CHAPTER 6

Challenging Conversations with Patients

In Chapters 3–5 we introduced the fundamental communication skills that foster effective connections and relationship-centered care. Participants in our courses often say that they imagine the skills will be effective with patients that they get along with, but worry that the skills will fall short with the patients who are bringing their experience scores down. Clinicians seem most distressed when they have to break bad news, manage high levels of emotion such as anger or mistrust, and address expectations they can’t satisfy. In this chapter, we offer suggestions for how to apply the fundamental skills in the context of these challenging encounters.

All of these situations involve problems that clinicians can’t fix. There’s no prescription or procedure that will alleviate the grief that comes with a cancer diagnosis or the anger of patients who feel that the medical system has betrayed them. Many of us notice that these conversations distance us from our patients and as a result, we may believe we’ve failed. Though we truly can’t control others (as much as we would like to), we can support patients through these difficult times and enhance our connections by relinquishing control and using the very relationship-centered skills that we’ve become familiar with.

When Emotions Are Running High

Our core communication skills are invaluable when emotions are running high. Strong emotion can’t be ignored. People who are overwhelmed with grief, fear, or anger can’t take in new information or form relationships. The emotions must be addressed before anything else can be done effectively. Emotions are contagious; when we encounter someone who is angry, we may feel angry ourselves. Our emotional level will rise in response to theirs. Instead of communicating our distress, we can manage our emotions by cultivating an awareness of our physical responses and choosing words that will express our empathy for the other person.

I (Jenni Levy) met Ms. King when she was admitted to our inpatient hospice unit. She was 38, and she had metastatic cervical cancer. Her partner, Ms. Long, sat by the bed. Ms. Long had supported Ms. King through the terrible six weeks since her diagnosis and planned to be there until the end. Ms. King made it clear to the hospice staff that Ms. Long was to make her decisions when she could no longer do so, and she filled out all the paperwork to make that legally binding. “You’ll have a bad time with my parents,” she told me. “I apologize in advance.”

Ms. King’s parents came to visit the next day. They were furious. They did not agree with their daughter’s choice of hospice care. They were convinced Ms. Long was influencing their daughter, and they blamed her for what they saw as a late diagnosis. They wouldn’t speak to Ms. Long; when they were alone with their daughter, they spoke so harshly to her that the nurse ordered them to leave the room. The nurse, who was so angry and upset that she was in tears, warned me when I arrived. I was apprehensive and took some time to gather my thoughts and catch a few deep breaths before entering the room.

Ms. King’s parents were sitting in the family counseling room with their arms and legs crossed, girding themselves for battle. Mr. King stood up and pointed at me when I walked in. “You WILL send our daughter back to the hospital. We are her next of kin. We are legally allowed to make her decisions.” Mrs. King nodded. He continued: “She can have more treatment. We will not allow that woman to send her to an early grave.”

How would you feel in that situation? I felt angry and defensive. How dare they act so aggressively! My heart was pounding and my mouth was dry. I wanted to scream, “You will not speak to me that way!”—but I knew that would only escalate the confrontation with Mr. King. I took a deep breath and sat down. It’s easy to empathize with people who react in a calm, thoughtful manner. How was I supposed to connect with a man who was threatening me? When I don’t know what to do next, I have learned to try a PEARLS statement (see Chapter 4). I remembered what other parents had told me about the tragedy of watching their children die, and I remembered the times when my own grief had caused me to lash out in anger.

I looked up at Mr. King and said softly, “I can’t imagine how difficult this time has been for you.” He dropped the hand he had been pointing at me. “You love your daughter very deeply.” He sat down. His wife started to cry. I no longer felt threatened. I was able to see them as grieving parents, and my own anger started to fade.

Over the next half hour, they told me about their only daughter. They talked about her high school soccer trophies, her difficulties in college, her brief marriage to a man they thought was perfect for her. They both cried when they told me how distant they’d been for the last two years since their daughter came out to them and moved in with her partner. If only they’d known … if only they’d seen her more often and realized how sick she was, they would have done something sooner. Ms. Long should have done something. This shouldn’t be happening.

I listened and reflected what I heard: their love, their frustration, their confusion, their anguish, and their grief. Of course they were angry. Anyone in their situation would be. I realized that I couldn’t change their minds about Ms. Long, as much as I wanted to defend her. When we walked out of the room, they both hugged me and then went down the hall to sit with their daughter, peacefully.

