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Difficult Conversation: How to Control and Document

Studies have shown that physicians rate as many as 15% of their patient encounters as "difficult."  Communication that is angry, threatening, rude or inappropriate when communicating with office staff is often seen as difficult. Patients exhibit these behaviors for a variety of reasons including:

  • Unemployment or reduction in work hours.
  • Loss of healthcare benefit or large increase in deductible.
  • Fear over new or pending diagnosis and perceived changes to lifestyle.
  • Low level health literacy and discomfort with expressing lack of understanding.
  • Feeling that staff members are disrespectful.
  • Feeling that physicians and/or staff members are uncaring.

When a patient or family member approaches office staff or a provider in an angry or threatening mode, the following may also help in defusing the issue. These steps are outlined in Medical Mutual’s Practice Tip Communication: Strategies for Effective Communication.

The 6 Es: A tool you can use to communicate more effectively in conflict situations

Building Skills:

The first step in developing an effective method for dealing with conflict is to know yourself. Ask yourself the following:

  • What is your conflict style?
  • How adept are you at communication?
  • What are your triggers and beliefs that might interfere with the way you handle conflict?
  • Do you need to improve your communication skills?
  1. Evaluate:
    When conflict arises take a moment and do a quick self-assessment. Ask yourself the following:
    • What are you bringing to the discussion?
    • Does your background affect how you are communicating with this person?
    • Are you making certain assumptions about the person or situation and is there anything that is influencing the situation, such as being short staffed or other issue at home or the office?
    Next, ask yourself what you want from this discussion:
    • Do you hope to find a resolution with a win-win outcome?
    • Are your emotions in control?
    • Do you have the necessary skills to handle this conflict?
  2. Engage
    After you have evaluated the situation and you feel ready to handle the interaction, engage the person:
    • First, acknowledge them if you haven't done so thus far.
    • Elicit their concern.
    • Remember to remain calm and be respectful and professional.
  3. Empathize
    After you have evaluated the situation and you feel ready to handle the interaction, engage the person:

    Empathy has been described as attempting to temporarily walk in the shoes of another. Through empathy it is possible for two people to be connected in the moment. One JAMA article states that empathy has become a critical component of today's physician-patient relationship.

    The article states that when patients are treated empathetically they are more forthcoming with symptoms and concerns, participate more in their care, and gain autonomy, which in turn yields more accurate diagnosis and better care.

    Employing empathy can help to diffuse difficult patient encounters. Another article addressing difficult patient encounters notes that "extending empathy, by focusing on the patient's emotions and being firm but compassionate can return a difficult encounter to success."

    When interacting:
    • Actively listening to the patient with a posture signaling openness, good eye contact and a non-threatening tone of voice will show the patient you are willing to listen to their concerns.
    • Remember to accept the patient and not judge them.
    • Acknowledge their feelings and thoughts and then reflect on your understanding of what they have presented to you.
    Here are some expressions that can help signal to the patient that you heard their concerns and care about them:
    • Let's see if I have this right.
    • Sounds like you've reached your limit.
    • That must have been very frustrating.
    • I can understand why you might be feeling angry.
    • I'm sorry that you had to go through that.
  4. Educate:
    After you have engaged the patient, listened to their concerns and empathized with them, you can take steps to educate them: (if needed, they may be educating you)
    • Explain the situation as you understand it and provide the patient with useful information to help them better understand the situation. This might include information about your organization's procedures or state and federal regulations that may have impacted the present situation.
      1. Example: Explain why you are recommending a certain medication, course of treatment, or lifestyle change. Show (not just explain) the patient what this will do for them. By attaching an explanation to an example, you further connect action with outcome. Focus on positive results they will experience by following the treatment plan versus the consequences of not following.
    • Educate beforehand. Do not delay reinforcing or communicating after the patient fails to adhere.
    • Use less medical jargon and more open ended questions to confirm the patient’s understanding and to clarify any misconceptions.
    • Answer any questions they may have and then confirm that the patient understands what you have discussed (teach back, show me).
  5. Enlist:
    At this point you can:
    • Discuss with the patient the known available options for addressing the issue.
    • Remember to allow the patient to have input in the outcome.
    • Reach an agreement about what will happen if the solution doesn't work.
      1. Example: Determine patient’s commitment to the treatment plan by asking:
        1. On a scale of 1 to 10, how confident are you that you can follow the recommendations we discussed. (This allows the patient to provide level of commitment. Once a number is received follow up with)
        2. What would raise that number for you? (Continue until you feel confident, have explored any concerns and provided any education, additional support or reassurance to increase patient understanding and commitment to treatment plan).
  6. End:
    End the interaction by:
    • Verifying the plan with the patient.
    • Commit to continually communicate expectations moving forward.
    • Confirm that the patient feels the conflict has been resolved.
    • Document the entire communication in the patient’s medical record

Steps to take if the situation becomes out of control

If despite your best efforts, you perceive the situation is out of control:

  • Locate yourself in a safe non-public section of the office. Alert your staff to assure they are nearby and on standby to offer you assistance. Never be the first in the room with the patient controlling the exit. Assure a staff member stays close to a phone and dials the police, if requested.
    • Avoid claims of false imprisonment by assuring the patient/family member must enter the room cooperatively and feel they can leave at will.
  • Set limits for the discussion if the patient's language and/or behavior is unacceptable. State that their language/behavior is unacceptable. "I realize you are angry, however, when you raise your voice, I find it difficult to assist you. If you lower your voice, we can work together to solve the issue." The goal is to gain control of the conversation while you investigate if there is a need and a way to meet the patient's voiced concerns.
  • Write a simple document containing the behavior and the actions the patient has agreed upon and have the patient sign it. Ask the patient to verbally repeat the agreement. Place the agreement in the record and provide a copy to the patient.
    • Ensure the following: if the behavior escalates and the threat of physical harm exists:
      • You have a witness.
      • There is a way out of the room.
      • There are no sharp or heavy objects accessible.
      • You have a plan for contacting the police.
  • Include the following when documenting the discussion:
    • Describe the inappropriate behavior factually.
    • Include, in quotation marks, the patient's or family member's rude, threatening, or inflammatory statements.
    • Expletives such as vulgar language. If vulgar language is used, the following documentation may be made, "While using vulgar language, the patient complained about the office practice of ... The patient stated he would not put up with..."

Resources

The 4 Es model: Developed by the Institute for Healthcare Communication (IHC), formerly the Bayer Institute
Additional Practice Tips that may assist in these situations: