. • Reach out • Establish self-care strategy

22. Alter Thoughts to Change Feelings • The only way individuals can control their reactions is to alter their thoughts about the situation. • Physicians should identify which feelings they are experiencing in response to the patient and then ask how these feelings might be affecting the physician-patient relationship and the management plan. • “What can I tell myself about this situation that will make me feel less _______?” Pomm, et al. (2004)

23. Countertransference • Doctor’s attitudes and wishes based on past relationships projected onto present ones. • Everyday occurrence. • Learn to pay attention to your feelings and thoughts about patients. Use them (e.g., if you are anxious, patient may be also). • Try to determine if feeling is “real” or a projection. Common signals of countertransference • Using derogatory labels (“crock,” “druggie”). • Increased use of tests or referrals. • Acting differently than usual (more time, asking more personal questions, avoidance). • Boredom, sleepiness, or irritability. • Excessive positive or negative feelings.

24. CALMER • Catalyst for Change • See Physicians should remind themselves of what they can and cannot control about the situation. • Physicians cannot control the patient’s behavior, but they can control their own reaction and try to be helpful by offering practical advice. • Alter thoughts (changes feelings) • Discuss patient's specific negative feelings and their impact on the encounter • Providers should also identify their own negative feelings • Listen first (then diagnose) • Eliminate barriers to communication and find ways to improve doctor-patient relationship • Make Agreement • Co-author a health improvement plan with the patient • Education • Set reasonable goals for the next appointment/interaction/day/week. • Reach out • Establish self-care strategy

25. Managing Angry Patients • Always address anger; don’t ignore it. • Take a “one down” position and apologize for real transgressions or for not meeting patient’s expectations. • Correct mistakes when possible. • Avoid escalating anger. • Ask patient to speak more slowly since you are having trouble following him. • Assess danger (prior history of violence, escalating behavior, clenching fists, etc.); Get help. • Arrange for both of you to be able to “escape” room if necessary.

26. Leaving Against Medical Advice • The average patient who leaves AMA is young, male, living alone, and has additional medical issues. Psychosocial issues include anger, fear, and psychosis.  • A signed AMA form is not an absolute defense of medical liability. In fact, if the patient left AMA after a dispute with the physician, courts may view the premature discharge as a retaliatory move by the physician and then view the physician as liable.

27. What can we do? • Try to determine why he or she insists on leaving. They may be afraid of being hospitalized or about financial implications, in which case you may be able to offer treatment options that may not require hospitalization. • Identifying family members or friends who might be persuasive can help eliminate the need for an AMA discharge. Even bargaining for time—such as by offering a meal—can be helpful in avoiding an AMA discharge. The added wait may allow the patient to reconsider the decision. • determine whether the patient has the capacity to make the decision to leave AMA. Patients who are under the influence of drugs or alcohol should probably not be allowed to leave. It may be necessary to obtain a psychiatric evaluation to determine mental competency. • In the event that an AMA discharge cannot be avoided, make sure to document that the patient understands the nature of the illness and the consequences of leaving against medical advice. Also document that the patient possesses the mental capability in making this decision.  • Finally, ascertain that the patient does not meet the state standard for involuntary psychiatric hospitalization.

28. 8 Parts of the Safe AMA Process 1. Capacity This term refers to the patient’s medical ability to make a decision. Documenting that the patient “understood” offers little protection, while documenting a patient’s ability to carry on a conversation and demonstrate reason provides a much more compelling example of their capacity to make decisions. Additionally patients should be noted to be clinically sober as a way to support their capacity. Example: “The patient is clinically sober, free from distracting injury, appears to have intact insight and judgment and reason and in my opinion has the capacity to make decisions.” 2. Signs and Symptoms The patient and provider need to agree on both the patient’s symptoms and also the providers concerns. Example: “The patient presents with abdominal pain. I have explained that I am concerned that this may represent appendicitis; they have verbalized an understanding of my concerns.” 3. Extent and Limitation of the Exam Document what has been done as well as the limitations that still exist. Example: “I have told the patient that while their labs were normal, they could still have appendicitis.” 4. Current Treatment Plan Example: “I have discussed the need for a CT scan to get more information about potential causes of the patient’s pain.” 5. Risks of Foregoing Treatment Simply documenting “you could die if you leave” is inadequate. Patient should be informed of reasonably foreseeable complications including disability and death. Specific threats such as loss of fertility for testicular/ovarian pathology or loss of vision for ocular complaints should be included when appropriate. Example: “I have told the patient that if they leave and have appendicitis, they could get much worse, could become critically ill, and could possibly become disabled or die.”

29. 8 Parts of the Safe AMA Process • 6. Alternatives to Suggested Treatment • Providers should clearly document the efforts they have made to prevent the patient from leaving AMA. In addition to alternative diagnostics and treatments, discussions with family and friends can be included. Example: “I have offered to give the patient more pain medication. I have asked them to stay in the hospital for serial abdominal exams. I have offered to have an ultrasound performed instead of a CT scan. I have discussed these concerns with the patient’s wife who is at the bedside and she is unable to convince them to stay for further evaluation.” • 7. Explicit Statement of AMA and About What the Patient Refused • Example: “The patient is not willing to undergo a CT scan. He is unwilling to stay overnight for monitoring. He is refusing any further care and is leaving against medical advice.” • 8. Questions, Follow-up, Medicines, Instructions • When patients leave AMA, providers should do whatever is possible to limit bad medical outcomes. A commonly held misconception is that providing a patient with prescriptions or paperwork somehow negates their AMA status and places the provider at risk. In reality, refusing to provide any discharge medication or instructions only increases the chance that the patient will have a bad outcome, which significantly increases the provider’s risk. For instance, if a patient with pneumonia is leaving AMA, they should be given appropriate antibiotics, and the provider should offer to set up outpatient follow-up. All questions should be answered. Example: “I am unable to convince the patient to stay, I have asked them to return as soon as possible to complete their evaluation. I have spoken with coverage for their primary care doctor in regards to their abdominal pain. I have answered all their questions.”

30. Final Thoughts • If you have been manipulated by a patient, you may be angry with them and yourself. • These feelings are normal and natural. • Once recognized, forgive yourself (we have all been manipulated at one time or another). • Treat manipulation as a symptom and be curious about the cause. • Indentify and adopt strategies to reduce personal stress associated with these encounters and to change patient behavior. • Just don’t say this……

31. QUESTIONS ?