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ACP-SGIM Regional Meeting – Indian Wells, CA Board Review Session – Oct 23, 2009 Charlie Goldberg, MD Simerjot K. Jassal, MD, MAS San Diego VA Healthcare System & University of California, San Diego School of Medicine. Can We Talk?

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ACP-SGIM Regional Meeting – Indian Wells, CA

Board Review Session – Oct 23, 2009

Charlie Goldberg, MD Simerjot K. Jassal, MD, MAS

San Diego VA Healthcare System & University of California, San Diego School of Medicine

Can We Talk?

Communication & Conflict Management…

Bridging The Gap

disclosure of financial relationships
Disclosure of Financial Relationships
  • Drs. Goldberg has no relationships with any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.
  • Dr. Jassal received a Regional Unrestricted Educational Grant-In-Aid from Procter and Gamble Pharmaceuticals in 2004 & 2007 to support her research in epidemiology on the Rancho Bernardo study.
importance of communication
Importance of Communication
  • Effective communication critical to providing optimal care & patient satisfaction
  • Many well described problems w/communication @ all levels health care significant negative impact
  • ACGME, LCME, IOM, TJC, ACP all highlight communication as important target for learning & practice improvement
can we talk topics and goals
“Can We Talk?” - Topics and Goals
  • Topics
    • Conflict
      • MD-Patient
      • MD-Patient’s family
      • Cross Cultural
    • MD-Pharma relationships
    • Dealing with prescribing ethics/impaired colleague
    • Initiating End-Of-Life discussions
  • Goals: provoke reflection, provide opportunity for skill building
format for this session
Format for this Session
  • Provocative video
  • Group discussion
  • Take home messages
thoughts for discussion
Thoughts for Discussion
  • From the perspective of the clinician: What visceral feelings do you have towards the patient?
  • From the perspective of the patient: What visceral feelings do you have towards the physician?
  • If you were the clinician, what might you have done differently?
  • How would you move forward from here?
take home messages
Take Home Messages
  • ~ 1 in 6 outpatient visits viewed as difficult by MDs
  • Physicians w/more difficult encounters 12x more likely to burn out & more likely to report adverse events
  • Patient characteristics
    • Mental disorders (depression & anxiety), threatening or abusive personalities
    • High use of health services
  • Physician characteristics
    • Younger
    • Women
a practical approach to framing the issues
A Practical Approach To Framing The Issues..
  • Take a step back and think about what are you trying to accomplish
    • Are you making yourself clear?
    • Acknowledge that the patient's symptoms are real