Mr. and Mrs. King’s outbursts were increasing their daughter’s suffering and causing distress for her partner and for my staff. Early in my career, I would have stood up to Mr. King and matched his anger with my own. Years of practicing these skills gave me a better choice. I was able to build a relationship with Mr. and Mrs. King that allowed them to trust me and to express the grief I knew they were feeling—the grief that I suspected was the real cause of their anger. I didn’t try to educate them about hospice care or the legal issues of advance directives. I tried not to think of them as unreasonable, demanding, or homophobic; I concentrated instead on their love for their daughter, their sadness, and the regret I heard as they told me their story. When I used reflective listening and PEARLS statements, Mr. and Mrs. King felt understood and were able to move past their own defensiveness. By the end of the conversation, they wanted to feel connected to their daughter again more than they wanted to force her to leave hospice care.

Not all confrontations end this well. When Mr. King stood up and pointed at me as I walked in the room, I wondered if I was in physical danger. I left the door open until he sat down and I felt the tension ease. If he had continued to physically intimidate me, I would have ended the conversation until I could come back with a colleague.

In this case, the cause of the distress was directly related to the work I needed to do with this family. I had to abandon my agenda and spend the entire visit building a relationship and helping them process their feelings. This enabled me to have another conversation the next day, during which we reviewed their daughter’s advance directive, and I explained that we were obligated to follow it. If I had tried to have that discussion at our first encounter, it would have exacerbated their anger and sabotaged our relationship. The investment I made in the first half hour I spent with Mr. and Mrs. King paid off for the rest of their daughter’s stay in our facility.

When a patient is angry or upset about something outside of the encounter such as family trouble, work difficulties, or frustration with the medical system, you may not feel it’s appropriate or necessary to address that in your discussion. The problem may exist outside your exam room, but the emotion comes right in with the patient. If you can identify the distress early in the encounter and provide support and empathy, the patient will feel relieved and the emotion itself may subside, allowing you to move on. If the patient remains angry, anxious, and preoccupied throughout the visit, he or she is less likely to retain any information that you offer and to follow the plan that you develop.

In instances when emotions are running high, practice the following skills:

•   Cultivate awareness of your emotions and manage your own distress.

•   Safety first; if your physical safety is threatened, walk away.

•   Focus on the relationship by using PEARLS statements to express empathy and understanding.

•   Be willing to abandon your agenda in favor of support and relationship.

•   The primary goal is support of the patient/family member, not getting someone to agree with you.

Breaking Bad News

Ask medical students and clinicians about breaking bad news, and they will respond with stories about cancer, traumatic accidents, and HIV. These are devastating, life-changing diagnoses to be sure. But our patients may have different ideas about what constitutes bad news. The receiver of bad news, not the giver, is the one who will have the emotional reaction. Therefore, though we may have an idea of how a patient might hear it, bad news is defined fully and solely by the receiver.

Mr. Richards was 52 years old when he saw me for the first time. “I’ve been having a hard time lately,” he told me. “My last doctor gave me some really bad news and he was—I don’t know, kind of glib about it. I just had the sense he didn’t care at all.”

“What was the bad news?”

“He told me I have diabetes. My grandfather had diabetes, and he lost both his legs. I’m a healthy guy. I try to eat right, and I work out. I never thought I’d have diabetes. I didn’t even know they were looking for that—it was a routine blood test. The doctor just told me, bam, like it wasn’t a big deal. I don’t even remember what else he said, and I never took the pills he gave me. Since then I’ve had a hard time sleeping because I’m so worried. I don’t want to lose my legs or end up blind or on a kidney machine.”

As clinicians, it’s easy for us to think of diabetes as routine. We see it all the time. It’s a chronic illness. It’s so common that most of our patients will know someone who has diabetes. They may be aware of the potentially devastating complications. That can make something we consider a routine diagnosis to be truly devastating news for a patient.

When we use the ART (Ask, Respond, Tell) method (see Chapter 5) to break bad news, we can avoid the trap Mr. Richards’s first doctor fell into. We can support the patient through sometimes unexpected emotional responses, so that he or she can process the information we are providing.

I wanted Mr. Richards to know that I heard what he told me about his fear, and I wanted to express my willingness to work with him. After I asked Mr. Richards, “What was the bad news?,” I responded with statements of legitimization, apology, and partnership:

“I can see how terrifying it was for you to get that news. I’m sorry to hear that you feel that your other doctor didn’t understand you. I hope we can work together so you understand how you can take care of yourself and be as healthy as you can be.” He said, “Thanks, Doc,” and looked calmer.

