Approaches and Solutions to Tough Conversations

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Michigan Medicine - May/June 2016

By Veronica Gracia-Wing for Michigan State Medical Society

How do I talk about ...

Noncompliance?
Patient termination?
Patient satisfaction quality scores?
Drug diversion?
Disagreements with colleagues?
End-of-life care?

Physicians are increasingly called upon to engage in meaningful communication, both with patients and colleagues. With more and more demands and what seems like not enough hours in the day, how can we ensure the toughest of conversations are productive for everyone involved? Difficult, emotional conversations are a regular part of the physician's day -- read on to learn from your colleagues and other professionals about their tried and true approaches to tough conversations.

Pino D. Colone, MD, FACEP
Emergency Department Service Chief, Henry Ford West Bloomfield Hospital

What advice do you have as it relates to patient noncompliance?

This has been a very challenging question throughout time. I encourage students and residents to identify what is important to patients, what motivates them. When you try to find out what connects with the patient and offer feedback in a non-dictatorial way, you can have a greater impact on their care. Offering incremental steps for change is also an important approach.

For example, if I'm working with a morbidly obese teenager, I might talk to them about the importance of controlling their blood sugar as it relates to things like impotence. For incremental change, we'll talk about reducing eating fast food from five days a week to cutting down to three. Just telling them to stop the noncompliance isn't helpful. You've got to figure out what their priorities are and avoid setting them up for failure.

How do you use and incorporate patient satisfaction quality scores?

An ever increasingly important question ... Surveys have their limitations and the response rate isn't always great, but we always try to use feedback for improvement. As part of the leadership that reviews and is held accountable for that data, I also hold my staff accountable for the results. We use the data in our regular staff meetings, focusing in on the patient experiences as opposed to the score itself. I find that when you look at the experience first, the score will follow.

Typically we'll talk about what the scores are for the month, exploring the why behind the scores. It's an opportunity to make positive experiences for your staff and patients.

How do you address patient drug diversion?

This is a problem that has been growing in Michigan, and has hit us harder than in many other states. I believe the drug diversion trend stems from the late '90s concept of pain being the fifth vital sign, and the Federal government encouraging physicians to be more aggressive in the treatment of pain. This has, in part, led to the epidemic of overprescribing and the everyday problem of drug abuse. I encourage my physicians and physician assistants to use the Michigan Automated Prescription System and address the patient directly. We'll often offer a non-narcotic alternative, and, if the patient is willing, refer them to a drug treatment on the spot at a facility on our hospital campus.

How do you approach end-of-life care conversations as an emergency medicine physician?

Unfortunately it's an all too familiar conversation. So many times a critically ill patient has not had the discussion with other providers or family members about their wishes for end-of-life care. In the emergency room, we address particular concerns they might have, as well as understanding with specificity the level of intervention they're willing to accept.

We need to help patients understand what their options are and what each of those options mean. The time to have these kinds of conversations is not when something dramatic happens, but when patients can have an understanding of the situation.

Throughout all of these conversations, we want to ensure we're respecting patient wishes and approach the matter in a kind and caring way, emphasizing that our primary concern is their well-being. If you don't focus on patient well-being, then you run the risk of alienating a patient, compromising the dynamic and increasing your risk of noncompliance.

What is your advice on how to handle a situation where you see a colleague not performing their best?

The shadow you cast can take many forms. I believe in leading by example and come in to the ER positive and approachable, which fosters an environment of the same mood and tone. This helps in the understanding that if there is a decision to be made, and my staff doesn't agree, that ultimately the decision is mine. They respect that.

I want every conversation to be educational. I'm always open to collaboration and believe all relationships are founded in communication. We work together to build a solid foundation of communication, collaboration and cooperation. To do that, I address situations and behaviors directly. We leave little room for mixed messages or the perception that not performing well is acceptable.

My preference is one-on-one, situational coaching. If it's a procedure or management issue, we can talk about Continuing Medical Education and the vast resources available to them. If it's interpersonal interactions, we talk about what the specific behavior was and why it happened. We set up the expectations together so they have frame of reference for the future. If it turns out to be an ongoing conversation, then we'd talk about a performance improvement plan. Depending on the issue, management becomes more and more formal, but the overwhelming majority are individual conversations.

How do you handle conversations about the all too common issue of physicians not taking care of their own health and wellness?

I also handle this directly, even though I think it's probably easier to ignore. I have a good read of people and can sense a change in baseline mood or how they're interacting with others.

I'll express my concern to the individual and offer them the opportunity to open up. I let them know that I am a resource for them, and acknowledge that I'm seeing something out of character.

I believe in a healthy work-life balance and professional satisfaction. We spend a lot of time at work, so if I can improve satisfaction on this front, I will do it. I will often advocate for an individual or the department, and report back what the results of those discussions were, which helps builds creditability and validates concerns. It's important to me to take a genuine interest in my staff's families and make it more than just about work. It's impossible to completely separate our two lives, so being satisfied at work is a very important measure. I want my people to be happy.

