My friend and I took to the white board today to map out a talk we shall be giving at a behavioral medicine conference for a group of non-psychiatric residents. Although I have since erased the dry-erase pen marks, faint residues remain on the surface of the board like the lingering fragrance of incense that was burnt several hours prior.
The talk keeps evolving, primarily because we’re trying to cram hours upon hours of material into a ninety minute talk. The topic itself is also amorphous and is not amenable to transmission via language alone.
I like to lump these types of topics into a poker analogy: “You can read about poker all you want, but it is only when you actually play the game that you develop an understanding for poker.” (I didn’t come up with this analogy myself; I am fairly confident that I got this from an episode of Star Trek: The Next Generation—I think the crew was teaching Data how to play poker. I have now established my geek credibility, thank you very much.)
The residents specifically requested a talk about working with “the difficult patient”.
That’s such an unfair phrase; implicit in that sentence is that the patient is to blame for the difficult interaction. The phrase still persists in medicine, though; if one enters the phrase (with quotation marks) “difficult patient” into Pubmed, 301 articles show up, some published as recently as January 2007 (!).
Amongst other things, we hope to introduce the idea that it is the interaction that is difficult, not the patient. This idea that difficulties reside solely in the patient harkens back to Freudian psychoanalysis, where the analyst was viewed as absolutely objective and that any issues that appeared in the therapy were reflections of the patient only. Modern day psychoanalysis asserts that both analyst and patient contribute to the interpersonal dynamic; why hasn’t the rest of medicine adopted this idea?
Thus far, we intend to
- solicit the residents for general goals they have when interacting with patients (and explicitly explain that when these goals are not reached for whatever reason, this results in the “difficult” experience)
- provide a general framework to help categorize the types of difficult interactions (for which both parties may jointly hold responsibility—and how loathe we all are to accept responsibility)
- solicit the residents for what strategies they have used to ameliorate these difficult interactions and, whether they were successful or not, why they succeeded or failed
And this is the location of the impasse.
Initially, I (we) wanted to give a talk about interviewing skills (since psychiatrists, whether accurate or not, are considered the artisans of the clinical interview). After several incarnations, I now want to cultivate self-awareness in these residents and provide instruction in basic and effective behavioral (i.e. visible and tangible) interventions that can help minimize difficult interactions with patients.
The two are highly interrelated, however, and we just don’t have the time in one lecture period to satisfactorily address both topics.
In order for someone to change his behavior, he must first be aware of his behavior. If you’re not aware of what you’re doing, you will not have any impetus to change it.
Behavior is one point of a triangle in a (cognitive and behavioral) model of mental health. (There seem to be a lot of triangles in psychology and psychiatry.) The other points include thoughts and emotions. If you change one point, the other points shall be affected. (For example, if you’re feeling sad (emotion), you may have thoughts like, “I’m worthless,” and spend way too many hours in bed (behavior). By forcing yourself to get out of bed and do something (behaviors), you will likely change your thoughts and emotions.)
Ideally, we’d like to demonstrate to the residents that their thoughts and emotions affect their behaviors—sometimes in adverse ways. However, we want to make this point in a compelling fashion and not as a bullet point on a Powerpoint slide (because that’s not effective, but it is painfully boring). We also don’t want to be overly shrinky about it because, really, the task of reflecting upon our emotional states can be uncomfortable and threatening. Self-awareness is important, though, and, in the long run, awareness of the internal process will help optimize patient care and facilitate satisfactory interactions for all involved.
That being said, teaching concrete behaviors to the residents will probably be a more satisfying experience for them (because, you know, we live and work in a culture of doing, not reflecting) and, as a result, that will make the teaching experience more satisfying for us (because we want our talk to go well!).
The two points are not mutually exclusive, of course—time is just limited. At this point, our goal is to explicitly (but briefly) state the importance of self-awareness (as the rest of the lecture will implicitly highlight this) and introduce one or maybe two behavioral interventions for their use.
