Managing Difficult
Conversations
Social Psychology 201
For ED’s
Stephen H. Anderson M.D., FACEP
President, WA State Chapter ACEP
Seven Conversations
• Grieving
• 1) Someone is dying/ died.
• 2) Your child is going to have a bad
outcome.
Seven Conversations
• Sheriff/ Parenting
• 3) I think you have a drug/ alcohol problem.
• 4) I think you’re here too often.
• 5) Why are you REALLY here?
Seven Conversations
• Colleague/ Political
• 6) I disagree with you as a colleague.
• 7) That’s not how administration foresees it.
Overlying Principles
• There are rules/ givens.
• You have to listen.
Principles
• Know your allies…
• Know their allies.
• Find your support…
• Find their support.
Principles
• Believe in WIN- WIN.
• To thine own self be true.
• Document.
There Are Rules/ Givens
• Some are hard…
• Some are soft.
• Some are “ours”…
• Some are “only mine”.
There Are Rules/ Givens
The Key
Ownership
You Have To Listen
• Conversations are two way.
• Find out their goals.
• Find out their fears.
Give them enough rope…
Know Your Allies…
• Rally your troops.
• Build your allies.
Do you want to be an expert witness?
Know Their Allies…
• Introductions for EVERYONE.
• Note “Alleged Allies” not present
Acknowledge as appropriate.
Find Your Support
Find Their Support
• Key to the Grieving Conversation
• If you’re headed to war…
take them with you.
Believe In WIN-WIN
• Try never to define your win,
by their loss.
Believe In WIN-WIN
• Listen
• Repeat back
• Work toward a common goal
• Compromise?
To Thine Own Self Be True
• Never Lie
• Never Lie
•Never LIE!
These Are Difficult
Stressful
Conversations!
• Debrief
• Avoid being the one with the disease
Not All Conversations
Will End WIN-WIN
• Some won’t end.
• Have an exit strategy.
Document
• ANY conversation with “potential” is
worth documenting.
• Two documented views are better
then one.
• “They” know how to document too!
Someone Is Dying/ Died
• It’s someone’s job,
take ownership.
#1
• Find your support
Most
• Find their support
Important
Someone Died
• Focus on the closest,
talk to everyone
• Listen
• Account for beliefs/ cultures
• Physical contact, the “healing touch”.
Someone Died
Goals To Express
• 1) We did everything appropriate.
• 2) Address pain & suffering.
• 3) “Now we are here to help you…
& others.”
Someone Is Dying
Don’t lie
Don’t steal hope
Be realistic
Someone Is Dying
Listen ( Is the PATIENT speaking through an advanced directive?)
Find your support/ Find their support
Start the conversation
Geography/ proximity
Your Child
Is Going To Have
A Bad Outcome
• Find your support/ Find their support
• Don’t steal hope
• Be honest “in that moment”
Bad Outcome
Negative attitude leads to
negative outcomes…
Blame is for later
Bad Outcome
• Child’s safety first
• When do you include the
child in the conversation?
I Think You Have A
Drug/ Alcohol Problem
Society/ Legislature/ Peers now tell us
We MUST have these conversations
THIS is the pivotal time.
Drug & Alcohol Problems
The Principles
• There are rules/ guidelines
• Listen first
• Your allies/ their allies
“Their support” might turn out to be your best ally!”
• WIN-WIN
• Be true to yourself
Drug & Alcohol
Tools to Help
• Old Records
• EDIE
• WA state Prescription Monitoring Program
Educate patients that these exist
I Think You’re Here Too Often
PRC
Patient’s
Requiring
Co-ordination
You’re Here Too Often
New WA Hospital Requirements
• Identify PRC clients upfront
• Notify their PCP of visit
• Discharge patient with instructions along:
“the right patient-to the right place-at the right time”
Shouldn’t be a punitive discussion
You’re Here Too Often
“You’re Unique, but…”
Educate
“The Econ Lecture”
Why Are You REALLY Here?
• Constructively focuses the scatter.
• Gives an opening to the REAL difficult
conversation.
NEVER demean the answer
I Disagree With You
As A Colleague
Fatal Error VS. Difference Of Opinion
Fatal Error
Success comes through education first
Difference of Opinion
With A Colleague
Praise in Public/ Debate in Private
Ask yourself going in:
What’s my goal?
Am I a team builder?
How can I make this WIN-WIN?
Focus on the patient
Difference Of Opinion
With A Colleague
• Listen
• Agree on the easy, Work toward the hard.
• Set the stage for “The Next Time”
• If necessary, use the chain of command.
That’s Not How
Administration Foresees It
Administration’s Viewpoint
The Golden Rule
1)
Do unto others, as you would have others do unto you.
2)
Those with the gold, make the rules.
Every pathway has an economic angle.
Administration’s Viewpoint
What brought you to the table?
1)
What do they need from you?
2)
What motivates you?
Principles
Priorities
Administration’s Viewpoint
Great leaders
get input from
great followers
Managing Difficult
Conversations
• There are rules/ givens
• You have to listen
• Know your allies/ know their allies
Find your support/ find their support
• Believe in WIN-WIN
• To thine own self be true
• Document