- 02:26 Difficult Patients
- 10:25 Mediation Toolkit
- 17:20 Maxims of Mediation
- 26:46 When the Conversation Still Breaks Down
- 35:11 Conclusion
Sponsor: Glass Health is a platform that empower clinicians with best-in-class AI for clinical decision support Use promo code COREIM for 1 month of free access to Glass Pro for unlimited A.I queries !
- “Difficult” Patients
- The term “difficult” is defined from the perspective of the clinician, and open to implicit bias or unrealistic expectations of patient behavior
- Black patients are more likely than white patients to:
- Have at least one negative descriptor in their notes (.ie. “resistant” or “noncompliant”),
- Have security called on them during their first admission
- Be physically restrained
- Mediation Toolkit
- Mediation is a process of facilitated conversation between two parties who are in conflict
- “View from everywhere”
- People naturally view conflict from their own perspective
- However, the “view from everywhere” argues that all conflicts are shared
- To work towards resolution, try to put yourself in the other person’s shoes to understand their perspective
- However, the “view from everywhere” argues that all conflicts are shared
- Advocates for an analytical empathy
- People naturally view conflict from their own perspective
- Positions vs. interests
- Positions = What do you want?
- Interests = Why do you want it? (moral commitments, values, worries, needs, etc)
- To work towards resolution, focus on the interests that underlie someone’s positions
- “Seven Maxims of Mediation”
- “‘Difficult patients should be viewed as a syndrome, not a species”
- “Anger is a reactive emotion, so the key is finding its source”
- Try to find the source during the challenging times
- “It takes mere seconds to escalate or deescalate a brewing conflict”
- “Calling someone out for bad behavior will inevitably make matters worse”
- This can cause extreme anguish when when a patient is behaving badly towards towards a team member or trainee
- It is important to NOT choose sides
- Instead, think about what is best for your trainee and for your patient and separate the two
- “Exercising neutrality ups the odds of successful conflict resolution”
- “Naming the concern demonstrates alliance and avoids creating an adversary”
- “A sincere apology or expression of consolation can go a long way in defusing a tense interaction”
- When the Conversation Still Breaks Down
- While the 7 maxims should help diffuse and improve most situations, it’s important to acknowledge the toll that acrimonious conversations can take on our mental health
- Ask yourself: Have some of our own limits been violated beyond where we feel we can adequately continue giving good care to this patient?
- Most institutions have policies around how to handle cases of patient incivility or disruptive patient behaviors
- Reach out to ethics, risk management, and patient representative offices
- Conflict management rounds
- If you are concerned that you may be physically harmed, call security and leave the room
Dr. Margot Hedlin: I’ve been in my fair share of heated conversations. Tensions run high when people are sick, or in pain, or grappling with realities they never expected to face. I’ve been yelled at, called names I can’t repeat, and have dodged everything from shoes to punches to the contents of a colostomy bag. In residency I remember leading a goals-of-care discussion for a dying man whose family had questioned our medical judgment at every turn. I broke the news that we wouldn’t be providing dialysis, and in my white coat I must have felt to them like the embodiment of everything that was wrong with his care. They told me his blood was on my hands.
Dr. Margot Hedlin: In our very first episode of “At the Bedside”, we spoke with clinicians and trainees about their difficult patients. Who they struggled to care for, and what they’d learned along the way. Our goal with that episode, to understand the patients we label “difficult,” is still so important to work towards, but when patients and clinicians have fundamental disagreements about what should be done, empathy can only get you so far. Today, we want to talk about the communication skills that can help us de-escalate and resolve the deep, values-based conflicts that can arise. Welcome back to “At the Bedside.” I’m Margot.
Dr. Tamar Schiff: I’m Tamar.
Dr. Jafar Al-Mondhiry: And I’m Jafar.
Dr. Margot Hedlin: Today we’re speaking with Dr Autumn Fiester.
Dr. Autumn Fiester: I’m the director of the Penn program in clinical conflict management, which is a program to bring conflict management training to clinicians and to clinical ethicists. And I’m on the faculty in the department of medical ethics and health policy at the Perelman School of Medicine at Penn.
