for Difficult Interactions in the Office Setting Presented by Dr. Dennis Boyle Physician Risk Manager COPIC Copyright 2013 by COPIC. All rights reserved.
Page 2 Introduction to this course Hello, I m Dr. Dennis Boyle, physician risk manager at COPIC. Welcome to our course Difficult Interactions in the Office Setting. In the prerequisite course, Communication Techniques in the Office, we outlined seven techniques for effective communication. In this course, we ll help you determine what constitutes a difficult interaction for you, and show you how to formulate a skill set to use in difficult encounters with patients and others. Because we ll be referring to issues discussed in the previous course, I highly recommend that you complete it before beginning this one. Here s what we ll cover today: We ll discuss what difficult interactions are, and discuss techniques for how you can deal with them. We ll also provide scenarios of difficult interactions with a patient and give you the opportunity to rate whether or not the interaction was handled well. Finally, we ll ask you survey questions about how staff in your office manage difficult interactions. Now, pay close attention to this interaction between a receptionist and a patient. John: Look, I ve been waiting out here for 15 minutes, and no one has come to see me yet. What s wrong with you people? Judy: We had an emergency this morning, and we re just trying to get caught up. So, please have a seat and we ll be with you as soon as we can. John: Well, I can t wait anymore. I m leaving. Judy: Whatever Give a grade of either A, B, C, D or F to how the receptionist dealt with this interaction, and provide at least two reasons for your grade. A difficult interaction occurs when at least one person is uncomfortable with the emotions or demands of the other person. Usually, that other person is a patient, but it can be anyone you interact with during the day. The difficulty you experience may become a barrier. Your discomfort may arise from what s happened now or in the past, or what you re afraid might happen during the interaction. The person who is uncomfortable which could be you or the patient often lacks the skills to cope with the situation. That means you might ignore the cause of the difficulty, react emotionally yourself, call for assistance or storm out of the room. But the most important thing to do right away is to identify and understand the types of behaviors and emotions that are difficult for you to handle, and then learn how to handle them. Emotions The most frequent emotions that we see in healthcare interactions involve some degree of fear and sadness. However, there are many types of difficult interactions and they display the whole spectrum of emotions. Of all the emotions, anger is perhaps the least understood. It s considered a secondary emotion because it s masking a primary one, such as fear, sadness, or anxiety. It s always helpful to discover what the primary emotion is by listening to the patient and understanding what they re saying then deal directly with the main issue. Let s say that a patient comes in with an illness like chronic obstructive lung disease, and they re angry. If you re observant, you ll realize that the anger isn t directed at you but at their disease. And beneath their anger is sadness. They can t exercise anymore or even walk without an oxygen tank. In a larger sense, they fear that they can t be the person they used to be or thought they could be. And this makes them angry, but primarily it makes them sad.
Page 3 There s important research to help us understand emotional encounters. It s estimated that one-sixth of encounters with patients are perceived by clinicians as difficult. According to one study, difficult patients were more likely to have a mental disorder, more than five somatic symptoms and more severe symptoms than those who aren t difficult. They also had a poorer functional status, more unmet expectations, less satisfaction with their care and a higher use of healthcare services. This study found that patients in difficult encounters had less trust and less satisfaction with the clinician they saw. The study concluded while the label of difficult is usually assigned by the clinician, in reality both the clinician and the patient are troubled by the interaction. Costs and Consequences of Difficult Interactions The inability to resolve difficult interactions can stem from ineffective communication and interpersonal skills, as well as a lack of self-awareness. In the course Communication Techniques in the Office, we described the benefits of effective communication; namely, improved personal satisfaction for the staff, improved patient satisfaction, better patient outcomes, and a reduction in malpractice claims. The costs and consequences of difficult interactions are just the opposite. First, there s a tremendous amount of personal dissatisfaction when you face a difficult interaction that you re not able to relieve or resolve. For example, when you think a patient is angry at you, you might feel a knot in your stomach. You might fear that you ll get into trouble if you don t say exactly what the patient wants you to say and do everything you can to make the patient feel better on their timetable. Then, there s extreme patient dissatisfaction. If a patient presents a problem that you re unable to deal with because of an emotion that s difficult for you and you d rather rush through the encounter and leave this creates a bad impression of you in the patient s mind. If they don t like you, they won t believe what you say, they ll lose confidence that you can help them and they ll lose trust in you. They ll become unhappy, and unhappy patients will be much more likely to complain and threaten you with a lawsuit than happy patients will. Also, they have poor outcomes because they don t adhere to treatment due to their lack of trust. Finally, they re more likely to bring a malpractice claim against you, even if you provided them with the best care possible. In other words, one unhappy patient can wreck havoc in your practice. Does your office recognize the cost of a difficult interaction? Resolving difficult interactions at the outset, so that they don t worsen over time, can really improve conditions in your office and help maintain a successful practice. By the way, many of the examples in this course describe provider interactions with patients, but difficulties can certainly occur when other office staff deal with patients, family members and others, and the techniques we ll discuss to resolve these difficulties also apply. Now, pay close attention to this interaction between a nurse and a patient. Paula: Hey, Mr. Mason. Let s check your BP. (pause) You know, it s only been two weeks, but I didn t see in your chart that the doctor indicated a follow-up visit. John: Yeah, I just haven t been feeling well. Paula: You know This is your fourth visit in the last three months and we haven t found a thing. We re really busy with people who are sick. John: What do you mean? Paula: John, there s nothing wrong with you physically at least. Give a grade of either A, B, C, D or F to how the nurse dealt with this interaction, and provide at least two reasons for your grade.