So, I seek the collective wisdom of the internet: What tactics do you use during/to prevent difficult interactions with other people to (1) help reach collaborative goals and (2) maintain working relationships? I’m talking simple, *behavioral* tactics (versus purely *cognitive* tactics, such as thinking, “I’m not gonna get pissed off, I’m not gonna get pissed off…”), such as body language, verbal strategies, etc.—things that are concrete, tangible, and observable. Help me with the list I already have. I am particularly interested in hearing from people who regularly work with patients in health care settings…
… but since we all have had difficult interactions with people, leave a comment and tell me what *behavioral* interventions have worked for you in the past. Thank you for contributing to medical education.
10 Feb 2007 |
The thing that works best for me is to slow down the interaction. I find that it gives me a little longer to react in ways that will have a beneficial impact on the interaction. It allows me to think of reasons why the interaction may be going the way it is, and of strategies that I can use to make it go better. (And sometimes to remind myself, “I’m not going to get pissed off.”) I slow things down by verbal pausing techniques like, “let me think about this for a moment,” and “hmmmm.”
Comment by Kathy | 11 Feb 2007 @ 5:43am
I have to confess: on Friday I called a pt “difficult” (or some permutation of that, can’t remember exactly). Unfortunatly I was talking to the pt’s psychiatrist, who knows her well. (In my defense I had just spent 20 minutes trying to get the pt to agree to a catheter and pheresis, the things that she was admitted for.) I did apologize, saying that I had made a judgement that wasn’t fair to the pt. She accepted, and then agreed that the pt was not easy to work with. !!
Comment by Abby | 11 Feb 2007 @ 5:49am
Because I am in Community Mental Health, we often get the “difficult” patients because they have nowhere else to go. I accept that most of my initial interactions will be difficult until the patient and I reach some understanding of the parameters of our relationship. When I am particularly frustrated I stop and ask the individual what are they not getting out of the relationship that is making them unhappy. Often, what I have in my mind as the problem never enters the conversation. I am thinking one thing and they are on a completely different wavelength. It helps to empower (hate that word) them and helps them realize that I am not there to fix them but to help them find their solutions.
Comment by donna lee | 11 Feb 2007 @ 7:38am
Difficult situations are difficult, but before you say, “Duh!”, let me explain.
Most of the time, when a difficult situation arises (and let’s be fair, let’s call it a difficult situation, not a difficult patient) it has developed over at period of time, with a series of incidents, interchanges with staff, family, whoever.
The first job is to take the pressure cooker off the stove. Do not dive into the fire of emotions. You want everyone to sit down, including yourself, and try to collect information, with people taking turns, no shouting, trying to get to the beginning.
So you try to get a list of complaints, and in the process, try to see a pattern, a key incident, a key person, who really set this thing off (sometimes the patient is the key person). Sometimes there is a staggering laundry list of complaints, so diverse that it becomes obvious there is something in the background that needs to be found — stress at home, anniversary of someone’s death…
Restrain yourself from being Mr/Ms Fix-it. Your job is not to go down the list, one-by-one, with little fixes for each thing. Many of these are past history, some unavoidable.
Do not promise that “I promise that I won’t let this happen again” unless you are God.
Do not say infuriating things like, “I’m sorry you feel this way”, “Well, we’re doing the Best we can”, “If that’s the way you feel, then maybe you should sign out AMA”, “You know, you’re not really paying for this out of your pocket.”
The rest is seat-of-the-pants interpersonal relationships.
And finally, “It ain’t over till it’s over.” You need to find the time to do a debriefing with the staff, not as a finger-pointing exercise, but trying to help them not let a patient go up in flames, to get help defusing the situation. An ounce of prevention….
Comment by Greg P | 11 Feb 2007 @ 7:49am
man, i wish i had the ability to not see certain people as “difficult.” the interaction is surely the most fruitful to look at, but some people have a knack for warping interpersonal space no matter how detached you try to stay.
if you need texas holdem poker lessons, let me know :)
Comment by drcharles | 11 Feb 2007 @ 10:38am
I have a private practice that lies outside the formal boundaries of psychotherapy or health care, but I believe my experience and perspective may be helpful here. I experience few or no “difficult” interactions in my practice, and I believe I can point to one particular tangible behavior responsible for the ease of my professional relationships: listening.