Dr. Margot Hedlin: Dr. Fiester teaches conflict mediation workshops, in which she hopes to empower as many people as possible to address conflicts before they devolve.
Dr. Autumn Fiester: If we think about conflict as having two categories, and of course there are more, but call them two categories: rooms that are on fire and kitchen fires. So one requires firefighters, the other requires the use of a fire extinguisher. I think we need to get more fire extinguishers into the hands of healthcare providers so that we can prevent as many blazes as possible.
Dr. Margot Hedlin: In this episode, we’ll talk about data on difficult patients, Dr Fiester’s strategies for defusing tense interactions, and then discuss what to do if the conversation still breaks down.
Dr. Tamar Schiff: As we explored in our previous episode on the topic through narratives from physicians and medical students, it is much more often a difficult situation, rather than a “difficult” patient, that raises concerns and distress. But even knowing that, we still hear—and, admittedly, use—this label with certain patients. So what do clinicians generally mean when they label a patient “difficult”?
Autumn Fiester: Clinicians are usually talking about what those interactions feel like to them. So difficult patients could be individuals who are not compliant with what the clinician has prescribed or the course of treatment that’s been agreed to, and that would be probably at the most mild end of behavior. And difficult patients could be described all the way at the other end of the continuum where patients or their families might be rude or even using obscenities or racial slurs and everything in between. So difficult patients and families get defined from the perspective of healthcare providers who are finding it challenging to manage interactions.
Dr. Tamar Schiff: And what leads patients or members of their support system to act this way? In response to some older literature suggesting that “difficult” behavior is often the product of psychiatric diagnoses, Dr. Fiester emphasized the inadequacy of that type of conceptualization.
Autumn Fiester: My view of the difficult patient and the difficult family. So these are typically normal people with normal mental health status and just typical moral character, who in these circumstances are comporting themselves in ways that healthcare providers find challenging. So I’m not denying that there are individuals with challenging mental health conditions, but I am focused on the vast majority of patients who become difficult or their families become difficult because of the situation that they find themselves in.
Tamar: Dr. Fiester pointed to how we may also be quicker to label a patient “difficult” now-a-days than we used to be.
Dr. Autumn Fiester: The entire American society is short fused compared to what they were prior to COVID. We talk about how patients have fewer reserves, but healthcare providers also have fewer reserves. And it’s totally understandable what healthcare providers have been through in terms of their own exhaustion and burnout and trauma is extraordinary. And so it’s reasonable for healthcare providers to have low reserves, but it’s also reasonable that patients and their families have low reserves and the systems have not been improved. In fact, if anything, many of these systems given work shortages, economic pressure, some of these systems have become even worse.
Dr. Tamar Schiff: Clinicians often empathize with the vulnerable position of patients and their loved ones. But we still see that people can be labeled as “difficult” for problematic reasons, and very unfortunately, some of these scenarios may involve implicit biases around racism or mental health discrimination, among others.
Dr. Autumn Fiester: Yesterday’s traumatized individual is tomorrow’s challenging patient, the legacy that individuals bring from their traumatic experiences and not just systemic offenses and injustices, but micro interactions and micro aggressions, they are legacies that are then carried forward into tomorrow’s clinical encounter.
Dr. Tamar Schiff: Everyone expresses emotions like grief, frustration, or anger in ways that are shaped by their past experiences, cultural context, and a host of other factors. And the difficult label is almost entirely informed by the perspective of the clinician, so when behavior doesn’t conform to our expectations, we may be quick to slap the label on. There’s important data on how the medical profession, which is predominantly white and comes disproportionately from relatively economically privileged backgrounds, can perpetuate inequities.
Dr. Autumn Fiester: Minority patients’ families are much more likely to have security called on them and they are much more likely to have an ethics consult called on them. And to me that raises a huge red flag about perceptions of behavior and not at all about actual behavior.