Then I addressed the concern he’d expressed. “We have a much better understanding of diabetes than we did in your grandfather’s day, and we can prevent a lot of the complications he experienced.”

I might have gone on to talk about HgA1c monitoring, oral medications, insulin resistance, reducing carbohydrates, finger-stick glucose testing, and the other details essential to someone with a new diagnosis of diabetes. All the information would likely have been overwhelming to Mr. Richards and might have left him again confused about what he needed to do. We are much more effective when we “chunk and check” by offering small, comprehensible pieces of information and then checking for understanding (see Chapter 5). “We have several medications that can help get blood sugar under control. What do you know about medicine for diabetes?”

That’s the Ask for another cycle of ART. In this visit, I wanted to initiate treatment with one medication and refer Mr. Richards to the diabetes educators. The referral required its own ART cycle. At each step, I checked in with Mr. Richards to see how he was responding. He was open to the idea of taking medication and was grateful for the referral. He wanted to learn more about managing his diabetes. He felt calmer with the increased understanding and support. I had a sense that he was much more likely to follow through on the plan (and to sleep through the night again). Providing information in small, manageable chunks using ART, checking understanding, and making empathic statements helped Mr. Richards cope with both the news itself and the emotional turmoil that he was feeling.

In instances of breaking bad news, practice the following skills:

•   Use ART (Ask, Respond, Tell) to elicit understanding, express empathy, and deliver information.

•   “Chunk and check”—don’t overwhelm the patient by downloading data.

•   Give the patient only the information he or she needs to get the next step of care; more information can follow later.

Unmet Expectations

Unmet expectations are another type of bad news and can be approached in much the same way. These conversations also require strong attention to the clinician’s own emotions and reactions.

Mr. Martin was 34. He worked in construction and had been pushing through his back pain for weeks. The pain was now worse despite chiropractic care and over-the-counter medication, and he came to the office to get an order for an MRI. He had no evidence of nerve impingement on examination and his pain was limited to his lower back, where he had evident muscular spasm and decreased range of motion.

Mr. Martin presented his request for testing as his primary complaint: “I need an MRI.” This type of request can also become clear in the second set of communication skills when we ask about ideas and expectations (see Chapter 4).

I suspected that Mr. Martin would be upset with my assessment and suggestions for treatment. I did not believe he needed any imaging, and hearing that would likely be bad news for him. As I transitioned to the close of the interview, I reflected what I’d heard and made a statement of partnership before telling him the bad news:

“The pain is making it hard for you to work and keeping you awake at night. You’re worried that you have a slipped disc, and you asked me for an MRI. I really want to work with you to improve your pain. And, I’m afraid I have some news that might be hard to hear: I don’t think you need an MRI.”

This was the beginning of an ART cycle. There’s a lot more information I could have given Mr. Martin about MRIs and lower back pain. I didn’t know what information would be most helpful for him. I knew that if he was angry that I wasn’t ordering the test, he wouldn’t really hear anything I said. And he was angry.

“You’re just trying to save the insurance company money. Do they pay you more if you say no?”

That insinuation made me angry, but striking back at him wouldn’t help. I tried to speak to the concern that I thought might lie under his accusation, using a reflective statement. This was the Respond portion of this cycle of ART: “You feel really strongly about getting that MRI. It’s very important to you.”

“I know I need an MRI to check out my discs.”

I wanted to tell Mr. Martin that MRIs are only necessary to guide operations. Before I did that, I responded, using legitimization. My Tell was very brief and was followed by another Ask: “Lots of people want an MRI for their backs, and with all the football players getting MRIs every time they turn around, I can understand why.” (Respond) “MRIs are crucial for people who need back surgery.” (Tell) “Do you think you need surgery?” (Ask)

“I sure hope not. Do you think I need an operation?”

“No, I don’t. I didn’t find any evidence of nerve damage when I examined you. You have a lot of muscle spasm, and I think that’s causing most of your pain. The MRI won’t tell us anything about that, and it wouldn’t change the treatment I’m going to suggest.”