  • What is the patient trying to accomplish?
    • What are his/her underlying fears & concerns?
    • Ask him/her directly!
making progress
Making Progress..
  • Recognize your own negative feelings
  • Summarize & interpret test results:
    • What has been accomplished? What's ruled out?
    • Acknowledge limitations of tests
  • Explore contribution of depression/anxiety
  • Set boundaries
  • Review goals, plan, etc., as appropriate w/staff if clear they’re involved
thoughts for discussion1
Thoughts for Discussion
  • Who is at fault for this error? (Is this the right question?)
  • If the family had been unaware of the missed CXR, should the clinician have disclosed this to them? Why?
  • What might Dr. Michelsen be feeling? How about the patient and family?
  • How might you disclose to the family the medical error which has occurred? What points are critical?
general approach to error disclosure planning
General Approach to Error Disclosure – Planning
  • 1st - recognize & admit error has occurred
  • Discuss as appropriate w/other clinical parties
  • Plan what you're going to say beforehand
  • Seek guidance from (& inform) risk management group @ institution, others w/expertise
  • Address quickly
general approach to error disclosure the meeting
General Approach to Error Disclosure – The Meeting
  • Discuss issue in open manner with patient/family focusing on:
    • Acknowledge error has occurred - face to face, quiet/private area
    • Describe what happened & why, implications for patient’s health → clear, straight forward language
    • Plan for moving forward
    • Clearly express regret/sympathy
    • Explain event will be investigated, w/goal to understand & prevent future occurrences (e.g Root Cause Analysis)
  • Remember to take care of yourself!
thoughts for discussion2
Thoughts for Discussion
  • How would you handle this situation?
  • What are the good things that the physician did? What could have been done better?
  • What communication skills are most important when interacting with upset family members and patients?
take home messages dealing with upset people
Take Home Messages – Dealing With Upset People
  • Listen carefully, respectfully & empathetically
  • Cut ‘em some slack  Remember that they’re dealing w/emotionally wrenching issues
  • Don't feel personally attacked
  • Calmly address issues in ordered, logical fashion
  • Make sure other clinicians’ comments are consistent
  • Offer regular communication
    • 2 way
take home messages dealing with upset people cont
Take Home Messages – Dealing With Upset People (cont)
  • It's reasonable to expect to be treated w/respect
  • If you feel personally threatened, assure your own safety first!
  • If you’re unable to communicate effectively, excuse yourself politely & request assistance from colleague.
thoughts for discussion3
Thoughts for Discussion
  • Why did this occur? What would you do?
  • How many of you have given care outside MD-Pt relationship?
  • Have you ever been made uncomfortable by a request for care? What did you do?
  • How draw line? How gray? How keep from the steep (inappropriate) part of the slope?
md patient relationship
MD-Patient Relationship
  • Agreement between patient & doctor to deliver professional care, w/goal of helping & not causing harm
  • Defined, formalized & familiar structure/boundaries
  • Key components of “usual” care:
    • Appropriate: Evaluation (Hx, PE, labs), Treatments, Follow-up, Documentation, Communication, Continuity, Accountability
casual care rx outside typical pt md relationship
“Casual Care” – Rx outside Typical Pt-MD Relationship
  • Common & part of culture of medicine
  • >50% of MDs write own scripts or self rx from samples (not pain meds); 100% approached for advice
  • Why? convenient, accepted, flattering, anonymous, sense of kindness, save $s, loyalty to colleagues/family

Casual Care - Spectrum of Involvement

Very Minimally


Operations/Procedures Meds Exam Self Rx Curbside/Advice

problems w casual care
Problems w/Casual Care
  • ? Exact nature of relationship – roles & responsibilities hazy
  • Lack of objectivity
  • Incomplete info (ie no pe, hx, labs)
  • No f/u or mech for addressing problems, no records
  • While rare, difficult to defend adverse outcomes in court
  • No data re outcomes; suggestion that MDs & their families @ risk for worse care:
    • Delayed dx, poor communication, erroneous assumptions, sub-optimal referral patterns
thoughts for discussion4
Thoughts for Discussion
  • What factors might have contributed to the patient's "refusal" to go ahead with the catheterization?
  • Are you convinced that the patient doesn't want to proceed?
  • What else could the physician have done to achieve a better outcome?
overview culturally competent care
Overview – Culturally Competent Care
  • Cultural perspective cant be determined based on appearance, language, dress
    • People may "look different" yet have

"westernized" views

    • Others look "just like you" yet have widely varying

takes on health care

  • Possible causes of patient's "refusal":
    • Lack of understanding/misunderstanding (language!)
    • Cultural issues, different expectations
    • Fear, lack of trust
  • Cultural sensitivity a call for partnership
practical suggestions
Practical Suggestions
  • Use a professional translator; family members may not be appropriate
  • Sit down & take time
  • Ask patient:
    • What’s his/her understanding of their illness?
    • How do they believe it should be addressed?
  • Explain in clear language, w/pictures:
    • purpose of procedure/therapy, urgency, dangers
  • Give patient/family time to decide
    • Re-visit, re-discuss, negotiate
    • Consult w/family members
thoughts for discussion5
Thoughts for Discussion
  • Is there anyone here who hasn’t accepted something from Pharma?
  • What’s the range interactions that you’ve seen?
  • Why do drug company representatives visit clinicians?
  • What should clinicians accept from drug company representatives? Is this consistent with what you've observed?
pharma clinicians a few facts
Pharma & Clinicians - A Few Facts
  • 88,000 drug co reps visit MDs/hospitals each yr (1 rep per 5-6 MDs)
  • $12-18 billion/year spent by industry on drug promotion ($8k-13k/MD)
  • Most students, residents & attending physicians recognize that one of drug co's goals is to affect MD prescribing practices
  • Most also feel sense of immunity from drug co influence & entitlement to receiving gifts
take home thoughts
Take Home Thoughts
  • Drug companies
    • Are an integral part of the health care system
    • Help advance medical care but also profit driven
  • Pharmaceutical companies can purchase lists detailing individual physician prescribing practices
  • This info passed on to local repsuse it to customize presentations to MDs
take home thoughts cont
Take Home Thoughts (cont)
  • When interacting with drug reps, be realistic:
    • Interactions & small gifts do affect prescribing practices & generate sense of obligation
    • No free ride - "free" samplesincreased use of


