1 in 6 patient encounters considered difficult by physicians. More than Words Medical-Legal Issues and Patient- Physician Communication

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More than Words Medical-Legal Issues and Patient- Physician Communication Objectives Identify key medical-legal

Advisor, CMPA Memorial University of Newfoundland, Wednesday@Noon CME Series Health Sciences Centre, St.

roles unexpected Promotes self-doubt (threatens competence or control) Raise negative feelings Difficult Clinical

behavior is not An occasional out of character reaction Constructive criticism in good faith Expressing dissatisfaction

1 More than Words Medical-Legal Issues and Patient- Physician Communication Objectives Identify key medical-legal patient-physician communication issues Develop and implement risk mitigation strategies Tim Zmijowskyj, MD, Physician Advisor, CMPA Memorial University of Newfoundland, CME Series Health Sciences Centre, St. John's, NL February 17, 2016 The person with difficult behaviours Different beliefs, values, characteristics Assumes roles unexpected Promotes self-doubt (threatens competence or control) Raise negative feelings Difficult Clinical Encounters Manifestations Verbal Physical Visual Absence reasonably interpreted to be demeaning or offensive Disruptive behavior is not An occasional out of character reaction Constructive criticism in good faith Expressing dissatisfaction through appropriate channels How frequent are difficult patient encounters? 1 in 6 patient encounters considered difficult by physicians Arch Intern Med 2009; 169(4) 1

One that impedes the establishment or continuance of a

technical aspects of their clinical care? Stephen, et al.

Arch Int Med 154:1365-1370, 1994 J Health Care Law Policy.

2 Have you seen this patient? What is a difficult patient encounter? One that impedes the establishment or continuance of a therapeutic relationship What percentage of complaints and legal actions involve communication? How do physicians who have and have not been sued differ in the technical aspects of their clinical care? Stephen, et al. Scottish Government Report, 2012 Beckman HB. Arch Int Med 154: , 1994 J Health Care Law Policy. 2006;9:311 Mental health issues are the domain of clinical experts Difficult Encounters Disruptive Behaviours Intent Impact We judge ourselves by our motives and others by their actions. Dwight Morrow 2

Why is this important? Communication challenges?

turnover/loss Increased complaints and medical-legal

communication Communication that s what it s all about.

relationships Potential for frequent interruptions Time

the illusion that it has taken place George Bernard Shaw

3 Why is this important? Communication challenges? Preventable adverse events Increased cost of care Provider turnover/loss Increased complaints and medical-legal actions Begets disruptive behaviour Challenges to communication Communication that s what it s all about. Stress of high acuity situation Lack of established relationships Potential for frequent interruptions Time constraints The single biggest problem in communication is the illusion that it has taken place George Bernard Shaw The most common element of an adversarial clinician-patient relationship is failed communication. 3

The CMPA s experience (Disruptive Behaviour Files 2004 2013) Increasing volume Increasing legal costs Less

The quality of the doctor-patient relationship. J Health Care Law Policy.

of quality of care Safe Medical Care due to better information Authority (Rules) Collaboration (Goal

Lawyers Tell What Turns Some Patients Litigious cmpa-acpm.

4 The CMPA s experience (Disruptive Behaviour Files ) Increasing volume Increasing legal costs Less success defending legal actions The Most Important Factor in Predicting Who Will Complain or Sue? The quality of the doctor-patient relationship. J Health Care Law Policy. 2006;9:311 Consequences of Good Communication The ACE Difficult Encounters Toolbox Fewer Actions regardless of quality of care Safe Medical Care due to better information Authority (Rules) Collaboration (Goal setting) Adapted: Elder, MD, J Am Board Fam Med. 2006;19(6) Avery, JK. Lawyers Tell What Turns Some Patients Litigious cmpa-acpm.ca Med Malpractice Rev 1985;2:35 7 The Canadian Medical Protective Association Empathy (Positive Reinforcement) Vignette Difficult Encounters Toolbox Why do we complain? Authority Collaboration Empathy The Canadian Medical Protective Association 4

