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10/17/2017 Denise L. Davis, MD, FAACH Clinical Professor of Medicine UCSF Associate Director for Faculty Development SFVAMC Center of Excellence in Primary Care Education I have no actual I have no actual or potential or potential confli conflict of interest in relatio ct of interest in relation to to this progra this program/presentation. m/presentation. 1

10/17/2017 Think about a recent success with a difficult patient 2

10/17/2017  Share best practices in managing difficult patient encounters  Recognize common themes in difficult encounters  Review “basic life support” skill in medicine- communication  Using your own cases, practice 1-2 new skills 3

10/17/2017 “To have striven, to have made the effort, to have been true to certain ideals - this alone is worth the struggle. “ William Osler  Different E rent Expectati ctations ns  Anger Anger  Cultural Differences/Bias/I Cultural Differences/Bias/Inequity equity  Emotional Distress  Psychiatric Disorders  Bad News  Errors  Difficult Doctors  Burnout 4

10/17/2017 • How many patient interactions in your day? In your career? > 200,000 in a lifetime • Less training, practice, and feedback than other less common procedures • Difficult patient encounters add complexity Health outcomes  Safety  Adherence to treatment plans  Satisfaction with experiences of care  Informed consent  Trust and loyalty  Safran et al, J Fam Pract 1998; Stewart et al, J Fam Pract 2000; Levinson et al, Health Affairs 2010; Dwamena et al, Cochrane Database Syst Rev 2012 5

10/17/2017  Engagement  Satisfaction  Workload stress  Medical malpractice Levinson et al, JAMA 1997; Krasner et al, JAMA 2009 Skills: Skills: Create rapport immediately-warm greeting, A. introductions, roles, use patient’s name, sit down, address comfort Elicit ALL ALL concerns “What else.. What else..?” B. Negotiate the agenda “Could we talk about A. the abdominal pain now and let your PCP manage your toenail fungus?” 6

10/17/2017 Skills: Skills: A. Explore ideas, concerns and expectations (ICE) B. Express empathy  A sk open-ended questions  R espond with a summary or empathic statement  T each from your perspective Schillinger et al, Arch Intern Med 2003; Schenker et al, Med Decis Making 2011 7

10/17/2017 A 59 yo man with hx alcohol use disorder and HTN is admitted with LLQ pain, fever, WBC 22K and CT consistent with diverticulitis and perforation with intra-abdominal abscess. He wants to go home right now on po abx. 8

10/17/2017 • Step 1 Step 1 - Set the Stage et the Stage (Build Rapport, Elicit Agenda, Negotiate Agenda) • Step 2 Step 2 - Elicit and Respo licit and Respond to d to Patie Patient’ t’s Perspectives Perspectives (Ideas, Concerns, Expectations) and Express Empathy • Step 3- Step 3- Negotiate a Negotiate a Shared Plan ARTfully Shared Plan ARTfully (Ask, Respond, Teach) 9

10/17/2017 “I don't have to attend every argument I'm invited to.” Author Unknown 10

10/17/2017  Think of an angry patient you have seen- Difficulty level Difficulty level 3-4/10 3-4/10  In groups of 3, present 1 liner: “ I saw a 34 yo man, angry about waiting for 6 hours in the ED before he was admitted for an obstructing kidney stone.”  You have 5 minutes for entire group to share cases  To earn an A: respond to your colleagues with empathy!  Use early warning systems  STOP and (temporarily) let go of your agenda  Reflective listening  Empathy:PEARLS 11

10/17/2017 • Avoidance • Dread “ • Annoyance • Irritation • Fatigue • Feeling unheard/disrespected N Jensen, P Weiss, AACH STOP Give up on the apparent task at hand New Objective Listen for feelings and respond actively 12

10/17/2017 “ I I think I think I hear you sayi hear you saying…” or ng…” or “are you feeli “are you feeling..” g..” …no one is listening to you …you’re helpless to make things better …you’re afraid she won’t ever be herself again …nothing is going right …you’re worried about what will happen next …you can’t trust us Paraphrasing – listener makes a major restatement in which the speaker’s meaning is inferred “ You’re saying it seems like I didn’t care enough about you to take care of your pain. Is what your experience was ?” Adapted from Motivational Interviewing materials by David B. Rosengren, Ph.D. and from Motivational Interviewing by Miller & Rollnick, 1991 13

10/17/2017 Partnership nership: “I would like to work with you tonight on making you more comfortable Empathy Empathy: “ This seems like a sad situation for you” Apo Apolog ogy: “I made a mistake…I’m sorry” Respect: Respect: “I respect your honesty” Legitimization: gitimization: “Anyone would feel frustrated in your circumstances. ” Support: Support: “Would______ be helpful?” AACH Clarke, Fry, Hewson Made Made Didn’t make Didn ’t make empa empathic thic empathic empa thic state statemen ents ts state statemen ents ts Internists 16 min 18 min visits visits Surgeons 14 min 16 min visits visits Levinson et al, JAMA 2000; Hojat et al, Acad Med 2011 14

10/17/2017 “Today was a difficult visit. I would like to work with you to make our visit better when we meet again tomorrow.”  In groups of 3, using you own case, practice 1-2 skills: reflective listening and empathy statements until the “patient” says “yeah” 15

10/17/2017  The incidence of heart failure in young African American men is 30 times that of young white men (1)  Compared to neighborhoods with long-term low poverty, those with long-term high poverty and those that experienced increasing poverty early in the study period had 41% and 37% increased odds of pre-term birth (2)  Blacks and African Americans suffer from kidney failure more than 3 times higher than Caucasians. (3) 1. K. Bibbins-Domingo and Others NEJM Med 2009 2. Am J Public Health. 2015 3. 3. National Kidney Foundation 2016 16

10/17/2017  Hierarch Hierarchy: y: “ You know your own body. What do you think would be healthiest for you ?”  Educ Education: Address “White Coat Silence” with a menu of common questions (1)  Ackno Acknowledg dge: “ Though I wish it were not true, you’re right, African American patients have not received the same quality of care as others”  Respect: Respect: “ I have a great deal of respect for you and your openness to talking, given the difficulties you’ve had today.”  Timing and Trust: Timing and Trust: “ Trust takes time. I want to earn your trust” 1. Judson JAMA 2013 17

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