The first thing I notice about your request is that you ask for tactics for furthering “collaborative” goals and working “relationships.” Yet the framework for your presentation focuses on the residents: *their* goals and strategies, *your* framework for categorization. Missing is focus on *the patient’s* goals. My best advice is the following:
The most powerful tactic for creating felicitous interactions is active, intentional, conscious listening. Build your presentation around specific exercises in which residents can practice this skill.
Suggestions:
1. Start the interaction with a greeting establishing mutual humanity. “Hello, my name is Dr. Rudy Smith; I’ll be your physician today. Shall I call you Mrs. Jones, or would you prefer I use your first name?” Here you are establishing that you care about your patient’s preferences.
2. Continue by a) setting a clear framework for the interaction, including time available and overt purpose, and b) starting the necessary medical activities. This might sound like, “We have about 12 minutes today. I see you’re here for X (condition), so I would like to start by X (procedure/exam/etc.). Would that be ok?” Setting clear parameters establishes your authority, while asking permission puts the patient in charge.
3. This is the most important step. Ask an open-ended question about what the patient wants, regardless of the overt reason for the visit. This might sound like, “What is the most important thing you would like to get from your visit with me today?” Then, listen. I mean, really listen. You can do this while you’re continuing the exam or procedure; you can briefly interrupt for directions like “lift your arm please.” But most important is that you show you are listening by reflecting back what you hear. That might sound like, “I’m hearing that you’re concerned about being out of work for too long. Let’s talk about ways you can make your healing go faster.”
4. If there’s time, ask another open ended question, “Do you have any other concerns or questions you would like to share with me today?” This invites more fruitful dialogue and will often be the doorway to the patient’s REAL concerns. You’ve established trust in steps 1-3, so your patient will find it much easier to voice something that puts the patient in a vulnerable place.
Almost very “difficult” interaction has at its core a deep vulnerability. As a practitioner (of any kind), your job is to create the space where the patient feels safe enough to share that vulnerability. Listening is the most effective way to do that.
One more suggestion: you might find valuable a particular framework for communication called “Non-Violent Communication” developed by Marshall Rosenberg. It is applied to most dramatic effect in highly charged conflict situations. You can read more about it at several places on the web, and in Rosenberg’s book by the same title.
Good luck!
Comment by Joseph | 11 Feb 2007 @ 1:54pm
When I reached the point of no longer being able to interact with a psychiatrist, my new psychiatrist physically backed off and gave me space. On the first encounter, I cracked and screamed my head off and he left the room and called the Home Treatment Team that knew me well. On the second encounter (in my therapist’s office), he moved to a different chair when I was angry that he was sitting in my usual chair, then he sat and listened. When he realised I found it difficult seeing him in his small office with him sitting on his high office chair and me on a low easy chair, he moved the appointments to a larger room with the same height chairs for both of us and easy access to the exit for me.
I now feel safe with him and am grateful to him for respecting my need for space and safety.
Comment by Nutty | 11 Feb 2007 @ 5:26pm
This is such a great post, it has me still thinking about it. It ties into my fascination with factors that make an interaction naturally therapeutic. (A couple more books: _Becoming Naturally Therapeutic_ by J Small, and “The Heroic Client” by Duncan, Miller, and Sparks.) So there’s one more thing I’d like to share.
Difficult interactions most often happen because both parties are engaged in a dynamic involving “triggered” feelings. I believe it is possible to make yourself more and more trigger-free, and I believe it is the duty of every responsible practitioner to pursue their own personal work to that end.
So it comes back to one of your desires — to cultivate awareness. Toward this end, I imagine an exercise which would hold a mirror up, to create an opportunity for your participants to participate in creating a difficult interaction, and to facilitate them noticing their part in that. It might be as easy as writing a script or two of a “typical” escalating interaction between resident and patient, and having them “act it out” through simply reading the script in pairs, allowing them to improvise the final line or two of the dialogue. Different people are likely to react to different aspects of the interaction, but you should be able to write something that would at least minimally trigger almost everyone.