Patients sue or complain when their feelings are ignored or when they are

-Abraham Verghese MD, Stanford U More than words Etiology of disruptive

Slippery slope behaviours Isolation Fatigue Burnout Substance use Mental

5 Why do we complain? Unmet Expectations Addressing Unmet Expectations Ask respectfully Early on Patients sue or complain when their feelings are ignored or when they are angered by lack of genuine concern for their welfare. -Abraham Verghese MD, Stanford U More than words Etiology of disruptive behaviours Is there anything else? YES 53% Vs. Is there something else? YES 90% [Heritage et al. J Gen Intern Med 2007;22(10): ] Insight gap Lack of clear boundaries Slippery slope behaviours Isolation Fatigue Burnout Substance use Mental health dx Personality Family/home issues Unmet expectations Fear The Canadian Medical Protective Association A Changing Climate Economic challenges Diminished supports Personal health Employment Single What pushes your buttons? 5

Top 5 Difficult Patient Encounters 1. Insist on unnecessary prescriptions or tests 2.

Unrealistic expectations What difficult patient encounters have you experienced? 4.

Verbally abusive Arch Intern Med 2009; 169(4) A Changing Climate Barriers Feedback

reversals L Association The Canadiancanadienne Medical Protective de protection

6 Top 5 Difficult Patient Encounters 1. Insist on unnecessary prescriptions or tests 2. Express dissatisfaction with care 3. Unrealistic expectations What difficult patient encounters have you experienced? 4. Non-adherent 5. Verbally abusive Arch Intern Med 2009; 169(4) A Changing Climate Barriers Feedback creates change Denial Personal agendas Substance use Hostility Unavailability Role reversals L Association The Canadiancanadienne Medical Protective de protection Association médicale cmpa-acpm.ca Tools for Influencing Behaviours Meta-analysis of health behavior change programs (Mazzuca, 1982) Behavioral Skills Model Motivational interviewing "5 Why s' Active Listening In the moment techniques 6

Addressing disruptive behaviours Concrete Steps Address expectations Provide feedback

the behaviour Sooner rather than later Document Proportional response Boundaries

etc. Fees, forms, missed appointments, Follow due process Communication Email,

Receiving difficult feedback Non-Verbal Communication Learn to receive criticism Stay

doubt Be a good listener Body Language 80% of communication is non-verbal Doctors

7 Addressing disruptive behaviours Concrete Steps Address expectations Provide feedback Find common ground Willingness to have the difficult/crucial conversation Focus on the behaviour Sooner rather than later Document Proportional response Boundaries Receiving difficult feedback Establish expected norms Formal policies, procedures, etc. Fees, forms, missed appointments, Follow due process Communication , Texting, Social media, etc. Receiving difficult feedback Non-Verbal Communication Learn to receive criticism Stay calm Admit when wrong Proactively work on shortcomings/weaknesses Give benefit of the doubt Be a good listener Body Language 80% of communication is non-verbal Doctors with competent NVC have significantly higher patient satisfaction scores and are rated as more caring Pawlikowska T et al. Patient Educ Couns Jan;86(1):70-6 7

Active Listening S it square to the patient O pen to the patient L ean in Eye contact R elax In the Moment Techniques Address anger Low and slow voice Apologize as appropriate Correct errors when

I would never speak to you like that, and I will never speak to your son/daughter like that Knowing when to end a conversation Agree to disagree We can agree we don t want this to happen again What

NURS Mnemonic Elicit emotions and address them NURS Mnemonic Elicit emotions and address them Communication Mnemonics Naming: recognition and stating the emotion That sounds really difficult.

8 Active Listening S it square to the patient O pen to the patient L ean in Eye contact R elax In the Moment Techniques Address anger Low and slow voice Apologize as appropriate Correct errors when possible Avoid escalating Angry versus aggressive Focusing on the future Aggressive and abusive behavior Let them know this is not okay Mrs. XYZ please don t talk to me like that. I would never speak to you like that, and I will never speak to your son/daughter like that Knowing when to end a conversation Agree to disagree We can agree we don t want this to happen again What can we do differently next time? NURS Mnemonic Elicit emotions and address them NURS Mnemonic Elicit emotions and address them Communication Mnemonics Naming: recognition and stating the emotion That sounds really difficult. or That was sad for you. Understanding: acceptance and validation of emotion I can see that was frustrating for you. Respecting: respect their experience, praise their efforts You ve been juggling a lot. or You did a great job recognizing that he was getting more sick. Supporting: express support, create partnership, answer questions Let s work together to come up with a better way to address this. 8

The BATHE Method Eliciting Psychosocial Context BATHE: Eliciting Psychosocial Context Background: What s going on in your life?

