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Holding Difficult Physician-Patient Conversations


Repeatedly broaching a difficult conversation with a patient may mean you are missing the real issue. Don't be afraid to address the elephant in the room.

I went to a conference last week that featured the author of "Crucial Conversations," Joseph Grenny. He gave a very engaging and thought-provoking talk but centered on an intriguing concept. He told us that if you have the same conversation twice or if you are getting frustrated in your conversations, you are discussing the wrong thing. He further challenged us to consider whether the conversation needed to be about content, patterns or process, or relationships.

We are often criticized in medicine for the failure of communication. This can be a misunderstanding at the time of diagnosis either because of medicalese or because of the patient's difficulty accepting the words. We often fail to communicate well during handoffs of patient care. Physicians are also notorious for failing to have important conversations with impaired colleagues. Our limited communication is surprising given the inherently social nature of medicine.

I recently was told about an interaction between an emergency room physician in our hospital system and a primary-care provider over a patient who was transferred from the clinic to the emergency department. The ER physician bemoaned the transfer as being inappropriate and then went on to discuss other examples of patients transferred seemingly inappropriately. While the discussion was about content, it was clearly not the main issue and not the first time the ER physician had this conversation with a colleague.

What if we were brave enough to broach the conversations that need to occur? Instead of focusing on the ER patient who may or may not belong in the ER, the physician could discuss the relationship between the ER and primary care and where that relationship was not working. This would hopefully help build bridges and address the primary issue rather than lead to frustration and bad feelings on both sides.

Likewise, when do we confront our patients? Instead of focusing on the content, we can focus on the pattern. For example, instead of saying "Mrs. Jones, why didn't you take the atenolol I prescribed?" we can say "Mrs. Jones, you often haven't taken medication that I prescribed. What are your concerns with taking medications?" This could apply to the broken process that often exists between hospital discharge and return to outpatient primary care, or the manner in which a nurse treats patients, or how a physician treats the nurses. When the content issue doesn't seem to be the real issue, we could comfortably take the conversation to a deeper level - to a pattern of behavior or to the relationship challenges.

As physicians, we are increasingly called on to account for our communication with patients, clinical staff, and with each other. We have difficult, emotionally-laden conversations on a daily basis. So, next time you find yourself having the same conversation twice or getting frustrated with the way the conversation is going, I invite you to step back and consider what the real topic of the conversation should be.

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