I make the time as I'm working clinically, walking through departments and touching base. This takes interest and motivation, but not a lot of time. If something is important enough, you make the time -- whether it's five minutes or an hour.

Leading by example and casting a positive shadow encourages others to do the same. The smallest interaction is going to have a lasting impact.

Edward Christy, MD, CMD, FACP, FAAHPM, AGSF, MBA
Medical Director, Heart to Heart Hospice, Durand Rehabilitation Center, Shiawassee Medical Care Center, Genesee Care Center, Medilodge of Montrose, Whitehills Convalescent Center

What steps do you take when a patient doesn't comply with orders?

This matter needs serious improvement, because it is too easy for patients to not comply and slip through the cracks of care. I see this as a major system failure that makes patient noncompliance too common. As physicians, we prescribe medicine and then forget about everything else. I'm just as guilty as anyone, forgetting about things like exercise and diet. But we simply don't have enough people in the office to follow up with patients closely on the little things.

Why and how do you terminate a patient relationship?

I most typically terminate because of patient drug abuse; specifically those who are doctor shopping for pain medication. I have never discontinued care because of noncompliance. For those patients who we've identified using the MAPS, we'll have a sit-down conversation to show them the evidence, and clearly let them know that we are unable to help them.

How do you approach conversations about end-of-life care as a hospice provider?

I collect as much information about the patient as possible. I will find out what the patient knows about the disease. So much of the time the patient has not had anyone put together everything that is going wrong.

First I try talking with one person, moving to the next of kin if the patient is unable to have this conversation. That information is then brought to the next sit-down conversation.

At this second sit down with the patient and any family, we collect goals of treatment and goals of care, identifying what those goals are together to create a care plan. During these conversations, I strive to validate the opinions of everyone present and listen actively. After all this, I put a plan in place and explain what the possibilities are related to each care element and what the joint expectations are. I try to make these conversations as relaxed as possible. The care plan and goals are the focus during subsequent conversations to avoid confusion.

What is your advice on how to handle a situation where you see a colleague not performing their best?

In these matters, I try to collect as much data as possible, identifying exact details and dates associated with the incident. After this, I'll sit down to lunch or dinner with a colleague to discuss what happened. It's important to me to try to understand the "why" from my colleague's point of view before we discuss what went wrong. After getting input, I'll then explain different perception of the situation so we can find a solution together.

Robert Jackson, MD
Family Physician, Western Wing Physicians, Allen Park Medical Director, Medical Advantage Group, East Lansing

How do you handle matters where you don't necessarily agree with a colleague?

I think physicians have a hard time pointing fingers at one another. You want to make sure you're right before saying someone is wrong. I think it's hard to judge things with minimal information, so I go into those conversations with calmness, great empathy for everyone and data. When you go into those conversations with solid data and mutual interest in helping each other do better, the outcome is better.

It isn't always easy. With data you can show what may be lacking. Address what you know and what you don't in these conversations. It's a priority to get a colleague to improve performance rather than have a patient irreparably harmed and a physician unable to provide good medical care.

With tough conversations, I suggest we look for solutions rather than accusations. Anyone who has had performance issues at work can appreciate that kind of process. You need to be fair to the physician, the community and to the patients they're seeing.

How do you handle conversations about the all too common issue of physicians not taking care of their own wellness?

To be honest, sometimes it's hard for me to see if others aren't taking that all-important time for themselves. If I do, I talk with them about needing to find joy in what we're doing as physicians and helping them identify ways to find a work-life balance.

Physicians may work a lot of hours, but we have the ability to do a lot that's extraordinarily meaningful and fills our hearts. It's important that we're honest about that. If you see hints of a colleague struggling with balancing their professional and personal lives, you've got to have those conversations based in figuring out how to improve it, and help them change their situation.

Perspective: End-of-life care and advance care planning
Carolyn Stramecki
Director, Honoring Healthcare Choices - Michigan

Understanding the core strength of advance care planning and how it is to be utilized, is vastly different from the tasks that can be marked off with a checkmark at the onset of a patient encounter.

Be a part of the care process.

ACP is not the equivalent of a traditional code status conversation or determination. Rather, it is a process of communication that should occur throughout a person's lifespan with regularity and at times with spontaneity. This process of communication assists individuals in understanding their own choices for future health care; allows the person to reflect on his/her values; allows them time to discuss with their providers, caregivers, family, patient advocate and loved ones; and may involve choosing a patient advocate.

