Continuing Medical Education of Southern Oregon - PowerPoint Presentation

Slide1

Continuing Medical Education of Southern Oregon

Conversations as Medicine

(AKA Difficult Conversations)

INTRO

Laura Heesacker, LCSW

May 20

th

, 2016Slide2

I have nothing to declare in regards conflicts of interestWe all are rapidly using up our supply of pens and cupsSlide3

Laura’s 3 Truths

It is human nature to want to avoid things that are difficultWhen it comes to prescription opioids for chronic non-cancer pain, we can’t afford to avoid it anymoreIt is possible to turn a difficult conversation into medicineSlide4

Clinicians:

“ I am concerned about you and your medical conditions, both for your pain control but also for your safety. Oxycodone is no longer a good choice for either.”Slide5
Slide6

When a person’s survival skills are so fine tuned it feels like manipulation

ReframeSlide7

Does it ever feel like you have stepped into a trap?Slide8

Patient: ”Do you want me to suffer? Is that what you want?

” (Compassion Trap)Slide9

“You’re cutting me off and I have to live with my pain?”

(All or Nothing Trap)Slide10

“Are you accusing me of being an addict?”

Addiction Labeling TrapSlide11

“Don’t bother with any other meds, I’ll just kill myself.”

Desperate/Threatening TrapSlide12

General Objectives

Increased confidence in managing patients in challenging situationsIncreased understanding that having “The Difficult Conversation” will lead to both patient and provider enhanced satisfaction.Increased awareness of patient’s issues and agendasIncreased ability to engage the patient in a plan that will have a measurably improved functional outcomeSlide13

Difficult Conversations CyclesSlide14
Slide15

Difficult DISCUSSIONs

with patients:  How to Have a Positive OutcomeLee S. Glass, MDAssociate Medical DirectorDepartment of Labor & IndustriesSlide16

Disclosure #1

I have no financial conflicts of interest to discloseNo relationships with any company or organization, other than Washington StateSlide17

Difficult Discussions

Some of the most important moments in medicine involve communicationSome of the most important communications are sometimes avoidedDiscomfort, or fear of discomfort, is often the cause of communication avoidance in medicineWe are likely to be more successful as physicians if we can initiate difficult discussions in a manner that is comfortable and effective for all concernedSlide18

Definition

“Difficult Discussion”: A conversation, That involves content that may generate a negative emotional response in or from one or more parties, but which, if not conducted, will have consequences that one or more parties considers unfortunate or undesirable. Slide19

Goals

Understand the role that “difficult discussions” may play in the practice of medicineUnderstand some ways in which one can prepare for a difficult discussionLearn techniques that maximize the likelihood that a difficult discussion will have a mutually satisfactory outcome.Slide20

Disclosure #2

Nobody’s perfectWhat follows are conceptsMost of the concepts outlined below I learned through mistakesI made some mistakes more than onceOdds are great that some days we won’t do so well implementing the conceptsSuggestion: Keep practicing!Slide21

Difficult Discussion

Condition: Inexplicable swelling of the non-dominant hand, sharply demarcated at the level of the wrist.Followed early DIP then MCP amputations, 3rd digit, non-dominant handPatient sought amputation at level of wrist Differential Diagnosis: CRPS vs. factitious disorderOptions:Medical: continue workupLegal: litigateSlide22

Difficult Discussion

Option selected: Hospitalize and treatOutcome: Treatment sabotagedNoted in the chart: appearance of a band-like constriction at the level of the wristPatient’s explanation: elastic cuff on jacket sleevePhysician’s response: bilateral cuffs; unilateral swellingFinal Diagnosis: CRPSSlide23

Difficult Discussion

Outcome (2 years later):Per attorney: “He hasn’t killed himself yet”“Family is ruined”“He hasn’t killed himself yet”“The kids have problems”“He hasn’t killed himself yet”Slide24

Difficult Discussion

Why this outcome:Doctors involved were not trained in having difficult discussions with patientsHospital professional staff not trained in having difficult discussions (with doctors or patients)The system allowed all involved to ignore the diagnosis of “factitious disorder” made by pain clinic psychologistSlide25

Difficult Discussions

What are they?Necessary verbal communications that are, or are anticipated to beUncomfortable or difficult for one or more participantsSettings – anywhereExam roomHomeWorkEtc.Slide26

When They Don’t Happen

Opportunities are missedRelationships sufferProfessionalCollegialFamilialSupervisorySlide27

Why They Don’t Happen

Discomfort: One or more potential participants fear discomfort:AngerLossRevengePhysicalEconomicEmbarrassment Etc.Slide28

How We Avoid Them

DenialThere is no problemNot my jobAvoidanceDon’t return phone calls or lettersBody English (e.g. stand in doorway)IntimidationDemeanorContent of speech Slide29

