I have no actual I have no actual or potential or potential - - PDF document

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I have no actual I have no actual or potential or potential - - PDF document

Oct 12, 2022 221 likes •418 views

10/17/2017 Denise L. Davis, MD, FAACH Clinical Professor of Medicine UCSF Associate Director for Faculty Development SFVAMC Center of Excellence in Primary Care Education I have no actual I have no actual or potential or potential confli

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10/17/2017 1 Denise L. Davis, MD, FAACH Clinical Professor of Medicine UCSF Associate Director for Faculty Development SFVAMC Center of Excellence in Primary Care Education

I have I have no actual no actual or potential

  • r potential

confli conflict of interest in relatio ct of interest in relation to to this progra this program/presentation. m/presentation.

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10/17/2017 2

Think about a recent success with a difficult patient

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 Share best practices in managing difficult

patient encounters

 Recognize common themes in difficult

encounters

 Review “basic life support” skill in medicine-

communication

 Using your own cases, practice 1-2 new skills

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“To have striven, to have made the effort, to have been true to certain ideals - this alone is worth the struggle. “

William Osler

 Different E

rent Expectati ctations ns

 Anger

Anger

 Cultural Differences/Bias/I

Cultural Differences/Bias/Inequity equity

 Emotional Distress  Psychiatric Disorders  Bad News  Errors  Difficult Doctors  Burnout

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  • How many patient interactions

in your day? In your career? > 200,000 in a lifetime

  • Less training, practice, and

feedback than other less common procedures

  • Difficult patient encounters add

complexity

Health outcomes

Safety

Adherence to treatment plans

Satisfaction with experiences of care

Informed consent

Trust and loyalty

Safran et al, J Fam Pract 1998; Stewart et al, J Fam Pract 2000; Levinson et al, Health Affairs 2010; Dwamena et al, Cochrane Database Syst Rev 2012

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 Engagement  Satisfaction  Workload stress  Medical

malpractice

Levinson et al, JAMA 1997; Krasner et al, JAMA 2009

Skills: Skills:

A.

Create rapport immediately-warm greeting, introductions, roles, use patient’s name, sit down, address comfort

B.

Elicit ALL ALL concerns “What else.. What else..?”

A.

Negotiate the agenda “Could we talk about the abdominal pain now and let your PCP manage your toenail fungus?”

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Skills: Skills:

A.Explore ideas, concerns and

expectations (ICE)

B.Express empathy

 Ask open-ended

questions

 Respond with a summary

  • r empathic statement

 Teach from your

perspective

Schillinger et al, Arch Intern Med 2003; Schenker et al, Med Decis Making 2011

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A 59 yo man with hx alcohol use disorder and HTN is admitted with LLQ pain, fever, WBC 22K and CT consistent with diverticulitis and perforation with intra-abdominal abscess. He wants to go home right now on po abx.

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  • Step 1

Step 1 - Set the Stage et the Stage (Build Rapport, Elicit Agenda, Negotiate Agenda)

  • Step 2

Step 2 - Elicit and Respo licit and Respond to d to Patie Patient’ t’s Perspectives Perspectives (Ideas, Concerns, Expectations) and

Express Empathy

  • Step 3-

Step 3- Negotiate a Negotiate a Shared Plan ARTfully Shared Plan ARTfully (Ask, Respond, Teach)

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“I don't have to attend every argument I'm invited to.”

Author Unknown

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 Think of an angry patient you have seen-

Difficulty level Difficulty level 3-4/10 3-4/10

 In groups of 3, present 1 liner: “I saw a 34 yo

man, angry about waiting for 6 hours in the ED before he was admitted for an obstructing kidney stone.”

 You have 5 minutes for entire group to share

cases

 To earn an A: respond to your colleagues with

empathy!

Use early warning systems STOP and (temporarily) let go

  • f your agenda

Reflective listening Empathy:PEARLS

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  • Avoidance
  • Dread
  • Annoyance
  • Irritation
  • Fatigue
  • Feeling unheard/disrespected

“

N Jensen, P Weiss, AACH

STOP Give up on the apparent task at hand New Objective Listen for feelings and respond actively

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I think I think I hear you sayi hear you saying…” or ng…” or “are you feeli “are you feeling..” g..”

…no one is listening to you …you’re helpless to make things better …you’re afraid she won’t ever be herself again …nothing is going right …you’re worried about what will happen next …you can’t trust us Paraphrasing – listener makes a major restatement in which the speaker’s meaning is inferred “You’re saying it seems like I didn’t care enough about you to take care of your pain. Is what your experience was?”

Adapted from Motivational Interviewing materials by David B. Rosengren, Ph.D. and from Motivational Interviewing by Miller & Rollnick, 1991

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Partnership nership: “I would like to work with you

tonight on making you more comfortable

Empathy Empathy: “This seems like a sad situation

for you”

Apo Apolog

  • gy: “I made a mistake…I’m sorry”

Respect: Respect: “I respect your honesty” Legitimization: gitimization: “Anyone would feel

frustrated in your circumstances.”

Support: Support: “Would______ be helpful?”

AACH Clarke, Fry, Hewson

Made Made empa empathic thic state statemen ents ts Didn Didn’t make ’t make empa empathic thic state statemen ents ts Internists 16 min visits 18 min visits Surgeons 14 min visits 16 min visits

Levinson et al, JAMA 2000; Hojat et al, Acad Med 2011

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“Today was a difficult visit. I would like to work with you to make our visit better when we meet again tomorrow.”

 In groups of 3, using you own case, practice

1-2 skills: reflective listening and empathy statements until the “patient” says “yeah”

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 The incidence of heart failure in young African

American men is 30 times that of young white men (1)

 Compared to neighborhoods with long-term low

poverty, those with long-term high poverty and those that experienced increasing poverty early in the study period had 41% and 37% increased odds

  • f pre-term birth (2)

 Blacks and African Americans suffer from kidney

failure more than 3 times higher than Caucasians. (3)

  • 1. K. Bibbins-Domingo and Others NEJM Med 2009
  • 2. Am J Public Health. 2015
  • 3. 3. National Kidney Foundation 2016
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 Hierarch

Hierarchy: y: “You know your own body. What do you

think would be healthiest for you?”

 Educ

Education: Address “White Coat Silence” with a

menu of common questions (1)

 Ackno

Acknowledg dge: “Though I wish it were not true,

you’re right, African American patients have not received the same quality of care as others”

 Respect:

Respect: “I have a great deal of respect for you and

your openness to talking, given the difficulties you’ve had today.”

 Timing and Trust:

Timing and Trust: “Trust takes time. I want to earn

your trust”

  • 1. Judson JAMA 2013
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