Page 4 You view the difficulty of an interaction through your experience and expertise. It depends on what type of emotion or behavior troubles you the most. For example, if you have a hard time talking with a patient who s sad, then sadness is the emotion with which you have difficulty most times it occurs. If a patient is angry and you feel uncomfortable, then anger might be the emotion you struggle with the most. Unless you identify, understand and handle it, the emotion will always be part of a difficult interaction, and you ll see it come up again and again with different people. Of course, that also means your least favorite patient will continue to be your least favorite unless you try to work constructively through the difficulty. In addition, not all difficult interactions occur because of your problem with the patient s emotion or behavior. Instead, it may be your caused by something you ve done, and the patient doesn t know how to deal with your emotion or behavior. Also, a patient may not understand when they ve caused a difficult interaction for you. Does your office provide training to help you identify the type of patient that gives you the most difficulty? If you have a hard time with a particular emotion, such interactions might comprise 10% of patient interviews in a day. Now, if an average provider sees 20 patients a day, that s only two interactions per day that are difficult, but those two can ruin your day. And as a member of an office staff with several providers, you ll have many more than two difficult interactions in one day. Now, listen to this interaction between a nurse and a patient. Marie: Hi, John. Busy, busy day. Can you give me a quick rundown of what s going on with you? John: Sure. Last weekend, my wife and I were coming home from a weekend hiking the Colorado Trail, and she was driving home because I kind of felt tired after that. Marie: Umm (shuffling papers) John: And when we got home, my left leg hurt after I stood up. That s never happened before. So I put some ice on it and lay on the couch Marie: Excuse me, John. Can you move it along? I don t have time for this much detail. Give a grade of either A, B, C, D or F to how the nurse dealt with this interaction, and provide at least two reasons for your grade. Information and Emotion As you learned in the first course, Communication Techniques in the Office, the interactions in a medical office are vastly different from those in other situations. They are more serious and personal, and they frequently are laden with emotion. Patients may give you specific information about what s wrong with them and how they feel, but also may express feelings about it. So, medical interactions involve both information and emotion in a short period of time. Most interactions feature a dynamic mix of these two factors. You should separate the information from the emotion but understand both at the same time. During medical interactions, you are regularly exposed to intimate details about your patients. Even if you haven t met them before, you may talk to them about their sexuality, wishes and goals, and their fear of dying all sorts of things that you wouldn t discuss outside the office. A patient might be fearful of what s going on with their chronic obstructive lung disease or their arthritis, so you want to try to get information from them in a short period of time while still paying attention to their emotions. Does your office have procedures for dealing with emotional patients? Think of pure information as an air traffic controller: always cool, calm and collected. Conversations with them provide information with virtually no emotion. Now, think of pure emotion as a teenager: usually happy, sad, angry, fearful often all at the same time. Conversations with them provide emotion with virtually no information. At the office you ll likely have interactions at either extreme, and most of them will be somewhere in the middle.
Page 5 Now, pay close attention to this interaction between the PA and a patient. Jessie: Hello, Mr. Mason. How are you doing today? You remember me Jessie, Dr. Rawlins s assistant? John: Wait a minute, I thought I was going to see the doctor. Jessie: Unfortunately, the doctor s schedule is pretty full today. Since you phoned us yesterday afternoon and set up an appointment for this morning, we really couldn t squeeze you in. I m sorry! So how can I help you today? John (shouting): That s just not right! I pay a lot, and I should be able to meet with the doctor! Jessie (soothing): I understand exactly how you feel believe me, I ve been there myself. But you ll see: I m pretty good at helping people. Now, please tell me what I can do for you. Give a grade (A, B, C, D, or F) to how the PA handled the interaction, and provide at least two reasons for your grade. Techniques Let s talk about techniques that can help you manage difficult interactions. In the course Communication Techniques in the Office, we learned seven effective techniques that are helpful in most medical encounters, even difficult ones: introducing yourself, ensuring congruence between verbal and nonverbal communication, building rapport and engagement, asking open-ended questions, listening reflectively, educating and communicating final instructions, and practicing effective phone communication. These are all valuable tools, and there s also another effective technique. First, after you ve listened to the patient s words of anger or sadness, take a time-out to clarify your thoughts and feelings. Continue to pay attention to the nonverbal cues you see in the patient: their furrowed brow, their bowed head, clenched fist, a trembling lip, fidgeting and so on. Just pause for a moment and understand what s happening. At the same time, understand your feelings and how you re being affected by this encounter. Above all, don t lose your cool. Maintain your poise and continue to exercise courtesy throughout the interaction. Next, recognize that something has gone wrong, especially if you feel it in your gut or sense it. If you feel you d rather be anywhere else than with this angry, sad or demanding patient, you re in a difficult situation. It s not helpful to deny or ignore what you re up against, or react in a way that s counterproductive to the situation. You need to learn to deal with it, or you could be leaving behind a dissatisfied patient who will eventually hurt your practice. Also, if you ve seen this patient before in a difficult encounter, you might compound the damage by being defensive or nonresponsive to their needs. Then, after you recognize something s wrong, build rapport by asking what s going on in their life. If you re able to connect with the patient, it ll be harder for them to be angry and hide their true emotions. It ll be easier for them to be sad and easier for you to feel empathy for them. Finally, ask open-ended questions and listen reflectively to the patient s complaints. For example, say, You seem upset; tell me why. This helps the patient tell their story. While you re interacting with the patient, monitor your body language. Focus on where the patient is coming from and understand why they re upset. Then, when you reflect your description back to the patient, it will help resolve the emotional conflict.