Dr. Tamar Schiff: We wanted to review a few important studies that back up and underscore what Dr. Fiester told us. So, in a paper by Valtis and co-authors, recently published in the Journal of General Internal Medicine, a retrospective cohort study of over 24,000 non-psychiatric inpatients found that compared to white patients, Black patients had higher odds of security personnel being called to the bedside during their first admission, even when adjusting for age, sex, length of stay, mental health or substance use disorder diagnoses, and insurance status. Another study by Sun and colleagues published in Health Affairs last year used machine learning to analyze over 40,000 notes from the electronic health records of over 18,000 patients. Their concerning findings were that, compared to white patients, Black patients were over 2.5 times more likely to have at least one negative descriptor in their notes—for example, terms like “resistant” or “noncompliant.” And as a final example, in a cross-sectional study of over 700,000 adult Emergency Department patients published in JAMA Network Open, Wong and colleagues showed significant associations between an increased risk of being physically restrained and a number of demographic variables, which included Black or African American race and lack of private insurance. So how can we re-conceptualize the “difficult” patient to start approaching these situations in a productive way?
Dr. Autumn Fiester: Most patients and families who are behaving in ways that providers find challenging are in that continuum of normal. And so what we need to do is think about why is this particular person engaging in behaviors that are maladaptive or are unpleasant or are rude when they typically would not? And that’s what I mean by reconceptualizing. And my answer is from their perspective, things are not going right. It’s not just that they’re ill or that their loved one is ill, it’s that the standard that they have in their mind for what healthcare ought to be is not the standard that this interaction or this experience or this hospital’s various structure or systems, that’s not the bar that’s being met. And so people get angry, they get frustrated.
Dr. Tamar Schiff: In her workshops, Dr. Fiester encourages clinicians to think about circumstances that have pushed them to be rude or impolite, as a way of illustrating how all of us can be pushed past our limits. Then, we need to apply that same empathy to our patients.
Dr. Autumn Fiester: When we talk about trying to mitigate the problems of the difficult patient, I don’t see enough attention to all of the layers and the histories and the previous experience that brings someone to that moment, even from appointment scheduling, trying to get an appointment, trying to get parking. The runaround that you get when you get there, everyone is down on their reserves, but what patients and families experience would be frustrating, I think to Joe, to anyone even with extraordinary patience and then make someone ill and potentially seriously ill and frightened, terrified, maybe even. I don’t understand why we would expect anything less than challenging interactions.
Dr. Margot Hedlin: Now that Tamar has walked us through some of the data and the preconceived notions we may have about difficult patients, let’s turn to the strategies for navigating contentious conversations. We’re going to talk about Dr Fiester’s 7 maxims of mediation, but before we dive in – what exactly is mediation?
Dr. Autumn Fiester: Let’s redefine mediation to being just facilitated conversation, conversation among individuals that has the supportive role from someone who knows conflict management or mediation so that voices can be amplified so that the vulnerable voices can be protected so that people can hear each other. That’s the spirit of mediation.
Dr. Margot Hedlin: The first key mediation lesson that we wanted to share is an idea called “the view from everywhere.”
Dr. Autumn Fiester: When individuals are in conflict with each other, they naturally inherently define the problem from their own perspective. The view from everywhere is the idea that a problem is shared, a conflict happens between individuals. So if there is only a one-sided perspective on that problem, that problem can’t be solved because the other person’s perspective hasn’t even made it into the diagnostic process of what’s happening. So the view from everywhere is the idea that if you really want to solve a conflict, you have to understand the perspective of each of the individuals that are involved in the conflict.
Dr. Margot Hedlin: What’s a good strategy for understanding each person’s perspective?
Dr. Autumn Fiester: What would your view of that problem be if it were about you, not about some person that you’ve made a caricature of, but if you yourself with all your mental intactness and all of your character strengths, if you were in that scenario, if that were your problem, how would you see the problem? And it’s just a simple exercise of putting yourself in someone else’s shoes.
Dr. Margot Hedlin: The view from everywhere is a way of helping learners cultivate a very specific type of empathy.
