Teaching About the Challenging Patient Visit:Focus on Perspective

Tracy Kedian, MD

Alexander Blount, EdD

Objectives• By the end of this session participants will be able to:

– Recognize the techniques used by experienced providers in challenging encounters.

– Identify barriers to teaching perspective taking with in a challenging patient encounter.

– Describe 2 techniques for teaching perspective taking in a challenging patient encounter.

– Apply the RAP strategy in a difficult patient encounter.

Chief Concern

“The chief complaint is merely the opening to the physician-patient

conversation.”Desmond, 2003

Challenging Visits

• We all have been in patient visits which:– Hang us up– Frustrate and anger us– Make us think “there is no hope for this one”

• As experienced providers, we may have more strategies for finding the kernel of potential in the relationship with our challenging patients

When is this difficult?

When do we find perspective taking most challenging?

– Personality Disorders– Narcotic Seeking– Addiction– Disability Seeking

When we cannot bridge the gap between our perspective and theirs

What Do You Do?

Your patient is a 35 year old mother of three who is parenting alone. She has quit her job because she is overwhelmed by the responsibility of caring for her children with no help and working. She says she is not depressed but needs you to tell the state she is disabled because she cannot manage to work. She won’t go to counseling. She won’t visit with the social worker in your office. She just needs you to fill out this form. She knows if she can just stay home from work, she will be able to cope.

But as a teacher?

A first year resident comes to the library to precept this visit.

Taking Care

• Of our Learner– Reflect– Validate– Instruct

• Of our Patient– Reflect– Validate– Negotiate

What Does Your Learner Need To Know?

• Reflection

• The value of listening

• Insight into one’s own biases

• How to express a caring attitude

• How to form and communicate a consistent plan

What are the patient’s expectations?

How do you forge a relationship while saying no?

A Story about Perspective

Once upon a time in Austria, a group of school children came upon a large house with an iron fence around it. In the front yard, they could see an old man crouched down waddling in the tall grass and quacking like a duck. They stopped to watch the strange sight and the crazy old man. The information that would have changed the meaning of the scene was hidden by the tall grass.

Konrad Lorenz, Nobel laureate in Medicine, was being followed by a group of ducklings. Here he is studying imprinting in geese. Turns out geese imprint by sight, ducks imprint by sound. For geese to think he was their mother, he had to be there at the hatching. For ducks to do the same, he had to be the first thing that said “quack” to them after they hatched.

Perspective Taking on Sesame Street

“Oh, the big becomes the little

If you take it back a bit.

That’s about the size of it.

That’s about the size,

Where you put your eyes,

That’s about the size of it.”

Exercise in Perspective Taking

• Tell me a story of a case, a patient where you were pretty sure you knew what the patient’s situation was and then something happened that made you understand their situation in a completely different way.

• Let the stories get going. Many will have one. Then get them to design a plan or a process that will be more likely to find out the perspective changing information earlier on.

• When we ask our learner about non-adherence, what is their perspective?

If the patient is not on board with the plan, why doesn’t that story come

across?

• The Classic Reasons – Subject too sensitive– Lack of established relationship – Insufficient time

More Subtle Reasons

• Missed Non-Verbal Hooks and Cues– Look of surprise/fear– Sighs

• For many patients is it not OK to question or give voice to doubts and fears– They don’t want to insult you by challenging

your medical competence.

Words have different meanings

• Shock– Circulatory collapse– An upsetting surprise

• Depression– Sadness and Anhedonia– Crazy – Abnormal - Unfit

True Cultural Divide

• The Body– Confluence of energies?– Humors?– Discrete organs with

biochemical communication?

Eight Questions• What do you call your illness? What name does it have?

• What do you think has caused the illness?

• Why and when did it start?

• What do you think the illness does? How does it work?

• How severe is it? Will it have a short or long course?

• What kind of treatment do you think you should receive? What are

the most important results you hope to receive from this

treatment?

• What are the chief problems the illness has caused?

• What do you fear most about the illness?

Arthur Kleinman, MD Department of Psychiatry

Harvard Medical School

Expectations Differ

• Patient desires an “MRI to look for cancer”– Presents with a symptom which we spend

time exploring rather than their concern and desire for the MRI

• What are you worried about?

• Do you know anyone who has had this before?

• What do you think might be going on?

• What do you think might help us to find out?

Techniques to Teach Perspective Taking

• Where do we start?

An exercise to teach using positive attribution to improve the doctor-patient

relationship...

Ask the learner to list the attributes of patients they don’t like to work with in one column and the

attributes of patients they do like in another column.

The list usually look like this:

• Patients we don’t like– Demanding– Unreliable– Unmotivated– Non-compliant– Suspicious– Don’t care– Late– Lots of issues– Drug seeking

• Patients we do like– Compliant– Clear issue– Takes care of self– Informed– Honest– Involved in own care– Trusting– Motivated– Interesting

If attribution is the most effective form of influence (and it is):

• Think of how patients you have described in the left hand column could be described by the words in the right hand column.

• Practice describing the behavior that was troublesome to you using the new adjective with the person next to you.

• Notice how it changes the dynamic for the doctor and patient.

A Matter of Perspective?

• Can working with the ever challenging “chronic pain patient” be considered an exercise in perspective taking?

The Perspective Divide

• Do:– Learn about their illness– Make a contribution to pain

management– Make them feel

heard/attended to

• Don’t – Make bad decisions

regarding pain management

– Contribute to an addiction problem

– Feel/be “used”

• Do– Find a provider who listens– Get relief– Get support/paperwork– Feel validation

• Don’t– Feel disrespected– Leave without what you

“need”

Provider Patient

Bridge the Gap:Elicit their perspective

Reflect

Assess

Plan

Bridge the Gap:Elicit their perspective

• Reflect– On their own biases/experiences– On how the patient arrived at this perspective

• Assess– What can actually be done and what cannot

• Plan– Negotiate shared goals

Our Learners Can

• Elicit the patient’s perspective

• Validate their symptoms

• Affirm their commitment to helping

• Assure the patient of our concern

• Offer other possibilities

Small Groups