Page 6 Role-Playing Role-playing is another useful technique. Write a role-playing script on paper or in your head in which you deal with the difficult interaction through words and nonverbal communication. Then, act out the script in your office. Perform it in practice sessions with other staff. If the most difficult interaction for you is a demanding patient who wants more pain meds, spend your lunch with a co-worker acting out the script. Start the role-playing by recognizing that there is an emotion, identify the emotion and call attention to it. Ask an open question and listen to the patient s story. Maintain eye contact and make sure that you re calm, your body language is congruent with your words, and that you re listening reflectively. Respond with an empathic statement, such as I m sorry, I can t imagine what you re going through. I can t imagine how hard that is for you I d like to see if I can help you with that. After you ve rehearsed a few times and feel comfortable with the script, try practicing it with your patients. These words and skills will help the patient know you care about them. Tips for Managing Difficult Interactions Focus on mastering one technique before you start the next one. As a result, managing difficult interactions successfully will take time. Here are some of the tips to follow that will help you get there: Acknowledge if you feel bad during or after a difficult encounter. Pay attention to any physical symptoms that might be brought on as the result of your unresolved anger, fatigue, stress, depression and so on. Talk with other office staff about the problems you re having; ask them for advice on how they deal with similar situations. When you can t make progress dealing with a difficult patient, no matter what or how hard you try, ask your supervisor to reassign them to another caregiver. Leave your work issues at the office. Don t take them home with you. Take care of yourself and your health. Don t be afraid to call a co-worker s attention to their symptoms of extreme fatigue, stress and changes in their behavior as the result of the unresolved issues. Their problems can damage the health and well-being of everyone else in the office, as well as impair patient encounters. If you can, help them address and resolve their issues. And document and report any threats of lawsuits or physical action against you or others to your supervisor. If you are an office manager, there are additional steps you can take: Provide training for all the staff in handling difficult interactions, and Report any incidents or threats of violence that occur in the office to the proper authorities. In the past, has your office offered training in techniques to handle difficult interactions? Summary Now, let s summarize the main points in this course: A difficult interaction occurs when at least one person is uncomfortable with the emotions or demands of the other person. Usually, that other person is a patient, but it can be anyone you interact with during the day. The most important thing to do is to identify and understand the types of behaviors and emotions that are difficult for you to handle, and then learn how to handle them. Anger is considered a secondary emotion because it masks another, primary emotion, such as sadness, fear or anxiety. It s always helpful to discover what the primary emotion is by listening to the patient and understand what they re saying and try to identify the primary emotion and then deal directly with this main issue.
Page 7 The costs of difficult interactions include personal dissatisfaction, patient dissatisfaction, poor patient outcomes and increased malpractice claims. Unless you find a solution to dealing with a particular emotion, it may be part of a difficult interaction, and you ll see it come up again and again with different people. Medical interactions provide both information and emotion in a short period of time. You must separate the information from the emotion but understand both. The seven effective communication techniques are equally useful in dealing with difficult interactions: introducing yourself, ensuring congruence between verbal and nonverbal communication, building rapport and engagement, asking open-ended questions, listening reflectively, educating and communicating final instructions, and practicing effective phone communication. There is another effective procedure to help you deal with the most difficult interactions: o Take a time-out to clarify your thoughts and feelings. o Continue to pay attention to the nonverbal cues you see in the patient. o At the same time, understand your own feelings and how you re being affected by the encounter. o Recognize that something has gone wrong. o Build rapport by asking about what s going on in their life. o Ask open questions then listen reflectively to the patient s complaints. Role-play the situation. Write a script in which you deal with difficult interactions through words and nonverbal communication. Finally, managing difficult interactions successfully will take time. Until you ve mastered these techniques, don t bottle up the negative emotions you experience. Conclusion of This Course In summary, before you can manage difficult interactions, you should remember which emotion or behavior is the most difficult for you. Then you can work on resolving it. If you have a patient who seems upset, you need to understand them, and then they need to understand you. Finally, difficult interactions are common in office situations, and you can t avoid them; so, work toward effectively resolving them. Use the techniques we ve described, and seek training in managing difficult interactions.