Dr. Autumn Fiester: Sometimes when people are charged with “go forth and be empathic,” they read that as a mandate to feel the pain of others and to be sympathetic for what other people are going through. But the kind of empathy that mediators are advocating is an analytical empathy where you are not trying to feel for other people, which would short circuit your emotional sensibilities. That’s where compassion fatigue would set in. No, empathy in the mediation sense is to try to put yourself in their shoes as they’re narrating to understand the worldview from their eyes. That’s a full on cognitive activity that does not require you to emotionally bleed.
Dr. Margot Hedlin: Another key lesson from mediation is to distinguish positions from interests. What are positions, and how do they differ from interests?
Dr. Autumn Fiester: I want you to start dialysis on my mother. That’s a position that people take. It’s their stated claim and the stated desires that they have or what they would like to see happen in a circumstance, that’s their position. But undergirding all positions are the “why does someone have that position?” The why question, not the what do you want, but the why do you want it? And those are called interests. And those interests can be your moral commitments or your principles or your values or what matters to you or what your worries are, what your needs are.
Dr. Margot Hedlin: How can this help us move a conversation forward?
Dr. Autumn Fiester: When people are in conflict, they are typically in conflict over a position. You do not actually want to start dialysis on Mrs. Jones and Mrs. Jones adult daughter wants you to start dialysis on Mrs. Jones. “Don’t start dialysis,” “start dialysis” are diametrically opposed positions being taken by two stakeholders who are in intractable conflict, but mediators knowing of course that the conflict is about positions, realize that the solution that the path forward is to get underneath the positions to the reasons why those two individuals take the positions that they take. So mediators focus the conversation on what is at stake, what are the interests? And we often think that we know the reasons that undergirds someone’s position. The reason you don’t want to start dialysis on my mother is because you want to save resources on her for someone else, that’s why. We have hypotheses or the reason that the adult daughter wants to start dialysis on her adult mother is because she’s waiting for a miracle. We have hypotheses about each other. They are often patently false. So what we’re trying to do when we’re navigating conflict between two stakeholders is get to the reasons that are the true reasons that undergird those positions and magic can happen when you do that. Well for one thing, you can actually understand why someone wants something, wants what they want. And maybe that reason changes your approach to it. And maybe you think, well, those are actually pretty good reasons and so maybe I should change my mind and maybe I should change my position. So that’s one thing that can happen. I just change my mind. But another thing that can happen is I see you now in a way that I did not see you before, not somebody who’s trying to cheap it out on my mother, but somebody that’s actually caring and dedicated to my mother. Well, we may disagree and we may agree to disagree, but I will no longer be able to see you as heartless, someone who’s trying to save money on my mother, thank you. No, I’ll see you as somebody who’s a 360, who’s got dimensions, who’s got some heart in the game, and that is game changing in and of itself and vice versa. You can imagine what happens when I understand your “why.” And so trying to get people to stop focusing on positions and talk about interests and there are flag words that get us to interest. What is that person’s needs? What is that person worried about? What are the principles that are driving that individual?
Dr. Margot Hedlin: These two tenets – the view from everywhere, and positions versus interests – can be incredibly helpful for de-escalating conflict.
Maxims of Mediation
Dr. Jafar Al-Mondhiry: Okay, now that we have the groundwork for understanding positions, interests, labels and biases, we want to dive in on some of the principles and tools to use when you’re out there on the frontlines of difficult patient interactions.
Dr. Autumn Fiester: So I call this the seven maxims of mediation. And I do think that these seven maxims cover a lot of the terrain for the fire extinguisher approach to nipping conflict in the bud when it’s in its early stages.