ACP is not intended to be a part of prognostication; of giving news, good or bad. It uses various communication techniques, shared decision-making and evidence based language to illicit treatment options that align with the person's self-identified acceptable goals of care. Providers are often not afforded the time based on business models to respectfully hold these conversations. The reality of the constraints put upon them as revenue generators leaves little opportunity to effectively provide this service without assistance. Having a skilled, certified facilitator to conduct the time-consuming pieces of the ACP conversation can be of great benefit to a provider. The facilitator (typically a social worker, nurse or clergy), can spend time with the patient, patient advocate and loved ones over multiple sessions, which may result in the completion of an advance directive, a Michigan Physician Orders for Scope of Treatment form, or if warranted an out-of-hospital Do Not Resuscitate form.

The role of the providers in the ACP process is to:

  • Provide the patient with information about the diagnosis and prognosis prior to a scheduled ACP facilitation.
  • Introduce the topic of ACP as a standard of care and suggest the patient have a conversation. Remind the patient and family that to offer the good care that is desired, it needs to be discussed and shared.
  • Trust in the partnership formed with certified facilitators.
  • Answer questions and clarify information as a follow-up to facilitation as needed.
  • Acknowledge the hopes of the person and identify those that clinically can be supported.
  • Verify and sign medical orders (MI-POST, DNR form) if created.
  • Review with patients regularly.
  • Ask for the information when treating a patient.

Perspective: Honest and authentic approaches to tough conversations
Sandy Carter, MBA, PhD
Professional Certified Coach, The Center for Physician Leadership Coaching

I often see physicians are at the edge of their skill set - skills such as emotional intelligence, understanding their strengths or vulnerabilities haven't traditionally been taught in their educational or training programs. Physicians may lack confidence in dealing with conflict and interpersonal communication skills, such as how to deliver feedback and being empathic with one another. They may also feel stuck and externalize the problem, feeling overreactive and victimized. This is no surprise as traditional training focuses on rigor and often disconnecting from vulnerability.

Having these conversations requires practice and a willingness to fail. This is challenging for physicians who have been sued or shamed for failing and can associate danger with failing. Honest and authentic conversations invite us to be vulnerable. Physicians' environments are stressful with time constraints, large workloads, etc. and it becomes easy to rationalize and put things off that we anticipate will be hard.

Tough conversations are risky because we can't be sure of the outcome. If we attempt a conversation and it doesn't go as intended or hoped, we can feel rejected, attacked or misunderstood. We could even hurt others and/or damage the relationship with people we have to work with daily in stressful and intense environments.

It's important to have these kinds of conversations, because this is about relationship building with one another that strengthens team building and health care delivery.

  • It is how we build potential in our teams and ourselves.
  • It is through our conversations that we build trust and create transparent cultures that reduce redundancies and errors and improve quality.
  • When people perceive a sense of safety they can take risks to innovate, create, contribute, challenge and celebrate with one another.
  • Research suggests improving patient safety is connected to improving trust, communication, teamwork and learning from past mistakes which requires in part, dealing with messier situations that make people feel vulnerable.

Physicians can frame tough conversations for productive outcomes by starting from within.

Sandy's tips to approaching challenging conversations:

  1. Mindset - Stay engaged in a learning state of mind. Don't expect to be perfect. Mastering difficult conversations requires practice, patience and a willingness to fail, learn and get better. It is about experimenting through baby steps, reflecting and integrating knowledge and evolving confidence and wisdom over time.
  2. Reflection - Before your difficult conversation, give yourself time and space to ask some important questions: what would be an ideal outcome? What do you hope to accomplish? Ask - what is really going on for me?
  3. Be completely honest with yourself! Examine your personal beliefs and assumptions. What feelings and emotions are activated in you? We all have habitual behaviors and conditioning that creates blind spots - what might you be contributing to the issue?
  4. Mindfulness - Be present! Take time to choose the right time and place to have the conversation where there will be minimum distractions. If possible, don't look at your cell phone, read your texts, glance at charts or test results. These distractions may make you feel more comfortable, but they will prevent you from attending fully to the situation at hand.
  5. Be empathic - Think about how you would want to be treated and place yourself in their shoes. What might they be feeling and how can you help them to feel as safe as possible for a respectful dialogue to take place?
  6. Identify big picture outcomes, as opposed to problems - You'll want to place focus on where you're going and not where you are. Reframe negative thinking to sustainable positive outcomes.
  7. Educate yourself - Dealing with conflict is a natural part of relationships and working with a coach and/or reading and developing skills in this area will serve you well for the long-term. There are a number of good books and articles on the topic: "Difficult Conversations: How to Discuss What Matters;" "Crucial Conversations: Tools for Talking When Stakes are High."
  8. Take purposeful action - Empower yourself by following through on tough conversations. Do your best to stay present, engaged and lead with integrity - learn from your experiences and build on them through practice, practice and more practice!
  9. Celebrate - Working through tough relationships can be deeply satisfying and meaningful. When you master new skills such as being mindful, empathic and focusing on positive outcomes, a person can more effectively deal with complexity and relationship challenges. Your confidence can increase, and one has a sense of empowerment and engagement; which enhances happiness, resiliency and well-being.