Mr. Martin still wasn’t happy about my answer, but he knew I understood his concern, and he was starting to trust our relationship. He sighed and asked, “What kind of treatment is that?” I began the next ART cycle: “I’d like you to see a physical therapist. What do you know about PT?” He said, “I know it usually hurts more after you see the therapist! My wife had PT for her shoulder. It helped, but she was in a lot of pain for a while.” I responded to this concern: “Anyone would be worried about pain after that experience.” I went on to explain: “Sometimes PT does cause discomfort; the therapists can offer you ice or heat to help with that, and I can give you some anti-inflammatory medication as well.”(Tell) “Have you ever taken that kind of medication?” (Ask) He agreed to try an anti-inflammatory medication and a course of physical therapy, with the understanding that if he didn’t feel better, he would come back and we could discuss the MRI again.

Participants in our communication courses tell us that patients in pain and patients requesting pain medication have a particularly troubling subset of unmet expectations. Clinicians understand the need for caution in prescribing opioids; they also understand that most of their patients are actually having pain and they want to help. They also want to reduce the risk of diversion and addiction.¹ Patients in pain, like patients who are angry, have difficulty processing information. As noted in Chapter 1, the combination of an anxious clinician and an angry and uncomfortable patient makes for a very challenging encounter.

The core relationship-centered skills will help build a connection with patients through the interviews. Using reflective listening and PEARLS statements to show that you understand the patients’ concerns will help them trust you and increase their willingness to try opioid-sparing alternative treatments. Understanding their concerns and validating their distress does not mean that you will accede to their requests. You can hold your professional boundaries and express your compassion simultaneously.

No approach can guarantee a positive outcome; some patients will not be willing to take “no” for an answer. In such instances, there is little value in repeating the discussion.

When I saw Ms. Allen, she started the visit by requesting a refill of the Percocet she’d received from her previous doctor. I identified her concerns about her back pain and the impact of the pain on her ability to function at work and at home. I did not believe Percocet was appropriate: “I can see that you’re suffering. I know you’ve gotten Percocet before.” (Respond) “Unfortunately, I’m afraid I have some news that might be hard to hear: I can’t give you another prescription.” (Tell)

She replied, “I want my Percocet. There isn’t anything else that works.”

“Sounds like you’re convinced that’s what you need, and you’re understandably upset. I know we need to address your back pain so you can work and take care of your kids. I’ve had success with other approaches and I’d like to work with you.”

Again, she said, “It’s just the Percocet. That’s what I need.”

“I’m sorry, I wouldn’t be doing my job if I gave you an inappropriate medication. If you’d like to discuss alternatives, I’m happy to do that.”

Her response: “I want Percocet.”

“I’m very sorry I won’t be able to help you then. If you change your mind, I’ll be happy to see you again.”

This was not a satisfying encounter for either of us, although I knew I was doing the right thing. When we build strong relationships and attend to the emotional needs of our patients, we can provide better, more compassionate, and more efficient care. We cannot satisfy every patient in every situation. A relationship-centered approach will improve the overall experience for both the patient and the clinician, so these difficult encounters occur in a different context and are easier to cope with.

Unmet expectations combine bad news with high emotions. When we use a relationship-centered approach throughout the interview, we have a better chance of a successful negotiation at the end. Using ART, chunk and check, and repeated PEARLS statements can help you maintain a connection with the patient and hold to appropriate practice.

In cases of addressing unmet expectations, practice these skills:

•   Identify expectations early in the interview.

•   Plan the approach for the delivery of bad news.

•   Use ART to hear the patient’s perspective and respond with empathy (PEARLS) while explaining your thought process.

•   Move to conclude the conversation if agreement is not possible.

The Distrustful Patient

If there ever was a time in the United States when doctors were universally regarded as wise and benevolent, that time has passed. Many of our patients have had painful or even harmful encounters with the medical system. People of color and other members of marginalized populations are treated differently by many clinicians (see Chapter 14).² Patients with obesity feel stigmatized and marginalized as well, and many of our patients have difficulty navigating the increasingly complex American healthcare system.

We expect patients to trust us as a matter of course and often feel angry and hurt when they do not. These encounters can be managed using the approaches we have discussed for other challenging encounters. We can build relationships when we maintain an awareness of our own emotional responses and keep our focus on the patient.

Ms. Williams came to see me after her insurance changed, and she could no longer remain with her longtime primary care physician. She made it very clear that she was not happy about the shift: “Dr. Robinson has been taking care of me for 20 years. He knows me. And he’s a lot older than you.” Dr. Robinson, I knew, was also African American, like Ms. Williams. I am white.