Dr. Jafar Al-Mondhiry: So the first maxim is actually a callback to what Tamar started with at the top of the episode, and maybe something that should be etched into the walls of medical call rooms across the country: “‘Difficult’ patients should be viewed as a syndrome, not a species”
Dr. Autumn Fiester: What I am advocating is that instead of thinking about an individual as being a difficult person, they should think about this as being just a normal person who’s behaving in ways that you’re finding difficult, Why is that so important? Briefly, it’s important because if you have in front of you the species called difficult, there’s really not much you can do. Best thing you can do is to get in and to get out without getting bit because that’s the kind of species that this is. They’re dangerous, but if you think this is a normal human being exhibiting a cluster of symptoms that are very unpleasant, but they are symptoms, it strengthens your resolve, but it also focuses on what you ought to be thinking about, which is what is causing this and to look for that causal mechanism.
Dr. Jafar Al-Mondhiry: So taking that last point a step further, it’s time to get down to causes and conditions. The elephant in the room is basically this – the patient, the family members, they are really angry right now, but the anger is only a secondary emotion.
Dr. Autumn Fiester: The second maxim is about the emotion anger, and the maxim says that anger is a reactive emotion, and so the key is to find its source. What would the reason be that this person is angry right now at you or your colleagues or your system. So not allowing the move to, “they’re angry at God, they’re angry at faith, they’re angry at bad luck,” no, they’re angry at you, they’re angry at you, or they’re angry at the system or they’re angry at what just happened in the parking lot. So the question is what is it that they’re reacting to and what can you do to find the source of that anger and to do something about it? That’s maxim 2.
Dr. Jafar Al-Mondhiry: Dr Fiester went on to describe anger as a unique kind of “moral emotion.”
Dr. Autumn Fiester: People become angry or indignant or resentful when they believe that they are under siege, physically, psychologically, socially, emotionally. In other words, as bloodhounds for threat to our personhood, we can be angry even before we can analyze cognitively what it is that you just did that made me angry.
Dr. Jafar Al-Mondhiry: So anger bubbles up from this very core, very vulnerable place of self-protection. And while it may a very unpleasant thing to bear witness to, Dr. Fiester’s point is that we need to reach past that initial unpleasantness to see that, fundamentally, this is a person going through intense suffering, down in their very core self, the kind of suffering that needs to be honored instead of dodged or avoided or scolded.
Dr. Autumn Fiester: When people see anger, they put up their shield, they put up their defenses, there’s something wrong with this person, it’s very ugly, I’m not dealing with that. Whereas if they were weeping, you would not have that reaction and asking healthcare providers to take anger and plop it into that other category, an emotion that needs your assistance that is calling for your help, that requires your attention and not your rejection.
Dr. Jafar Al-Mondhiry: When someone is reacting in anger, the challenge, but the ultimate solution, is to “find the speaker’s truth.”
Dr. Autumn Fiester: When I talk about finding the speaker’s truth, I’m asking for the healthcare provider to do that during the diatribe, when the person is angry, when they are saying things that seem rude, I’m not talking about in the easy times, in the good times, all healthcare providers do that in the good times. I’m saying you need to find hunt for that truth in the bad times, in the challenging times. Rather than saying, first speak politely, first calm down, or I’ll call security when you’ve done that, then I’ll find your truth. No, all at the same time you’re looking for that truth.
Dr. Jafar Al-Mondhiry: Trying to manage emotions when they run high seems like a very daunting and time consuming task, but this is where our 3rd maxim comes into play – “It takes mere seconds to escalate or deescalate a brewing conflict.”
Dr. Autumn Fiester: Healthcare providers are understandably very worried about the time commitment in any of this conflict management because they have so little time and that’s completely understandable. But conflict can be created in a mere seconds you can throw kerosene on a flame and make things very bad very quickly if you are, for example, dismissive. Somebody has come into your office and they’ve been waiting a very long time and you say, “Well, we could spend more time talking about how you waited a long time or we could just get to your problem.” Guaranteed kerosene on a fire. Took, how many seconds did it take for you to say that? Not very many seconds, 10 seconds, many seconds you have now blown up the conflict potentially, but it only can take a couple of seconds to de-escalate it. If you think about your last time in the grocery store where you ran over somebody’s toe with the cart, you were able to get that thing calmed down in seconds by looking the person in the eye saying in a heartfelt way, I’m so sorry, I was reckless, I wasn’t looking where I was going, are you okay? That’s again 10 seconds of investment.
