Challenging clinical encounters and practical management strategies

Setting: Two female physicians, standing looking towards the camera.

Dr. Liisa Honey: Welcome to our CMPA Webinar. Today we are going to talk about challenging clinical encounters and some practical management strategies.

Before we begin, I would like to acknowledge that the CMPA offices, located in Ottawa, are on the unceded, unsurrendered territory of the Anishinaabe Algonquin Nation, whose presence here reaches back to time immemorial. We honor and pay respect to these lands and to all First Nations, Inuit and Métis Peoples throughout Turtle Island.

So, my name is Dr. Liisa Honey, and I'm the Director of Safe Medical Care Learning at the CMPA.

Dr. Katherine Larivière: And I'm Dr. Katherine Larivière. I'm a Physician Advisor in the same department.

Liisa: So, by way of disclosure, we are both full-time employees and paid by the CMPA but nothing else to disclose, and everything possible has been done to mitigate any potential bias.

So, these are the objectives for today. We're going to discuss the link between effective communication and patient safety and then talk about some tools to help facilitate communication, engagement and ultimately de-escalation of conflict.

Before we start, we're going to launch a poll to ask you: How confident do you feel with your ability to manage challenging encounters with patients?

• Zero is not confident at all;
• Five, somewhat confident;
• Ten is very confident.

And if you're watching the recording, just note the number on a piece of paper.

Katherine: So, let's begin by reviewing the question: What is a challenging encounter, in fact? So, we consider that a challenging encounter is an encounter that impedes the establishment or continuation of a therapeutic relationship. And this is important to acknowledge because challenging encounters impair our ability to provide care.

Before the pandemic, studies show that about 15% of patient encounters were considered challenging by physicians. And, we know that these encounters are increasing in frequency and in intensity. They can chip away at our enjoyment of medicine and at our ability to provide safe care to our patients.

A very small minority of challenging encounters can even pose a threat to our immediate safety. Although we always hope to avoid this, we need to be prepared. And although this will not be the main focus of our discussion today, we will touch on the subject because safety is crucial.

Studies show that encounters can be challenging for a variety of reasons. Sometimes we feel there's a disconnect between our beliefs and our values and those of our patients. On other occasions, our agendas can conflict with those of our patients.

On screen list identifying what make encounters challenging. Requests for unnecessary forms, tests or prescriptions, verbal or physical abuse, unrealistic expectations, non-adherence to treatment, and hostile family members.

There are also encounters where emotions run high. This has been amplified in recent times, where healthcare has become more difficult. There are issues relating to access to care or increased wait times, issues around the politicization of medicine in response to public health measures and stresses relating to the polarization of opinions on vaccination. All of these placed additional burden on clinicians, on our staff and on our patients.

So, these challenging encounters are difficult not only at the time of the interaction, but even after the interaction ends. They take a toll on us and they can result in negative feelings or even self-doubt.

So, what can we do about this? How can we foster and strengthen relationships with our patients? How can we manage those challenging encounters more easily and continue to thrive in our practice of medicine?

Liisa: So, this has actually been really well documented in the literature, and there's a large body of evidence that shows a link between challenging encounters and their effects on patient care. So, when patient interactions with healthcare professionals are difficult, the patients are often subjected to considerable stigma, and they may start to experience a broad range of healthcare disparities. So, they're also at increased risk of diagnostic error and often end up receiving fragmented care, which can lead to greater morbidity and mortality.

So, the literature also shows that reduced diagnostic accuracy, when physicians are involved in encounters that we would describe as challenging. So, it becomes harder to focus on the patient's issue when so much of our mental energy is spent focusing on the dynamics of the encounter. We may spend less time with the patient. We may fail to address some of the non-urgent concerns or prematurely close an assessment. We may act less professionally or compassionately, in which case the patient may not divulge all the information about their health that we need. So, we may even succumb to pressures to provide a treatment or an investigation that's not indicated or potentially harmful. And these are all responses that are completely understandable because we're human, after all. And it's difficult to be in a situation where we feel that we're really trying our best, but the person we're trying to help is not happy.

So, in addition to increasing the likelihood of diagnostic errors, challenging encounters are likely to contribute to physician burnout and job dissatisfaction. And this ultimately can lead to poorer health care quality, which in turn reduces safety for our patients.

So, what we need to do here is break this cycle. Better patient relationships and more rewarding encounters can help to decrease that moral injury and burnout, which then increases patient safety and satisfaction, which in turn improves patient relationships. So, physician engagement and patient safety go hand in hand.

Katherine: So, we can also look at things from the opposite perspective. What can we expect when the patient-physician relationship is healthy?

First, positive and effective patient-physician communication is known to improve patient outcomes. When our relationships with our patients are strong and effective, we're more likely to adopt a positive attitude towards work and we're more likely to be optimistic and helpful to others. We positively impact health outcomes, we improve patient safety and we provide safe care.

Next, we are more focused and we feel more engaged with our patients. We are also more likely to provide appropriate testing, treatment and consultation. We are more likely to advocate for our patients. These all, in turn, positively impact our patients' mood, who then, our patients, are more likely to be satisfied with their treatment and adhere to the health plan that we develop together.

So, Liisa, we've discussed that healthy relationships with our patients are a rewarding part of the work, and positive relationships can impact patient care delivery and patient engagement.

So, now let's look at how to enhance our relationships to optimize patient care. As health care professionals, we know that the work we do makes a difference in the lives of our patients and of our colleagues. Building a strategy for positive communication can help a bit like we would build a house. And, this may decrease the likelihood of experiencing challenging interactions and can help maintain professional well-being, improve relationships, and ultimately result in improved patient health outcomes.

So, how do we begin? First, we build the foundation, and that will be the establishment and implementation of clear policies and procedures and setting up best practices for documentation.

Next, we select our tools. Many effective communication tools exist and today we'll present only a few. These tools can be used in diverse practice settings and for care provided in single visits or in the context of longitudinal relationships.

Finally, we need to know when to react, and this means identifying when our safety might be threatened and when a call for help may be needed.

Liisa: So, building your foundation really starts with developing and implementing clear policies for expected conduct and the consequences for breaching that code of conduct.

So, of course, if you work in a hospital setting, you may not have the opportunity to develop and implement these policies and procedures, but it's always a good idea to ensure that patients are aware of those institutional policies and procedures.

And it's useful to have policies and procedures for some of these commonly occurring situations that we know are going to be emotionally charged. Things like requests for opioids, filling out forms, vaccine exemptions, urgent appointment requests, accepting new patients and on and on. So, having these policies in writing can really add weight to them and may reassure your patients that they're being treated fairly.

A transparent and consistent approach promotes open relationships with your patients and may help them understand why you may not be able to comply with a specific request, while reassuring them that you're keeping their best interest at heart.

It's also important to have boundaries, and these clarify the roles and expectations of patients and physicians. And we're going to get to that documentation piece in a little bit.

So, it's a good idea to have clear office or institutional policies for expected conduct and consequences for abusive or aggressive behavior and refer to these policies, as needed.

So, this is an example of a poster that was developed by the Doctors of B.C., and this can be displayed in your office. And you can all find this poster on the Doctors of B.C. website under "We all deserve respect".

On screen display of poster developed by Doctors of B.C. Top heading states “Your health is our top priority. So is the safety of our staff”. On the left of the poster, in all capital letters “WE ALL DESERVE RESPECT”. On the right, “IF you have respectful feedback or have any concerns that we can help with, let us know. However, if you are treating anyone in an aggressive or verbally abusive manner, you may be asked to leave.”

Katherine: So, now that our foundation is laid, we need to ensure that we have a good toolkit. There are many different communication mnemonics that you could select, and today we'll look at three of them. But before we get to them, recall that your most important tool is open and empathic communication with your patients.

Good patient-physician communication that fosters understanding, that recognizes barriers and finds ways to resolve them in a professional manner, and that is done with etiquette and mutual respect.

So, speaking of foundational tools for patient-centered communication, we will begin with FIFE,which many of you will likely have learned as a med student if you're not using it on an ongoing basis with your patients already.

On screen display of the mnemonic FIFE. F for feelings, I for ideas, F for function, E for expectations.

So, the FIFE approach is one way to remind oneself to understand the patient's disease and illness experience, and it bears presenting again. Understanding the patient experience can help us better understand and address their needs.

This can help potentially avoid some triggers for challenging encounters, which can include when patients feel misunderstood or dismissed, when they feel they're not receiving the treatment or care that they believe is necessary.

Unmet expectations have been quite common during the pandemic. For instance, when care had to be delayed or when in-person care was just not available.

FIFE helps us consider the four dimensions of patients' experiences with their illness or their presenting problem. The F stands for feelings, especially fears. You might ask the patient what concerns them the most around their illness. Questions like "What worries you the most about this problem?" They can be helpful to better understand the patients' feelings and experience around their illness.

The I is for ideas. You might ask "What is it you think is going on?" Or "Do you have any ideas of why this might have started?" We don't want to assume that we know what our patients think, based on the information we've given them. Knowing the meaning a patient ascribes to their situation is key to understanding their perspective and to heading off potential conflicts.

The second F is for function. It can be very useful to gather from our patients how their illness is impacting their life. We may be surprised about the impact a symptom we might have assumed is mild is having on their daily life.

This could also affect our next steps around treatment or further investigation. Without asking directly, we may never be able to create a true, patient-centered plan and leave our patients feeling unsupported and unheard.

The E, finally, prompts us to explore a patient's expectations of their care. When we don't know our patients' expectations, this can result in conflict or dissatisfaction with the care that ends up being provided. Patients may feel they need a specific type of treatment.

They may expect specific care that just can't be provided. By eliciting expectations, we can address them. Asking explicitly around expectations by asking, for example, "What is it you're expecting to happen today?" Or "Do you have a particular plan in mind already?" These can help facilitate those conversations with a spirit of curiosity.

So, some patients may have expectations that surprise us, and that can be addressed compassionately once out in the open. When physicians address these four aspects of illness, patients are more likely to be satisfied with their doctors, more likely to comply with the treatment recommendations, and also more likely to recover.

So, in just a few minutes, using communication tools such as FIFE, it's sometimes possible to defuse a potential crisis, provide explanations and allay the fears of our patients. This can end up saving us time, in the end, by reducing the potential for minor irritants to become major challenges.

We must also be mindful of our own reaction to patients who challenge the care that we offer. It may be normal to feel frustrated when someone's rejecting what we truly believe is a safe course of action. But once the patient experience has been explored, questions addressed, and any misunderstandings resolved, it may be important to remind ourselves that patients have that right to autonomy.

So, FIFE can be used in all clinical settings, whether you're a family physician, a surgeon, an internist or any patient-facing specialty. While it may seem like this might add a little bit of time to your encounter, it can often end up saving time and decrease that risk of conflict.

Additionally, it may be useful to FIFE ourselves from time to time and explore whether we have expectations of patients that are, in turn, contributing to challenging encounters.

Liisa: Thanks, Katherine. Sometimes, despite our best efforts to manage these expectations, emotions can run high and patients may express frustration or anger.

So, handling a difficult situation that involves an angry or upset patient is a reality that most health care providers have experienced at some point in their career. And how we respond is just as important as the issue itself, if not more so. The way in which we deal with the situation can make the difference between a resolved outcome and a strengthened relationship versus a compromised doctor-patient relationship.

So, the patient may have a lot going on. They may be upset for reasons that are out of our control. And, being prepared with an approach in mind is really helpful. We introduced FIFE to help avoid these challenging situations, but sometimes these encounters occur and now we need tools to de-escalate.

So, the second communication tool we're going to talk about today is the HEART protocol that was developed by Gerald Hixon at the Vanderbilt University. So, this tool is a useful approach to consider when you want to repair a relationship with an upset patient.

On screen display of the mnemonic HEART protocol. H for hear the patient, E for empathize, A for apologize, R for respond, and T for thank the patient.

The most important thing we can do when faced with an upset patient is to just stop what you're doing and give them your full attention. Take your own vitals signs, slow down and model the behavior that you would like your patients to demonstrate to you. Take a few big breaths, ground yourself, slow your voice, talk calmly and quietly, and be aware of your physical presence and gestures. So, give them the time to express their concerns and try not to interrupt. So, this means that you're actively listening and not planning your response to their issues or your comeback.

So, the H in the HEART protocol is about creating a safe space to hear the patient and hear their concerns. E is show empathy. Try to be compassionate and respectful. A is apologize, if appropriate. Expressing that you're sorry that their experience or expectations haven't been met is not an admission of guilt, and it can be important in helping to repair that relationship. R is for respond to their concerns. Find some kind of mutually agreeable grounds. And then T is thank them for sharing, for how sharing how they feel and for trusting you enough to open up.

And finally, here's the last tool we're going to go over. This is the APE mnemonic. When physicians have told us that this can really help with de-escalating situations.

On screen display of the APE mnemonic. A for acknowledge, agree, apologize, P for pause, paraphrase, and E for empathy, explore.

So the A is acknowledge, acknowledge their feelings. "You're right, it's frustrating." Or agree, find something that you can agree with them about. "I agree parking here is difficult." Apologize for the problem or the perceived problem, if it's appropriate. "I apologize that you've been waiting" or "I'm sorry that you feel that I was rude. That was not my intention."

