ACP-SGIM Regional Meeting – Indian Wells, CA Board Review Session – Oct 23, 2009

1. ACP-SGIM Regional Meeting – Indian Wells, CA Board Review Session – Oct 23, 2009 Charlie Goldberg, MD charles.goldberg@va.gov Simerjot K. Jassal, MD, MAS sjassal@ucsd.edu San Diego VA Healthcare System & University of California, San Diego School of Medicine Can We Talk? Communication & Conflict Management… Bridging The Gap

2. 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.

3. 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

4. “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

5. Format for this Session • Provocative video • Group discussion • Take home messages

6. Difficult Doctor-Patient Relationships

7. 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?

8. 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

9. 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 vs. • What is the patient trying to accomplish? • What are his/her underlying fears & concerns? • Ask him/her directly!

10. 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

11. Disclosure of Medical Errors

12. 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?

13. 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

14. 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!

15. Emotionally Charged Exchanges

16. 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?

17. 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

18. 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.

19. Out of Bounds?

20. Boundaries and Health Care

21. 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?

22. 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

23. “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 I-----------------------------------------------------------------------------I Operations/Procedures Meds Exam Self Rx Curbside/Advice

24. 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

25. Culture, Conflict & Health Care Decision Making

26. 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?

27. 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

28. 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

29. The Drug Rep

30. 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?

31. 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

32. 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

33. 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 product • 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

34. Initiating Code Discussion

35. 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?

36. 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?

37. 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?

38. 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..."

39. 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

40. 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

41. 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.

42. Acknowledgements 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

43. Charlie Goldberg, MD charles.goldberg@va.gov Simerjot K. Jassal, MD, MAS sjassal@ucsd.edu Feel Free To Contact Us If We Can Be of Use!

44. References General Accreditation Council for Graduate Medical Education (ACGME) Competencies -http://www.acgme.org/outcome/comp/compFull.asp Liaison Committee on Medical Education (LCME) – Functions and Structure of a Medical School: Standards for Accreditation of Medical Education Programs Leading to the MD Degree,June 2007. http://www.lcme.org/functionslist.htm#educational%20objectives United States Medical Licensing Examination – Examination Content 2007. http://www.usmle.org/General_Information/bulletin/2007/content.html Institute of Medicine. Committee on Quality of Health Care in America (2001). Crossing the quality chastm: A new health system for the 21st century. Washingto, D.C.: National Academy Press. Report Brief - http://www.iom.edu/CMS/8089/5432.aspx Institute for Health Care Communication – Annotated Bibliographies http://www.healthcarecomm.org/index.php?sec=biblio Makour G. Essential Elements of Communication in Medical Encounters: The Kalamazoo Consensus Statement. Academic Medicine 2001; 26: 390-3.

45. References Conflict and Communication – Physicians, Patients and their Families An PG. Burden of Difficult Encounters in Primary Care: Data From the Minimizing Error, Maximizing Outcomes Study. Arch Int Med 2009; 169: 410-413. Barsky A. Cognitive behavior therapy for hypochondriasis: A randomized controlled trial.JAMA 2004; 291: 1464-70. Branch W. Teaching the Human Dimensions of Care in Clinical Setting. JAMA 2001; 286:1067-74. Epstein R. Communicating Evidence for Participatory Decision Making. JAMA 2004; 291: 2359-66. Goldman T, et al. Ten Commandments of Effective Consultation. Arch Intern Med. 1983; 143: 1753-5. Gordon-Lubit R. Risk Communication: Problems of Presentation and Understanding. JAMA 2003; 289: 95. Gould SJ. The Median Isn’t The Message. Cancer Guide, 1982. http://cancerguide.org/median_not_msg.html Lazare A. Apology in Medial Practice: An Emerging Clinical Skill. JAMA 2006; 296: 1401-4. Lautrette A. A Communication Strategy and Brochure for Relatives of Patients Dying in the ICU. NEJM 2007; 356: 469-78. Lo B. Discussing Palliative Care with Patients. Ann Int Med 1999; 130: 744-9.

46. References Conflict and Communication – Physicians, Patients and their Families Makoul G. Communication Skill Education in Medical School and Beyond. JAMA 2003; 289:93. Marvel M. Soliciting the Patient’s Agenda: Have We Improved? JAMA 1999; 281: 283-7. McNutt R. Shared Medical Decision Making: Problems, Process, Progress. JAMA 2004; 292:2516-18. Medical Professionalism in the New Millennium: A Physician Charter. Ann of Int Med 2002;136: 243-246 Quill T. Physician Recommendations and Patient Autonomy: Finding a Balance BetweenPhysician Power and Patient Choice. Ann Int Med 1996; 125: 763-9. Poulson J. Bitter Pills to Swallow. NEJM 1998; 338: 1844-6. Rabow M. Supporting Family Caregivers at the End of Life: “They Don’t Know What TheyDon’t Know.” JAMA 2004; 291: 483-91. Rice B. 10 Ways to Guarantee a Lawsuit. Medical Economics July 8, 2005.Http://www.memag.com/memag/content/printConentPopup.jsp?id=168737 Salernao S. Principles of Effective Consultation. Arch Int Med 2007; 167: 271-5. Saltman D. Conflict management: A primer for doctors in training. Post Grad Med 2006; 82: 9-12. Yedidia M. Effect of Communications Training on Medical Student Performance. JAMA 2003;290: 1157-65.