Follow that with some self-reflective time, perhaps with pen and paper, for each person to notice what they felt in the middle of the interaction. Then, allow discussion about what they’ve learned about themselves and problem-solving on what to do about it.
You could provide tactics/strategies, of course, but I advocate for allowing each person to come up with a clear plan of their own to a) reduce the strength of their personal feelings that come up in a situation like that, and b) behave in such a way as to redirect the interaction toward a more fruitful end. People will generally be pretty creative, and the things they come up with themselves will stick with them much longer and be more readily accessible when they actually need them on the job.
I’m drawing in part here on the expertise of a friend and colleague who has presented at conferences on relationships in medicine as well as facilitated workshops on diversity & tolerance-related issues for corporations. His background is in theatre, and he uses acting exercises to provide people real experience upon which to reflect on how they hold relationships in the workplace. His work shakes people up and creates new dialogue and change in ways that conventional workshops do not.
So I’m advocating for more of a focus on your first-stated goal of bringing people’s awareness to their role in difficult interactions. Providing an experiential opportunity for that will create strong motivation for your participants to find their own solutions. Providing recipes instead, of situational assessment plus tactical response, is less likely to root deeply and actually influence behavior in the long run.
You say you chose to focus on concrete behaviors in part because we are a culture of doing, not reflecting. I say it is exactly for that reason that providing an experiential opportunity for deep personal reflection - *because* it runs counter to expectation - can be one of the most powerful ways to teach.
Again, good luck.
Comment by Joseph | 11 Feb 2007 @ 6:29pm
One thing I forgot to add is that, regardless how skilled you become at handling difficult situations, you realize that prevention is the best plan. What this means is that rather than just watching the CBC, the X-ray reports, the “data”, you also watch the interpersonal dynamics, with yourself and the rest of the staff, to look for signs that there is going to be trouble. It’s also easier to teach/help the staff on the front end than it is after the emotional bomb explodes.
Comment by Greg P | 12 Feb 2007 @ 6:58am
Here are the strategies I use before a conference when I know I will be speaking with a “difficult” parent.
I take a deep breath and relax my muscles before engaging in the encounter. I try to slow myself down so that the tone of the meeting is peaceful rather than antagonistic. When I am rushed, stressed, or frustrated other people sense it and they react to it, even if it is not specifically directed towards them. I believe that a person who exudes a calm persona will have a calming effect on others, and hopefully a difficult interaction can be avoided.
I also try to address their concerns in thoughtful manner. Every parent / person wants to be heard, wants to have a voice, and by doing this I am acknowledging her point of view on the matter. I may not agree with it, or my perception of a situation may be different, but I have given her a part in the conversation rather than telling her something will be done just because I am the teacher and I say so.
Comment by catherine | 13 Feb 2007 @ 3:39am
I spend a pretty good amount of time working with patients who might be considered by some as “difficult.” Over the past few years, I’ve developed strategies that work for me - at least most of the time. I think the absolute most important thing that I do is to treat each and every person as a valid individual that has worth and deserves respect. So often, all a person is looking for is some basic respect and some indication that you care about them and don’t look down on them, especially when you are in a position of authority. I’m not kidding when I say that this diffuses what might turn into a difficult situation for me about 80% of the time.
So since that’s not very concrete, I guess the way I tend to do this is to provide my time, eye contact, and so on. I take the time to explain things to them, and then ask them if they have any questions, and I truly take the time to answer the questions as best I can. If there is something they start to get agitated over, I review in my mind another way to explain what it is I mean. I find that when they truly understand why I’m doing something or saying something, then the anger subsides some - but many times, anger and frustration come out of misunderstanding.
So then I would like to talk for a minute about the flip side. I’m sure in that search on “difficult patient” you found some articles relating to the difficult headache patient. I’ve seen many articles on this. Now - occasionally that refers to a patient with complex headache problems, but more often than not it refers to working with a patient who has some difficult personality defect. (I’m not joking!)