Dr. Jafar Al-Mondhiry: So even one sentence can ignite a terrible flame during a conflict. I mean, just imagine you’re in an argument with someone and you say something like “calm down.” How well does that work? Just two words and you’ve completely made things so much worse. Just ask my wife. And how we respond when patients or families start acting out on emotion takes us to our 4th maxim – “Calling someone out for bad behavior will inevitably make matters worse.”
Dr. Autumn Fiester: I love the fourth maxim. Do not call people out for bad behavior. Unless someone truly is suffering from a very profound mental health condition, people already know what decorum requires in the setting of medical care. So they already know that they are not behaving, not comporting themselves in the standard that is typical or even appropriate for that setting. So to call them out on it and say, you are behaving badly, which wouldn’t be the phrase, but that’s the sentiment, is to tell someone not only what they already know, but to focus wrongly on the form of what someone is saying rather than the content that they’re trying to deliver to you. To focus on the kind of words people are using, the labels that they’re using, the tone, the volume is to say to them, whatever it is that matters to you, will only matter to me if you comport yourself in a way that I think is appropriate. And so you have now shown them, you have dismissed their concern in that you have inappropriately hierarchized something that’s trivial instead of hierarchizing something that’s profound. What their need is should come first, not the way they express their need.
Dr. Tamar Schiff: And this can of course be challenging for anyone in a situation with some tension. Clinicians in these scenarios certainly don’t deserve to be yelled at or spoken to inappropriately. To explain her position, Dr. Fiester brought us to maxim 5 – “Exercising neutrality ups the odds of successful conflict resolution.”
Dr. Autumn Fiester: When healthcare professionals say to me, we should not be on the receiving end of rudeness or insults, I say, let’s get some fire extinguisher skills because the number one fire extinguisher skill is to maintain neutrality, which is maxim number five to be Teflon in that these people are not your friends, they’re not your spouses, they’re not your children or your parents, these are people who need your help. You’re not equals; you are the powerful because you are well, you’re powerful because you have skills. You’re powerful because you are dressed in a white coat. And they’re vulnerable because they’re ill and they’re in pain and they’re in a paper gown. You have to be bigger than that. You have to just let that roll and be the one who can solve the problem and not focus on how your feelings are getting hurt. And if your feelings are getting hurt, that’s what the fire extinguisher skills are designed to do. They’re designed to help you get some Teflon so that when somebody says something nasty to you, you say, “It’s not about me. This is about them and what do I need to do?
Dr. Tamar Schiff: But what if it’s not just about you. What about when you’re not concerned about how you’re being treated, but rather how your trainees are being treated?
Dr. Autumn Fiester: Yeah, I think that that is a source of enormous anguish for those that are trying to work with trainees because your protective instincts towards patients also are your protective instincts towards trainees. And so you’re conflicted about who gets the attention and one person is being bad to another person. But my suggestion is that to the extent that’s possible, you have that trainee exit the tough situation so that you can work to solve the patient’s needs while then follow up with the trainee saying that “This is not about you. Do not take that on. Patients are hurt, they’re sick, they react sometimes badly.” You don’t have to do all things at the same time.
Dr. Tamar Schiff: Dr. Fiester went on to explain how important it is not to choose sides, but instead to think about what is best for your trainee and for your patient and to separate the two. You can back your trainee and protect them from a hostile situation by getting them out, and discussing the interaction with them later. And by not scolding the patient in front of them, you’ve also hopefully prevented the situation from escalating and preserved some opportunity for a good relationship with the patient as well. And with that we’ll move to maxim #6, which can help move past some of the tension – “Naming the concern demonstrates alliance and avoids creating an adversary.”
Dr. Autumn Fiester: Naming the concern is about interests. Rather than allow back and forth on positions, get down to their concerns, which are their interests. That does so much good in terms of transforming the conversation. Instead of having an adversarial relationship, you’re demonstrating an alliance.
