When Providers & Patients Disagree: Moving From Conflict to Collaboration

1. Session # B5b October 29, 20111:30 PM When Providers & Patients Disagree: Moving From Conflict to Collaboration Steve Simms, Ph.D. Philadelphia Child & Family Therapy Training Center George F. Blackall, Psy.D., MBA Penn State College of Medicine Collaborative Family Healthcare Association 13th Annual Conference October 27-29, 2011 Philadelphia, Pennsylvania U.S.A.

2. Faculty Disclosure • I/We currently have or have had the following relevant financial relationships (in any amount) during the past 12 months: • Royalties from the ACP Press for: • Breaking the Cycle: How to Turn Conflict into Collaboration When You and Your Patients Disagree

3. Need/Practice Gap & Supporting Resources What is the scientific basis for this talk? The scientific basis for this talk will be presented in our first nine slides

4. Objectives Should tie the Needs and Outcomes together • Describe how a systems approach to clinical conflicts can help a provider to see, understand, and ultimately resolve an impasse. • Be able to identify which model of practice (Physician-as-Expert or Physician-as-Collaborator) to apply in conflicted clinical scenarios. • Apply the model of the symptomatic cycle to the presented case scenario. • Be able to apply the Five Universal Principles for a Collaborative Doctor-Patient Relationship to conflicts with patients.

5. Expected Outcome Healthcare providers will be able to see, understand, and respond to impasses with patients and family members using the models presented in this workshop.

6. The State of the Union What percentage of patient visits do PCP’s classify as “difficult”? A. 5 B. 17 C. 9 D. 21 An, et. al. JAMA, 2009

7. The State of the Union How long do MD’s allow their patients to speak uninterrupted? A. 1 minute B. 2 minutes C. 90 seconds D. 23 seconds • Beckman & Frankel, An Intern Med, 1984 • Marvel et. al. JAMA, 1999

8. The State of the Union On average, when not interrupted, how long will patients spend presenting an initial concern to their MD? A. 4 minutes B. 120 seconds C. 90 seconds D. 5 minutes Langewitz et. al. BMJ, 2002

9. The State of the Union Patients can tell when their doctor does not like them. True False Levinson et. al. Pt Educ & Counseling, 2006

10. State of the Union • What percentage of patients who recognize their terminal illness prefer symptom-directed care over life-extending care? A. 27 B. 54 C. 83 D. 16 Mack et. al., 2010

11. State of the Union The # 1 thing dying patients want from their physician’s communication with them is: A. protect family members from the reality of the prognosis. B. talk with them in an honest and straightforward way. C. not take away hope. D. provide hope at all costs. • Wenrich, et. al. 2001

12. State of the Union • When cancer patients expressed negative emotions to their oncologist, the oncologists’ responded empathically in what percentage of interactions? A. 90 B. 50 C. 75 D. 35 Kennifer et. al., 2009

13. State of the Union • An empathic response to a patient’s expression of negative emotion, on average, lengthens visits by how long? A. 5 minutes B. 10 minutes C. 3 minutes D. None of the above • Kennifer et.al. 2009

14. State of the Union 21 Seconds!

16. Case #1 • 23 yo female recently diagnosed with recurrent and metastatic sarcoma. The diagnosis is terminal. • Original diagnosis 2 years earlier resulted in surgical removal of a sarcoma from her left thigh. • Patient was well until one month ago when she started experiencing night sweats and difficulty breathing. • Patient was about to graduate from college when symptoms appeared. • Patient is currently in the ICU and according to staff is uncooperative and making suicidal statements.

17. Case #1 • Social background: Patient was adopted and has a 14 yo adoptive brother. • Family is intact and high functioning. • No history of mental illness.

18. Case #1 • Pt. has been “uncooperative” with staff. • Pt. has asked nurses and residents things like: • “How many of these pills do I have to take to kill myself?” • “Can you give me enough medicine to end this?” • “What’s the quickest way to die?”

19. Case #1 • When the chief resident goes into the pt’s room, she motions for him to sit down. • As he leans toward her she says: • “Will you please shoot me tonight?”

21. THE SYMPTOMATIC CYCLE • “Symptoms in families evolve in a context of interpersonal isolation, characterized by conditional acceptance and efforts to control one another”. • Micucci, 1998, p. 17

22. THE SYMPTOMATIC CYCLE SYMPTOM ARISES • FAMILY & STAFF FOCUS ON ELIMINATING SX RELATIONSHIPS PT SEEN AS NEGLECTED THE PROBLEM RELATIONSHIPS PT FEELS DETERIORATE MISUNDERSTOOD SYMPTOM INTENSIFIES (Micucci, 1998, p.18)

24. Five Universal Principles for Collaborative Patient Relationships • Competence: All patients and families bring a pre-existing set of competencies to the illness experience. • Connection: Isolation and disconnection from important relationships breeds conflict and leads to psychological distress. • Control: Control is a Myth • Contribution: Your blind spots fuel impasses • Collaboration: The above principles apply to staff as well as patients and families. Blackall, Simms & Green (2009)

25. ARCHAn Impasse Prevention Tool • Acceptance • Respect • Curiosity • Honesty • Micucci, 1998

26. WHAT YOU CAN DO • Know your role, limits and function. • Know the role and function of all the people connected to the impasse. • Decrease your own isolation. • Focus on relationships.

27. FOCUS ON RELATIONSHIPS • Tolerate the intensity of emotions around the dilemma. • Highlight competencies. • Keep the conversation going. • People find common ground when they feel heard and understood.

28. Take Home Message • Highlight Competencies • Focus on Relationships • Decrease Isolation • Keep the Conversation Going

29. Session Evaluation Please complete and return theevaluation form to the classroom monitor before leaving this session. Thank you!