47. References Disclosure of Medical Errors Altman D, et al. Improving Patient Safety – Five Years after the IOM report. NEJM 2004; 351:2041-43. Background Paper and Draft Guidelines for the Development of National Guidelines for the Disclosure of Adverse Events. Edmonton, AD, Canada: Canadian Patient Safety Institue, 2006. http://www.patientsafetyinstitute.ca/resources/publications_new.html. Banja J et al. Perspectives on Safefy: In Conversation with…John Banja. PhD. Web M&M (webmm.ahrq.gov); Feb 2006: http://webmm.ahrq.gov/perspective.aspx?perspectiveID=19&searchStr=banja%2c+j . Bates D, et al. Error in Medicine: What Have We Learned? Ann Int Med 2000; 132: 763-67. Clinton H, et al. Making Patient safety the Centerpiece of Medical Liability Reform. NEJM 2006; 354: 2205-8. Delbanco T, et al. Guilty, Afraid and Alone – Struggling with Medical Error. NEJM 2007; 357: 1682-3. Gallagher T, et al. The Wong Shot: Error Disclosure. Web M&M (webmm.ahrq.gov); June 2004: http://webmm.ahrq.gov/case.aspx?caseID=64&searchStr=gallagher%2c+t Gallagher T, et al. Disclosing Harmful Medical Errors to patients. NEJM 2007; 356: 2713-9.

48. References Disclosure of Medical Errors Gallagher T, et al. Disclosing harmful Medical Errors to Patients: A Time for Professional Action. Arch Intern med 2005; 165: 1819-24. Gallagher T, et al. Patients’ and Physician’s Attitudes Regarding the Disclosure of Medical Errors. JAMA 2003; 289: 1001-7. Health care at the crossroads: Strategies for improving the medical liability system andpreventing patient injury. Joint Commission Accreditation of Healthcare Organizations. 2005. http://www.jointcommission.org/NR/rdonlyres/3F1B626C-CB65-468B-A871-488D1DA66B06/0/medical_liability_exec_summary.pdf) Lazare A. Apology in Medical Practice: An Emerging Clinical Skill. JAMA 2006; 296: 1401-4. Leape L. Error in Medicine. JAMA 1994; 272: 1851-7. Liang B. A System of Medical Error Disclosure. Qual Saf Health Care 2002; 11: 64-68. Pierlussi E, et al. Discussion of Medical Errors in Morbidity and Mortality Conference. JAMA 2003; 290: 2838-42. Wu A. Removing Insult from Injury – Disclosing Adverse Events. Web M&M (webmm.ahrq.gov); Feb 2006: http://webmm.ahrq.gov/perspective.aspx?perspectiveID=18&searchStr=wu%2c+a

49. References Code Status Balaban R. A Physician’s Guide to Talking about End-of-Life Care. J Gen Int Med 2000; 15: 195-200. Brody H, et al. Withdrawing Inensive Life-Sustaining Treatment – Recommendations for Compassionate Clinical Management. NEJM 1997; 336: 652-57. Chittenden E, et al. Discussing Resuscitation Preferences with Patients; Challenges and Rewards. J Hosp Med 2006; 1: 231-40. Fromme E. Care of the Dying Doctor: On the Other End of the Stethoscope. JAMA 2003; 290: 2048-55. Gazelle G. Understanding Hospice – An Underutilized Option for Life’s Final Chapter. NEJM 2007; 357: 321-4. Goold S, Et Al. Conflict Regarding Decisions to Limit Treatment. JAMA 2000; 283: 909-14. Hahn M. Advance Directives and Patient-Physician Communication. JAMA 2003; 289: 96. Lynn J. Serving Patients Who May Die Soon and Their Families: The Role of Hospice and Other Services. JAMA 2001; 285: 925-32.

50. References Code Status Prigerson H. Caring for Bereaved Patients: “All the Doctors Just Suddenly Go.” JAMA 2001; 286: 1369-76. Quill T. Initiating End-of-Life Discussions With Seriously Ill Patients; Addressing the “Elephant in the Room.” JAMA 2000; 284: 2502-7. Von Gunten C. When the Tumor is not the Target: Discussing Do-Not-Resuscitate Status. J Clin Onc 2001; 19: 1576-81. Von Gunten C. Ensuring Competency in End-of-Lie Care: Communication and Relational Skills. JAMA 2000; 284: 3051-7. Wright A. Letting Go of the Rope – Aggressive Treatment, Hospice Care, and Open Access. NEJM 2007; 357: 324-7.