So the P is pause and paraphrase. Again, like we talked about before, let them tell their story, don't interrupt them. Summarize and paraphrase. "So, it sounds like what you're telling me is..." or "Let me see if I have this right so that we know we're on the same page."

And then finally, E is for empathy, or uncovering their expectations, or exploring options and looking for a solution together. Explore a few options collaboratively with the patient, if possible, so that the focus shifts from being angry to finding a solution.

Katherine: So, you've now learned one tool to help foster good patient-physician relationships and two tools to help when encounters aren't going well. So, what if, instead of getting better, things get worse? What do you do when de-escalation just isn't working? Well, if those tools simply aren't working or even before or during the use of the APE or the HEART tools, it's important to name inappropriate behaviors and specify to our patients that they're unacceptable. Clarify with the patient the consequences of continuing these behaviors. At the end of the line, an erosion of trust may lead to termination of the physician-patient relationship.

So, after having verbalized the specific behavior and having clearly told the individual that it's unacceptable and outlined the consequences of continuing or repeating this behavior, ensure you document the encounter in a factual way, omitting any opinions or interpretations of the actions. Include any warnings you gave around consequences or future occurrences. Situations such as these may also be a good prompt to review your office safety policies and ensure consultation room layouts allow for a safe exit if consultations or encounters escalate.

So, while many situations can be de-escalated, despite our best efforts to resolve conflict, there are times when situations may not improve and could escalate to threatening behaviors and even violence. Listen to your gut. Some behaviors are obviously threatening, such as the use of abusive language or direct threats of violence. But some of these behaviors are more subtle. These can be nonverbal cues that make us feel unsafe. And it's important to remember that if we or any of our staff are faced with imminent violence, the priority is protecting us, our staff and our patients. And to call for help. Call security, another colleague or even police, if required.

Safety is paramount.

When reporting to police, they only require the information necessary to address the threat, such as the individual's name and the nature of the incident. It's important to avoid disclosing any unneeded personal health information that could be considered a privacy breach.

Once the acute situation is resolved, the question of terminating the patient-doctor relationship might often come up. If a physician doesn't believe that they can continue to offer care in a relationship of trust with a patient, then it may be in the patient's best interest to terminate that physician-patient relationship. This must always be done in a way that's compliant with College guidelines and policies.

The ability to care for a patient is always an individual decision for the physician, but shouldn't be taken lightly. If concerning behaviors are recurring but minor, it's up to you to make a decision as to whether or not you feel there remains sufficient trust in the relationship to continue providing quality care and whether that patient-physician relationship needs to end.

However, if the behavior is out of character for a particular patient, it could be part of the presentation of an underlying medical condition. Or there may be other factors that should be considered before a decision is made.

If the abusive behaviors are major or severe, then the decision to end the patient-physician relationship may be clear to you. The process you undertake once again must comply with College guidelines and policies in your province or territory.

If you have concerns around a patient's actions or your situation poses particularities that you're unsure how to manage, you can call us here at the CMPA for case-specific advice around managing your medico-legal risks in those situations.

Liisa: So, if you feel your safety is threatened, excuse yourself and leave the room. Get help either another colleague or security. But don't tell the patient or tell them or threaten them that you're going to get security because that can start to escalate the situation.

When faced with imminent or life-threatening violence, physicians should leave the area, take steps to protect other patients, staff and themselves, and call security or 911 as appropriate.

If a genuine threat is perceived, or if an assault occurs, physicians should call the police for help. And as we mentioned, despite the duty of confidentiality, physicians should not hesitate to contact the police if they feel that their safety or the safety of others is threatened.

A report to police should include only the information necessary to address the threat, such as the name of the individual and the nature of the incident. So, divulging any further patient medical information should be avoided.

And it's important to acknowledge that these challenging encounters have a real impact on our well-being. And as much as we want to be there for our patients, it's okay to acknowledge that we need a minute, that we need to take a moment to recover, to recenter and bring down that emotional energy. And that may be going outside for a quick walk, taking a few deep breaths, maybe even calling a colleague and taking a time-out for yourself. Whatever we need to do to take care of ourselves in that moment, so we can be in a better place with the next patient to reduce the risk of having another encounter where emotions can run high.

Katherine: So, this really wouldn't be a CMPA presentation if we didn't talk about documentation. So, like all other clinical encounters, challenging patient encounters need to be clearly documented in the medical record. So, here are a few documentation tips.

First, it's a good idea to document that our patients are aware of our office policies and procedures, especially around expectations for code of conduct. And we want to document that we've reviewed these policies and procedures with them. This might happen at a first visit or whenever policies and procedures are updated. An assistant may review these with a patient and answer questions, but it may also be useful for physicians to personally ensure patients are aware.