"The Fifteen Minute Hour: Practical Therapeutic Affect: Trouble: Handling: Empathy: What s that like for you? How do you feel about what is going on?" What about the situation troubles you the most?

"The Fifteen Minute Hour: Practical Therapeutic Interventions in Primary Care" 3rd Edition. Philadelphia: Saunders Interventions in Primary Care" 3rd Edition.

9 The BATHE Method Eliciting Psychosocial Context BATHE: Eliciting Psychosocial Context Background: What s going on in your life? Tell me more Background Affect Trouble Handling Empathy Source: Stuart, M.R. and Lieberman, J.A. III. (2002). "The Fifteen Minute Hour: Practical Therapeutic Affect: Trouble: Handling: Empathy: What s that like for you? How do you feel about what is going on?" What about the situation troubles you the most? How are you handling that? How would you like to see it handled? That must be very difficult. Source: Stuart, M.R. and Lieberman, J.A. III. (2002). "The Fifteen Minute Hour: Practical Therapeutic Interventions in Primary Care" 3rd Edition. Philadelphia: Saunders Interventions in Primary Care" 3rd Edition. Philadelphia: Saunders The BATHE Method The Tool of Last Resort Ending the MD-Patient relationship 1. Establishes therapeutic alliance 2. Identifies expectations 3. Promotes insight 4. Discourages dependency 5. Extends empathy Source: Stuart, M.R. and Lieberman, J.A. III. (2002). "The Fifteen Minute Hour: Practical Therapeutic Interventions in Primary Care" 3rd Edition. Philadelphia: Saunders Allegations after MD Terminated the MD-Pt Relationship The doctor: Was unreasonable Didn t warn Refused to listen Belittled, humiliated Was dismissive Discriminated Race, age, sexual orientation, disability, etc. Document Events, no-shows, etc. Describe behaviours rather than labeling Attempts to contact, efforts to resolve Reasons for decision 9

The Tool of Last Resort Consider 1. Informing in person 2. Confirming by registered mail 3.

We can t please everyone Attend to personal well-being Follow College policies Ending the Therapeutic Relationship Building

medical-legal patient-physician communication issues Develop and implement risk mitigation strategies CMPA Resources Resources?

10 The Tool of Last Resort Consider 1. Informing in person 2. Confirming by registered mail 3. Advising of availability In case of emergency Finishing Touches Safety first! We can t please everyone Attend to personal well-being Follow College policies Ending the Therapeutic Relationship Building Better Objectives Determine expectations early Document discussions / warnings Do follow College policies Identify key medical-legal patient-physician communication issues Develop and implement risk mitigation strategies CMPA Resources Resources? Crucial Conversations, by Kerry Patterson, et al Difficult Conversations, by Douglas Stone, et al Dealing With Different, Diverse, and Difficult People, -audio series, by Barbara Braunstein The Canadian Medical Protective Association 60 10

References 1. Fortin AH, Dwamena FC, and Smith RC; The Difficult Patient; UpToDate; http://www.uptodate.com/contents/topic.do?topickey=pc/2764; updated March 24

11 References 1. Fortin AH, Dwamena FC, and Smith RC; The Difficult Patient; UpToDate; updated March 24, 2010; accessed February 22, Levetown M and the Committee on Bioethics. Communicating with Children and Families: From Everyday Interactions to Skill in Conveying Distressing Information. Pediatrics 2008; 121: e1441-e Strous RD, Ulman A, and Kolter M. The Hateful Patient Revisited: Relevance for 21 st Century Medicine. Eur J Intern Med 2006; 17: Su Rehman, DW Cope, RM Frankel, and S Wali; Expanding Our Skills for Dealing With Difficult Patient Workshop WD04; Society of General Internal Medicine; April 28, 2006; accessed February 22, The Canadian Medical Protective Association 11

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