II. Causes: Medical Provider Factors in Difficult Patient Encounters

  1. Interpersonal Factors
    1. Communication barriers (e.g. language, raport)
    2. Expectation mismatch (e.g. patient expectations for encounter)
    3. Patient lacks trust in the provider
    4. Provider biases (e.g. medical conditions such as Chemical Dependency)
  2. Situational Factors affecting medical provider
    1. Provider lacks training or is insecure about their knowledge
    2. Provider physical or mental health or wellness (e.g. sleep deprivation)
      1. May affect patience, empathy and resilience under pressure
  3. Systemic Factors
    1. Inadequate time for patient care
      1. Compounded by documentation requirements and lack of support resources
    2. Social Determinants of Health (e.g. poverty)
    3. Health Disparities and socioeconomic disadvantages secondary to structural racism

III. Management: Patient-Centered Communication

  1. Bedside Presence
    1. Among our most important healing tools
    2. Make eye contact
    3. Hold a patients hand when appropriate (e.g. fearful patient, elderly, Dementia or Delirium)
    4. Use language appropriate for the patient (e.g. simple language in Dementia)
  2. Understand patient's agenda
    1. Introduce patient, provider, family and others in the room
    2. Welcome new patients
    3. Start with non-medical break-the-ice topics (if time)
    4. Ask open ended question (e.g. "How can I help you today")
    5. Allow patient to speak uninterrupted initially
    6. Ask, is there something else?
    7. Actively listen while the patient is speaking without distracting activities
  3. Understand patient's perspective, psychosocial context
    1. Avoid judging patient's emotions as appropriate or inappropriate
    2. Avoid offering premature reassurance or normalizing patient's concerns (e.g. "common reaction")
    3. Understand patient's expectations from encounter (e.g. work note, reassurance)
    4. Express empathy and concern
    5. See Breaking Bad News
    6. See Discussing Terminal Illness (Discussing Death, End-Of-Life Care)
  4. Shared treatment goals
    1. Discuss treatment options (including no treatment or watchful waiting)
    2. Avoid overwhelming the patient with too much information
  5. References
    1. Hashim (2017) Am Fam Physician 95(1): 29-34 [PubMed]

IV. Management: CLAP Mnemonic

  1. Curiosity
    1. Approach conversations with an nonjudgmental attitude, open mind and genuine curiosity
  2. Listen
    1. Actively listen and hear the patients concerns
  3. Aspirations
    1. What does the patient and their family want from the encounter
  4. Personal
    1. Avoid taking conflict personally

V. Management: Maintain good communication with patients and their families

  1. Establish a relationship with patient and families
  2. Listen well
    1. Avoid missing important details due to interruption
    2. Direct the patient to the current history and avoid interrupting for at least the first minute
    3. Gain credibility through reciprocal communication
    4. Listening to a patient's story allows them to unload details and free-up memory to absorb what medical providers say
  3. Apologize for medical errors (with administrative Consultation)
    1. Medical providers should consult with their employers and Risk Management teams prior to disclosure
    2. Some hospitals have full disclosure policies
    3. A majority of states have apology laws
      1. Protect providers and organizations to some extent when they disclose medical errors
  4. Address patient or family dissatisfaction, anger or other negative emotions associated with the visit
    1. See Conflict Resolution (for effective methods including better listening)
    2. See Emergency Department Patient Satisfaction

VI. Management: Benevolence correlates with best and most satisfied FP's

  1. Preserve and Enhance people's welfare
  2. Patient Descriptions of "Good" physicians
    1. Helpful
    2. Honest
    3. Forgiving
    4. Loyal
    5. Responsible

VII. Management: Shared Decision Making

  1. All decisions regarding patient care should involve input from the patient or their proxy
  2. Shared Decision Making lies on a continuum of paternalistic and informed decision making
    1. Incorporates information exchange, deliberation and choice
  3. Characteristics
    1. Respect for patient values
    2. Integration of care
    3. Communication and Education
    4. Involvement of family or friends
  4. Four criteria of Shared Decision Making
    1. Involves at least two participants (typically provider and patient/proxy)
    2. Both participants share information
    3. Both participants work together to form consensus
    4. Agreement on treatment plan is reached
  5. Numerical Data Best Practices
    1. Use a mix of numbers of pictures (e.g. pictograms, infographics, icons)
    2. Use numbers to define what you mean by "rare", "unusual", "uncommon" or "common"
    3. Use absolute risk instead of Relative Risk
      1. "Double the risk" is misleading when the risk increases from 0.5 per million to 1 per million
      2. In this case the Relative Risk is 2, but the absolute risk increase is 0.5 per million
    4. Use natural frequency instead of percentage
      1. Use "1 in 10 people" instead of "10% of people"
    5. Use consistent units (including the same denominator) when describing risks and benefits
      1. Avoid comparing, for example "1 in 14 versus 1 in 5"
      2. Instead, use a consistent denominator, "7 in 100 versus 20 in 100"
    6. Define risk over a fixed period of time (e.g. months, years)
      1. For example, "in five years, 5 in 100 people would have experienced this side effect"
    7. Frame benefits and risks in positive and negative terms
      1. "Treatment is a success in 8 out of 10 people, but 2 out of 10 fail to see any benefit"
  6. Three Talk Model
    1. Team Talk
      1. Patient and provider collaboration in a supportive environment
      2. Patient is autonomous, and asked to share their preferences and goals of care
      3. Patient and provider agree on an agenda with prioritized topics within encounter time constraints
    2. Option Talk
      1. Evaluation and Treatment options are compared with their associated risks and benefits
      2. Risks and benefits are described with numerical data when available using best practices (see above)
      3. Options (including "no treatment") are considered in the context of patient's preferences and goals
      4. Provider should ensure patient understanding at intervals along the discussion
        1. Break discussion into small chunks of information and then check that this is understood
        2. Consider asking patient to explain concepts discussed ("teach back")
    3. Decision Talk
      1. Joint decision making with a timeline for the ongoing plan and next review
      2. Provider summarizes decisions made with next steps, and documents in the medical record
      3. Patient may change their mind at any time
  7. Resources
    1. Shared Decision Making (UK National Institute for Health and Care Excellence)
      1. https://www.nice.org.uk/guidance/ng197
  8. References
    1. Boyle and Ponce (2018) Crit Dec Emerg Med 32(10): 11
    2. (2022) Am Fam Physician 106(2): 205-7 [PubMed]

VIII. References

  1. Swadron and Shoenberger in Herbert (2019) EM:Rap 19(7): 1-2
  2. Henry (2013) Avoid Being Sued, EM Bootcamp, CEME

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