Dr. Tamar Schiff: And that brings us to Dr. Fiester’s final maxim – “A sincere apology or expression of consolation can go a long way in defusing a tense interaction.”
Dr. Autumn Fiester: A lot of times clinicians don’t like getting into the terrain of apology because it has a whiff of malpractice and error and makes clinicians feel frightened. But the kind of apology and acknowledgement we’re talking about is rarely about error. And when we say, I’m sorry, we can mean two different things. “I’ve done something wrong. Oops, I feel bad about it and it’s my fault like running over your toe.” Or I could say, “I wish this had not happened to you.” And that’s the, “I’m sorry that…”, so if somebody, you learn somebody has a miscarriage, you can’t say, I’m so sorry to hear that fast enough. But you have to say it sincerely.
When the Conversation Still Breaks Down
Dr. Jafar Al-Mondhiry: So hopefully these 7 tips help defuse most conflicts. But many of us have been in situations that just seem impossible to resolve.
Dr. Autumn Fiester: People ask, are there conflicts that can’t be mediated? Well, there aren’t a lot of kitchen fires that can’t be put out, but there are blazes that can’t be put out, certainly not by the skill, the personnel that exists in a typical hospital. So what mediation can do is teach providers skills to nip this conflict in the bud to solve it now so that it never blows up into a conflict that would require technical mediation, true facilitated conversation.
Dr. Jafar Al-Mondhiry: So what should we do when a situation doesn’t improve with these 7 lessons? Short answer. Call for help, contact the patient representative office, ethics consultation, or palliative care consultation if appropriate. If the situation is still falling apart, Dr. Fiester noted there might be other ways to rebuild trust.
Dr. Autumn Fiester: The longer the conflict has gone on, the more your investment is going to have to be to chip away at it. That said, can trust be so broken? Sure. That kind of circumstance where the conflict manager just can’t get trust going would be the moment I would say, can I get race concordant or demographic concordant or ethnicity concordant or religion concordant conflict management going, where maybe whatever is happening here that is preventing trust from being built could be built by someone else.
Dr. Jafar Al-Mondhiry: With that in mind, chaplaincy or even that patient’s lay minister, rabbi or priest can be particularly helpful in cases where religious values play a big role in the conflict. Bottom line, the more help the better, especially from those who are more likely to win back trust. A bigger question is how we handle situations that devolve to the point where we feel like our physical safety is in real danger. When do we bring in that last line of literal defense and call security?
Dr. Autumn Fiester: When I recommend it, is when you have said to yourself and you’ve been honest with yourself, “Am I finding this unpleasant? Am I finding this insulting? Am I finding this offensive? Am I finding this hurtful? Do I feel that my physical wellbeing, not my psychological wellbeing, not verbal abuse, not my emotional life, do I think I’m going to be hit? Do I think I’m going to be struck? Do I think that I could be the victim of a crime?” And if your radar has gone off, I am going to get hit, then you need to stop talking and call security.
