Daniel O’Connell, Ph.D.
1816 1st Ave. W.
Seattle, WA
206 282-1007
danoconn@u.washington.edu
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Managing Difficult
Interactions with Patients
and Families
Adopted with permission from Copyright 1996, rev. 2002, 2005 Institute for Healthcare Communication
New Haven, Connecticut
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Objectives



To recognize and diagnose the causes of difficult
interactions
To learn strategies for navigating difficult
interactions more comfortably
To choose 2-3 strategies to apply in the next month
when sensing a difficult encounter is developing
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P R E M I S E S
“Difficult” is a function
of the interaction

Two or more
people

How they
interact?”

What is the
difficulty vs.
why are you
being so
difficult?
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The Mantra


You are not the problem
They are not the problem


Although it often seems that way
The problem is the problem

So what is the problem?
5
A M O D E L
Relationship difficulties
develop when….
• Success
is frustrated
• Expectations
are misaligned
• Flexibility
is insufficient
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Questions for patient, family and
yourselves

Successful outcome:


Specific expectations:


“What is the outcome that you were hoping for?”
“Was there something specific that your were
hoping we would do now/today about this?”
Flexibility:

“How open are you to considering a different
approach?”
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Procedures to improve
situations & relationships

Acknowledge and Assess Problems

Boundaries - Adjust

Compassion – feel it and show it

Discover Meaning – curious not
furious

Extend the System – to include others
for help vs. send to….
ACKNOWLEDGE
Pause to clarify thoughts
and feelings
• Recognize your
thoughts, feelings,
and their impact.
• Acknowledge the
difficulty and start
to assess its cause
and solutions
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ACKNOWLEDGE
Assess the difficulty
Which area(s)
What problem's)
•
Success
is frustrated
•
Expectations
are misaligned
•
Flexibility
is insufficient
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ACKNOWLEDGE
Acknowledge the
Difficulty to the Patient




“I can see that you are feeling frustrated.”
“Maybe I haven’t understood you
correctly. Let me summarize what I think
you have told me and you can correct me
when needed.”
“I can see that you were hoping there
might be a simpler way to address this.”
“This is not going the way you expected.”
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ACKNOWLEDGE
Act to build a partnership
• Encourage joint problem
solving:
“I’d like to work with you on this ,
even though we see some
things differently.”
“What have other doctors told you
about this in the past?”
“We will try to make that happen.
Let’s also talk about conditions
that may call for a different
approach”
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BOUNDARIES
Find Solid Ground
 Is
this a safe and effective way to
approach the problem?
 Is it likely to cause more harm than
good?
Best practice rather than personal
feeling
“We have learned…” rather than "I
am not comfortable with this…”
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BOUNDARIES
Set limit on yourself, rather than the
patient
“Let’s think about this together for a
moment. I’m open to any approach
that has shown to be safe and
effective. I just couldn’t allow myself
to prescribe something that could
cause more harm than good”.
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BOUNDARIES
Clarify your criteria for
common requests
“There are 4 criteria we use to
determine if Percocet is the safest
and most effective way to treat
these problems”
“The state wants physicians to use
3 criteria when deciding whether
to approve a disability request.”
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BOUNDARIES
Tell patients what you need
from them:

“For me to be effective though
I’m going to need your help.
Would you be willing to
________?”


“Please try to get here a few
minutes before your appt time
so we will not be so rushed
during your next visit.”
“Here in the office I go by Dr.
O’Connell.”
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BOUNDARIES
Interrupt and structure to
establish focus if needed

“Let me interrupt for a moment to see if I am
understanding this correctly.”

“Let’s first make a list of your concerns and
then we can take then one at a time. OK?”

“Maybe you can appoint a spokesperson
who can stay with Brenda in the exam room
to support her and keep the family up to
date. Would that be OK?”
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BOUNDARIES
Close boundaries
around time

Note and manage time proactively
“I can see that I am running short of time
and wanted to be sure we have a plan in
place for the issues we discussed before I
have to step out to see another patient.”
“I just have a moment now but you have my
undivided attention.”
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COMPASSION
Compassion is Empathy +

Recognize emotional moments
“I see you’re upset. Can you tell me what is
going through your mind.”

Seeing it through the patient’s eyes
“It is natural to feel upset at times like these.”

Short summaries show understanding
“So It seems that this has been getting worse
rather than better and you are losing hope for
improvement?”
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COMPASSION
Compassion is Empathy +

Notice the story you are telling yourself that
is upsetting you

Can you be absolutely certain that is true?

How do you feel and act when you tell yourself
that story?

How would you be feeling and acting if you told
yourself the most compassionate story you could
think of consistent with reality?
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D I S C O V E R
The patient/family has
expectations for the visit

Ideas, Self Diagnoses, Concerns
“What do you think is causing this/making it worse?”
-“I think I may have cancer.”

Expectations
“Was there something specific that you were
expecting we would do today for that?”
- “I was hoping you’d give me an antibiotic.”
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D I S C O V E R
The illness has meaning
for the patient
Ask about/pay attention for:
 Feelings
 Impact on function
 Personal meaning
 Context of personal and family history
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D I S C O V E R
The visit has meaning
for the patient

What is the meaning of the patient’s request?
“What were you thinking an MRI scan might reveal?”

Why is the patient coming in now?
“How did you decide to come in to see me at this time?”

Consider that the patient probably consulted others before
the visit (family, friends, co-workers, or the internet).
“Are there people at home who have an opinion about what is
going on here or what we should do next?”
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D I S C O V E R
Clinicians have “hot buttons”
-Recognize and own yours
Attitudes depend on past experience and get
projected onto the current visit

We tell ourselves a story and that story
shapes our emotions and our behavior

“They are challenging my expertise.”

“They refuse to be responsible.”

“They just want to make trouble.”
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E X T E N D
Extend the system
-When you are not enough
Family members

Friends and co-workers

Other health care professionals

Spiritual advisors

Support groups
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E X T E N D
“Including in” rather than
“referring out”

“I think we could use the help of a ____________ to
figure this out/better solve this problem”

“I would like to get the thoughts of a
psychiatrist/psychologist about how we can better
help you cope with this. What do you think?”

“Perhaps your mother/husband/boyfriend could come
to the next visit and we could think this through
together. Does that make sense?”
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S U M M A R Y
Relationship “difficulties”
develop when...
•
Success
is frustrated
•
Expectations
are misaligned
•
Flexibility
is insufficient
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