I have complex headache problems, and I’ve seen my own “difficult-ness” handled in a few different ways - and some of them trigger me to become difficult, in an emotional sense. I always go into every encounter with an open mind - but headaches are an area where I tend to feel very vulnerable. So I am a bit more sensitive about this - keep in mind I’m living with pain 24/7 - and anybody who lives in chronic pain can get frustrated, even over small things. My former neurologist was so great. First and foremost, he was patient - he took time to answer questions and to include me in my own treatment plan. He never said that we were out of things to try - my biggest fear used to be that I’d go in and hear, “That’s it - there is nothing left.” He always provided some sort of hope….even in the face of what appears to be a hopeless condition.
And then he left, and I went to a different neuro in the same practice who had even more experience. I’d been told that this particular neuro was excellent with college kids - which I was. Boy did we not click. I felt like he was very condescending and demeaning and that he never listened to me. I left many appts in tears. I started going to the ER on occasion - and I never went to the ER at all for headache the entire time I saw my other neuro. There was one point where I’d been started on a new med, and I had a major anticholinergic toxicity reaction that landed me in the ER, not having one clue who I was or what was going on for like 8 hours. I also had EKG changes and couldn’t see. I was totally delirious. I only know what I said because my parents told me and I remember a few things as I was starting to come out of it. But the thing was, while on the med those first 8 days, I called the office 3 times and had one appt and additionally stopped by the office one more time - all with concerns about the effects of the med. Each time, I was told to just stay on it and the side effects would wear off. Obviously they did not. After it was all over, I would have appreciated an apology. I was quite upset that I hadn’t been listened to in the face of some major side effects like heart palpitations, tachycardia, changes in blood pressure, confusion, lightheadedness, and I trusted them - and it resulted in a very dangerous and scary problem. My neuro’s response was that perhaps I was too angry to continue my treatment with them and that maybe it was time I went to this other well-known center that I would never go to, even if it meant I’d die first. I was so upset. Was I being difficult? I was not demanding an apology. I was saying, in a very calm and collected manner, that I felt that I wasn’t being listened to, and that I had concerns that this led to my having a major interaction. (It took so much guts for me to even say that - to confront my doc - I’m pretty sure I was shaking like a leaf.) I just wanted him to pay attention when I had a major concern over a med that resulted in serious results. And he flipped and blamed it all on me. So that’s not the way to handle an interaction.
We sort of get along now - but each time I go in, I never know if I’m going to see Dr. Jekyll or Mr. Hyde. I think he’s a great doctor - but I don’t think our difficult interactions are just my fault alone - and yet I’m sure they are also partially my fault. I never had these problems with my former neurologist, and I don’t have problems with any other physicians that I see. (And I see a lot!) I don’t have the option of seeing a different doctor, so I have spent a lot of time analyzing why the relationship doesn’t always go over well. I continue to go in to each appt with an open mind and a positive attitude, and I keep my fingers crossed that it’ll be a good day!
Good luck with the talk, if you haven’t had it yet! Take care,
Carrie :)
Comment by Carrie | 14 Feb 2007 @ 6:03pm
At risk of revealing my age, let me reference an out of print book,
The 15 minute hour. I read it in residency and still use the techniques today. It was designed for primary care doctors( who think and act in 15 minute blocks) and will experience severe eye-rolling when told to “take time”.
I even saw it referenced on another blog.
http://www.docnotes.net/000668.html
Second, I refer you to Ed Waker, MD, shrink at University of Washington School of Med(Dean) who gives a 45 minute talk on this with handouts.
His method is similar to yours(interactive) but more succinct, I suspect honed over years.
U of Wash psych department has a mission to improve psych care by Family docs since thats where 90% of it happens anyway.
Finaly, I theorize, and could probably do a dissertation on, the conjoned pathology of the doctor patient relationship. That which rings our bells, pushes our buttons(signifies a difficult patient) is there to teach us about ourselves. And we must be healthy to heal.
Comment by Dan J Schmidt | 15 Feb 2007 @ 11:31am