Ms. Williams had dutifully brought her medication list and her pill bottles to the appointment. I was concerned about her blood pressure medications; even though she was taking four medications, her blood pressure was still too high, and she had signs of early damage to her kidneys.

From the outset of the interview, I was careful not only to ask her about her entire list of concerns but also to ask what she valued in Dr. Robinson and other clinicians she had seen before. She said, “I want someone who listens and who understands me.” I said, “I certainly hope I can be like that for you.”

I then asked her about her expectations for the appointment. She said, “I need refills on my pills, and I don’t want you to mess with them. It took Dr. Robinson a long time to get this straight.” I responded, “Sounds like you two worked together to get something that worked for you. I know we’re just meeting for the first time, and that it’s hard to lose Dr. Robinson, with whom you’ve had a long relationship. I will work hard and hope to gain your trust.” She seemed to soften.

I continued to identify Ms. Williams’s ideas and expectations and to respond to her emotional cues. I was careful and thorough with the physical exam, and explained each transition. As always, I asked for permission before touching her and continued to use PEARLS statements and reflective listening throughout the visit.

At the end of the visit, I started an ART cycle by asking, “What’s it like to take all these pills?” She said, “It’s a lot to swallow, but I know it’s important. My mother had a stroke.” I responded, “The idea of having a stroke is pretty scary.” Ms. Williams nodded. I went on to tell her, “I’m concerned about your blood pressure today; it’s a bit higher than I’d like to see it. I know this is the first time we’re meeting. I’d like to get some more information.” I started another ART cycle by asking, “What would you think of requesting your records from Dr. Robinson, and coming back to see me in a couple of weeks?” She said, “Well, Dr. Robinson only needed to see me every four months, but I guess I could come in sooner.” I gave her a month’s worth of refills, had her sign a records release, and scheduled a three-week follow-up appointment. It wasn’t ideal; she was still taking insufficient medication. With distrustful patients, it can take longer to build a relationship, and we may have to accept some short-term compromises in the interests of better long-term outcomes.

On Ms. Williams’s second visit, her blood pressure was still too high. She seemed a bit more comfortable with me. When I came into the room, I asked after the grandchild she’d had with her at the first visit, and she showed me pictures of his school play. We were making progress with the relationship. I showed her the sheaf of records I’d received from Dr. Robinson and told her I’d looked through them to see what other medicines she’d taken, and what her blood pressure had been. She was pleased with my follow-through, and my attention to Dr. Robinson’s opinion. I asked her, “What would it take for you to be comfortable changing some of the medicines?” She paused and looked at me. “I guess I’d need to understand exactly why you wanted to do that.” I nodded and responded with two PEARLS statements: “Of course you would. I respect how much you care about doing the right thing for your health, and I want to work with you.” I moved on to the Tell: “You are taking two pills that work similarly. I’m proposing that we stop the losartan and increase the dose of this one, the lisinopril. What would you think of that?” She said, “Well, I guess it would be good to not take as many pills.” She agreed to make the change “on a trial basis,” and we scheduled another three-week follow-up. Her blood pressure was improved on the third visit, and she said, “I guess you know what you’re doing, Doc.” If I’d made that change on the first visit, she would have been less likely to take the medication I’d prescribed. I took a little longer to get her blood pressure under control, but in the process I laid the groundwork for a long-term trusting relationship.

With a distrustful patient, it is particularly important to make sure you follow through on any commitments you make. Be prepared to offer early follow-up in person or by phone, and continue to use excellent relationship skills each time you see or speak to the patient. As you demonstrate that you are respectful and reliable, you will have done everything you can to lay the groundwork for trust.

When trying to build trust with a mistrustful patient, practice the following skills:

•   Focus on respect early in the interview.

•   Elicit and respond to the patient’s concerns with PEARLS.

•   Incorporate the patient’s perspective into the plan.

•   Be scrupulous and consistent about follow-up.

Conclusion

In our most difficult patient encounters, we feel disconnected from the patient; we ourselves are anxious, angry, and sometimes afraid. Our emotions often mirror the patient’s. We must be compassionate with ourselves as well and ensure that we have the opportunity to process our distress with friends, colleagues, or other sources of support.

To help support patients through challenging situations, we can employ relationship-centered skills to overcome distrust and unmet expectations, support patients through the delivery of bad news, and provide compassionate care when emotions run high. When we focus on the relationship, everyone benefits.