Then, if we've had conversations with patients to discuss specific behaviors and their consequences, it's important to document these warnings and these conversations in the patient's chart.

Our third tip: Ensure that documentation of any behaviors in a breach of office policies around conduct is completed objectively and in a factual manner. It's prudent to document our efforts, as well, to defuse conflicts and our efforts to remediate any ongoing behaviors.

As an important reminder, when we document, it's important to describe the individual's behavior in a factual way and not what we think their intent is with what they're doing. It's also a good idea to train our staff to do the same. Sometimes it can be useful to include verbatim statements made by patients. In that case, use quotation marks to indicate that those statements in the chart are direct quotes.

Liisa: So, if the abusive behaviors are recurring but minor, there may be insufficient trust you continue in that patient-physician relationship and being able to provide continued quality care. And, this may lead to termination of that relationship. But if the abusive behaviors are major or severe, you really do need to think about ending that doctor-patient relationship, and certainly in keeping with any applicable medical regulatory authority or College guidelines.

So, this is a list of some of the things to consider if you're ending a relationship with a patient due to significant breakdowns in trust.

On screen display list of considerations for ending the relationship: Significant breakdown in trust, must comply with expectations of your College, the patient does not require urgent care, you have given adequate notice to find another HCP (healthcare provider), and have a face-to-face meeting and be clear about why and when and document.

First of all, as I mentioned, you need to comply with the expectations of your College, and ensure that the patient does not require any urgent care. You need to give adequate notice for that patient to be able to find a new health care provider, and having a face-to-face meeting with the patient and being clear about why this is happening and when the relationship will end and to document that discussion.

So, in summary, prioritizing the implementation of positive, patient-centered communication is crucial to maintaining and strengthening relationships with patients, and this will allow for open and transparent communication, making the patient an integral part of the team and optimizing delivery of care.

Consider your practice policies and procedures. Are your staff and patients aware of them? Making this explicit will ensure everyone is prepared to provide consistent messaging, and staff should be prepared and trained in de-escalating disagreements.

So, consider identifying steps that should be taken to address underlying issues that may contribute to a patient's unmet expectations. Be prepared and proactive if you know that a challenging situation might arise.

Have a huddle with your team, make sure everyone's on the same page and knows what to do and let your staff know that you have their backs. And if you do have a challenging encounter, have a debrief. What went well? What didn't go well? What did we learn? What should we consider moving forward?

And, you may also want to consult with other colleagues and coworkers on how they handle these situations in order to get different perspectives and ideas on how to handle these challenging situations.

And then, recognize the importance of having and being familiar with your security policy and your safety plan.

Katherine: So, the bottom line is that creating the space to have conversations that matter starts with building a solid foundation, practicing your tools and knowing when to react.

Honing your communication skills will not only optimize your competency as a physician, but will also optimize your relationships with your patients, who may also be struggling.

Improving relationships with our patients through effective communication strategies is also a way to find meaning in our work and to optimize patient care. Interacting with patients compassionately can help them preserve their dignity through challenging times in their lives when they need to interact with the healthcare system.

No matter what method or mnemonic you choose to help improve your communication, it's important to practice these skills and to feel comfortable using them. Consider practicing in a low-stakes conversation. Perhaps when a patient has concerns around parking, for example. Using these tools will feel more comfortable when something a little bit higher stakes happens, once you've had some practice.

If you feel that you could use some more training or if you're looking for other strategies, there are many options available. Remember to document challenging encounters and the actions of both yourself and your patient factually and objectively in the medical record.

Finally, foster a psychologically safe environment with your team, including your patient, so that you're prepared in the event that you do face a challenging encounter. Have an office safety plan in place in case of a dangerous situation.

Liisa: Before we finish, let's take a moment to think about your main takeaways from this conversation today. And we're going to put that poll back up. And, so, as a result of participating in today's webinar, how confident are you feeling in your ability to manage challenging encounters with patients?

• Zero is not confident at all;
• Five, somewhat confident;
• Ten is very confident.

We would love to see that there's been a little bit of improvement and that we have been able to give you some practical strategies as to how to manage these encounters.

So I would be remiss not to thank you all for the incredible work you do on a day-to-day basis. We know these last few years have been really hard, and yet you've kept going, showing up every day to help our patients. And in an environment that keeps changing and that keeps challenging everyone.

Katherine: And for that, we thank you.

On screen display: We invite you to provide feedback on your experience by selecting “Give us your feedback” following this recording.