    • Question information you receive from reps - review primary data & generate truly informed opinion
    • It's likely that your prescribing practices are tracked
    • Friendly behavior can be used to gain your trust - developing relationships enhances sales
thoughts for discussion6
Thoughts for Discussion
  • When, where, and with whom should "the discussion" take place?
  • What critical information do you need to know about the patient?
  • What questions/hurdles would you anticipate? How would you address them?
  • How would you begin the code status discussion? What points are critical?
setting up the discussion
Setting Up The Discussion…
  • The Setting:
    • When: Before patient is in extremis!
    • Where: A quiet, private place
  • From a medical perspective:
    • What is your/other clinicians' perception of this patient's medical condition?
    • What degree of recovery can be anticipated?
    • Try to separate: chronic progressive organ failure (irreversible) from acute decompensation (potentially reversible)
    • What treatments are available?
things you need to learn from you patient don t make assumptions ask
Things You Need To Learn From YouPatient.. Don’t Make AssumptionsAsk!
  • What's his/her understanding of resuscitation?
  • What's his/her understanding of their illness and the likelihood of recovery?
  • What's his/her perception of current quality of life?
  • What are his/her goals?
  • Family/social support?
  • Strong religious beliefs?
possible openings
Possible Openings…
  • "It would help me to know what you understand about your present illness..."
  • "Is it ok to talk about possible complications and about what you would want done?"
  • "This may be upsetting, but it is better to talk about this while you are not too sick to make decisions ..."
  • "You may not want every possible medical intervention..."
considerations during the meeting
Considerations During the Meeting
  • Be patient, calm & willing to repeat yourself
    • Develop rapport
  • Involve family members, if patient wishes
  • Emphasize:
    • You will do your best to treat whatever is reversible & continually re-evaluate
    • You’ll never abandon patient always available to re-visit issues.
    • Medicine can always ameliorate pain & suffering
10 general rules for communicating in difficult circumstances
10 General Rules For Communicating In Difficult Circumstances
  • Stop (deep breath), think (deep breath), don’t escalate (deep breath).
  • Consider: Why is the other person so upset? Put yourself in their shoes
  • Recognize, empathize, & validate.
  • Avoid blaming & finger pointing.
  • What are you trying to accomplish - are you being clear?
    • - Avoid jargon, use pictures, use interpreters, plan ahead-->organize thoughts
10 rules cont
10 Rules (cont)
  • What is the other person trying to accomplish - are they being clear?

- Ask directly, use interpreters

  • Expand your time frame - don’t demand understanding & answers now (re-visit for questions, re-explanation, re-exploration).
  • Listen >>>> Speak
  • Make communication a priority - practice & focus.
    • - When things don’t go well: reflect, consider alternate approach & give it another go.
    • - When things do go well: consider why (& give yourself some credit!

5. Be honest.


Tom Catron, MD Amir Larian, MD Jan Thompson

Gautam Deshpande, MD Jim Mooney Kien Vuu, MD

Sam Hughes, MD Margarete Dysico Daisy Salamat

Olga Kharitinova Emiliano Ritua Jeanette Lin, MD

Renate Pilz, MD Matthew Bengard, MD

Teddy Nelson, MD Sean Powell, MD Mary Rogers

John Allyn James Michelsen, MD

Kathleen Hardman Tom Delaney Elaine Robson, RN

Educational Comupting Staff, UCSD SOM

Designed, Filmed and Produced by:

Charlie Goldberg, MD

Tomoko Tanabe, MD

charlie goldberg md charles goldberg@va gov simerjot k jassal md mas sjassal@ucsd edu
Charlie Goldberg, MD

Simerjot K. Jassal, MD, MAS

Feel Free To Contact Us If We

Can Be of Use!



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