Why They Don’t Happen

“There’s no problem::One or more potential participants are blinded as to the need for a discussion“Pain” doctor prescribing 120 mg of morphine/day for back pain not precipitated by an injuryPatient (28 y.o. F) lost custody of 8 y.o. son 2 yrs before; on opioids last 1.5 years.When doctor was asked why father has custody, he answered: “Mother had a drug abuse problem.”Slide30

Why They Don’t Happen

One or more potential participants view difficult discussions as “not my job”Surgeon: will not delve into patient’s prior history of sexual abuseSurgeon: “not my job” to arrange for psychological treatment for severely depressed “surgical candidate”“Pain doctor” will not call primary care physician regarding psychological issuesSlide31

Difficult Discussions: Goals

Build, strengthen, or repair a relationshipProfessionalFamilySupervisoryStrategicAchieve health care goale.g. assent for substance abuse treatmente.g. discuss spousal abuse issuesEtc.Slide32

Difficult Discussions: Goals

Relationship is strengthened or advancedStrategic goal is achieved or agreeably modifiedFeel good when the discussion is overYou feel goodOthers feel goodSlide33

Difficult Discussions: Preparation

What is the best time to prepare for the next difficult discussion?NowWhy “now”?Because there may be a lot to doBecause nobody knows when the next difficult discussion will ariseSlide34

Difficult Discussions: Preparation

Major categories of preparation:SelfExpectationsLogisticsSlide35

Difficult Discussions: Preparation

SelfThe most important, by farThe only part of the process over which any of us have complete controlThe part of the process most likely to produce – or not produce! – comfortSlide36

Difficult Discussions: Preparation

SelfWho am I?Honesty – with self and othersTrust – of self and othersCommitment – What kind? How much? For how long?Comfort – How comfortable are you?With yourself?With your patients?With their problems?Slide37

Difficult Discussions: Preparation

SelfUpon what foundation will you build the discussion?Scientific / professionalKnowledgeTrainingSkillExperiencePersonalCommunication skillsValue / belief systemResources (e.g. available time, etc.)Slide38

Difficult Discussions: Preparation

SelfStrategic analysisFirst have to have a clear understanding of goals:Question: “What am I really trying to achieve?”Flows from goalsQuestion: “What is the best strategy to achieve my goals?”Slide39

Difficult Discussions: Preparation

PatientStart relationship on firm foundationOnly if it meets both parties’ needs will it lastPatient’s needs may not be fully understood initiallyPatient’s needs may change over timeExpectation settingFirst visit, whenever possibleClear, unambiguousTied to the patient’s best interestsConsequences of unmet expectations are clear to patientSlide40

THE TAKE-HOME MESSAGE

If an industrial injury is involved, the most important expectation is the role of the physicianPhysician is patient advocateAdvocates for care that is necessary to treat the effects of the industrial injury or occupational diseaseWhat the patient needs and what the patient wants may differDoctors advocate for medical needsLawyers advocate for patient wantsSlide41

Difficult Discussions: Preparation

LogisticsTimeEnd of day versus during normal clinic day?45 minutes versus 6 minutes?PlaceExam room?Office or conference room?Teleconference?ParticipantsPatient only?Others: Spouse? Employer? Etc.Slide42

Process

Principal ConsiderationsTrustComfortClarityIssue identificationSlide43

Trust

Cornerstone of the relationshipShould be a two-way streetBut patient MUST be able to trust the doctorShould be established as quickly as possibleI tell injured workers: “There are only four rules to which I have never found an exception, and the first is that patients never look like their medical records suggest.”Care should be taken to avoid ambiguities that might detract from trustSlide44

Process

ComfortCriticalFoundation for relationshipMaximizes chances for effective communicationMaximizes chances for maintaining a healthy physician/patient relationshipMinimizes risk of harmTo physician by patient (e.g. litigation, negative publicity)To patient by physician (e.g. damage to therapeutic relationship)Slide45

Process

Comfort – ContributorsSettingRespectful of patient? (e.g. exam room versus office)Physically comfortable? (e.g. chair versus exam table)Interruptions versus quietudeSupport for patient (e.g. spouse or other advisor present?)Slide46

Process

Comfort – ContributorsTimingOf the discussionBeginning or middle of day?Last appointment of day?In relationship to the issueA single event at issue?An established pattern at issue?Something in between?Slide47

Process

Comfort – ContributorsMoodPatient’s moodYour moodSlide48

Process

Comfort – ContributorsYour attitudeIs it what you want it to be?Is it likely to be clear to the patient?Difference between spoken words and body English?Will you be perceived as truthful and fair?Will you be perceived as trying to build a good relationship?What tone are you communicating? Slide49

Process

Comfort – ContributorsAdvanced noticeCan help reduce fearCan set stage for a win-win discussionAllows both patient and physician to prepare for discussionTo the alcoholic patient: “Let’s schedule you to come back in a week to take out the stitches. Let’s also plan to talk about why you fell. I promise you that you’ll feel a lot better after we talk than you felt after your fall.”Slide50

Process

ClarityThe basis of effective communicationOften perceived as present when actually absent“What you thought you heard me say is not what I had intended to communicate.”Three critical elements:Words that were spokenWords that were heardMeaning that was given by patient to words that were heardSlide51

Process

ClarityWords that are spokenCome from our background of knowledge – not shared by most patientsMay have cultural connotations that may or may not shared by the patientMay contain vocabulary not understood by the patientSlide52

Process

ClarityWords that are heardWhat is being said?Patient may not hear the words – e.g. what is heard following the word “cancer” may not be all that was saidWords will be processed – processing speed may be much slower than the flow of the spoken wordsWhy is it being said?Motivation may be misunderstood – e.g. previously abused patient may feel that words are hurtfulWho is listening?For the words to be truly understood, the patient may need others (e.g. spouse, adult child) to hear what is being said Slide53

Process

ClarityMeaning will be given to the words that were heardThe meaning will be created by the listener(s)This is the meaning that will be the basis for the listener’s decision-makingCorrelation with intended meaning may be poorSlide54

Process

ClarityNeed for clarity cannot be over-emphasizedToolsTry to use the patient’s vocabularyConsider the patient’s trade or profession and create analogiesConsider the patient’s level of educationTry to test patient’s level of understandingAsk questions that will provide feedback regarding understandingRepetition of fundamental points may be helpfulTry to have all necessary listeners presentSlide55

Content

Infinite variation in discussion content, butTwo important themes are invariant:1) Trust, always2) Comfort, to the greatest extent possibleContent should be reflective of the above themesHow can my words and actions most build trust?How can my words and actions help create comfort?Slide56

Content

Motive identificationBest to verbalize motivation at the outsetExample: Patient seeks surgery that doctor feels is unlikely to relieve patient’s chronic back painScenario 1: “I wouldn’t be doing my job as a doctor if I didn’t raise some pretty challenging issues regarding future treatment. Shall we explore them?”Motive – clearly stated – “I want to be a good doctor”Slide57

Content

Motive identificationBest to verbalize motivation at the outsetScenario 2: “I realize this might be upsetting to you, but I really don’t think you will be benefited by surgery, and I am not prepared to schedule back surgery for you.”Motive – unstated. Patient may conjure up any motivation to apply to the doctor’s message.You don’t like me…You’re just trying to save money for the insurance company…Etc.Slide58

Content

Issue IdentificationAgreement on issue identification is criticale.g. Patient focus on falls, physician focus on alcoholismMay need to connect falls to alcoholism as first stepe.g. High-dose opioid prescriber may cite standard of practice as explanation for prescribing problemIssues of safety and effectiveness may have to be discussed firstIssue clarificationSingle event?Pattern of behavior?Involve honesty or trust?Type of response will differ with types of issuesSlide59

Content

Content: establishing issues should be factualFacts can be powerful; you can harness that powerIf accurately stated, facts can usually be acceptedContrast:If I have heard you correctly, you have had three convictions for DWI, and you spent 10 days in jailYou have simply got to stop drinking and drivingSlide60

TAKE-HOME MESSAGE

Delivery should usually be unemotional and non-judgmentalGoal: Decision-making by cortex, not amygdalaContrast:Once the newspaper printed the story that you had been charged with child molestation, your daughter has found it difficult to maintain her friendships at her school.What you did was a matter of choice, but you know that you made a very bad choice when you did it.Slide61

Content

Tentative delivery can help minimize negative reactionsGoal: Decision-making by cortex, not amygdalaContrast:I am wondering if one possible solution might be ….What you need to do is ….Slide62

Content

Questions can help patients verbalize difficult realizationsLooking back on it all now, when do you think you first saw signs that your son was using drugs?Knowing what you know now, what would you tell another father to look out for, in raising a teenager?Slide63

Content

A focus on the patient’s interests may facilitate acceptance of your thoughts:Let’s consider the pluses of your not having the test, on the one hand, to the minuses on the other…It’s hard to have to start making decisions for a partner you have shared a lifetime with. Would it help to talk about what your wife might say, if we could ask her?Slide64

Listening

We all want to be heard and understood.Clarifying strategies can be very helpful:Help me understand why that is important to you…I heard you say …. – did I get that right?You seem a bit uncomfortable – was my question upsetting to you?Slide65

When our buttons are pushed

Patients with personality disorders many seek control through putting others on the defensive. Reduce the risk of being defensive by:Considering why the patient is adopting such a tacticFear that needs won’t be met? Concern that interests won’t be understood?Asking ourselves if we have anything about which to feel defensiveIf so, perhaps that could be put on the table for discussionSlide66

Summary

Know who you areKnow exactly what you want to achieveUtilize a process that develops trust and comfortListen carefully and activelyContent should be responsive to motivationRemember: It is often easier to be right than to do the right thing