Dr. Jafar Al-Mondhiry: To Dr. Fiester’s point, there is a considerable difference between physical safety and emotional and psychological safety. But does that mean our feelings are irrelevant? I think we’re becoming more and more comfortable asking questions about our working conditions in medicine these days—and it’s, well, it’s not great. A recent survey from the CDC found that between 2018 and 2022, healthcare workers’ reports of being harassed or threatened at work have more than doubled. Moreover, people who reported being harassed were significantly more likely to have symptoms of anxiety, depression, and burnout. These kinds of threatening encounters take a cumulative toll on our mental health, and we would be doing you a major disservice in this episode not to address it. As clinicians, we’re being asked to endure these often abusive words, at times aimed at our gender, ethnicity, or sexuality, and then still provide care to that person, and the person after them, sometimes just a few minutes apart. And then we wake up the next day and are asked to do it all over again. Recent surveys show that nearly 63% of US physicians report at least one symptom of burnout, and nearly 20% of physicians voice an intention to leave the profession. So how do we protect our mental and emotional integrity to keep doing our work? And where do we draw the line when conflicts with patients or surrogates break down to a point of outright clinician abuse? Unfortunately, there are no set answers here, and certainly some cases will come down to the individuals involved. As clinicians, our job is to ask ourselves if we feel like we’re still in a place to continue on in certain situations. Have some of our own limits been violated beyond where we feel we can adequately continue giving good care to this patient? Using the mediation approach Dr. Fiester offers will prevent many of these hurtful conflicts with patients and ease the emotional impact by getting us to a place of resolution faster. But we also admit that there will still be rare situations that will escalate to a point that just breaks our limits. And when it does get to that point, it should not be a question of individual clinicians anymore. Ethics, risk management, and patient representative offices can all play a role in providing support. In most institutions, policies around how to handle cases of patient incivility or disruptive patient behaviors can come into play to provide further support and intervention. This can come in the form of verbal or written warnings, formal behavioral contracts, enforcing visitation limits, referral to another clinician, or in the most severe cases, even administrative discharge from the hospital. The bottom line is that no clinician should feel alone in taking on these severe breakdowns in patient care. While we hope we’ve given you some tools to help put out those kitchen fires, we also wanted to show you how to keep yourself safe when the whole house is ablaze. Don’t let it take you out with it.
Dr. Margot Hedlin: As Jafar has described, these conversations don’t always go the way we would hope. And even when they do, it can be incredibly taxing for everyone involved. Given the toll these conversations can have on clinicians, we wanted to take some time to reflect on ways we can support everyone on the clinical team. One strategy I’ve seen used at my hospital is a debrief. Facilitators can lead the discussion by asking what went well, what could have gone better, and can give everyone space to share their perspective and reflect on the emotions that arose. Dr. Fiester also described an idea for conflict management rounds.
Dr. Autumn Fiester: I think that finding avenues to try to work through these problems to troubleshoot these problems might be the very best way to alleviate the toll that it’s taking. People have Schwartz rounds when there’s something very, very sad that happens. Well, you could have conflict management rounds to work through strategies and ways of trying to tackle the problem that would be fruitful and productive. Nothing feels better than helping someone to solving someone’s problem. It’s such a powerful, impact that it has on people to be able to help and to do good for others. So finding a way that as a team you can increase the good that you’re doing for challenging patients will be its own source of solace.
Dr. Margot Hedlin: A final thought before we go. One of the most important lessons I’ve learned in my mediation training is the value of introspection. In the book “House of God”, there’s a joke that the first thing you should do when a code is called is to check your own pulse. And when conversations get heated, I’ve learned to reflect on the values and biases I might be bringing to the table. These are tough conversations because it often feels like we’ve got skin in the game. My first year of residency, I practically begged some of my ICU patients to consent to a DNR order because I didn’t want to feel their ribs crack under my hands. I have my own personal views on what a good death looks like, on what makes life worth living. But I am not my patients, and it’s hard to understand their positions when I feel so strongly that my subjective views hold objective truth. We hope that our episode today has helped you learn how to find the values underlying staunchly held positions, and how to forge pathways towards reconciling with the patients that we often call difficult.
Dr. Jafar Al-Mondhiry: Thanks for tuning in! We know these topics can stir up more questions than answers, and we look forward to hearing more about your experiences managing patient conflict. Please continue the conversation with us online at our facebook page, on twitter, or email us directly. Find show notes and contact information for us on our website, coreimpodcast.com.
Dr. Jafar Al-Mondhiry: If you enjoyed listening to our show, and you want to start a fight in the comments section, please give us a review on iTunes or whichever podcast app you use; it helps other people find us. We work really hard on these podcasts so we’d love to hear from you. Let us know what we are doing right and how we can improve. And as always opinions expressed in this podcast are our own and do not represent the opinions of any affiliated institutions.
Dr. Jafar Al-Mondhiry: Finally, special thanks to all our collaborators on this episode, our wonderful audio editor Daksh Bhatia, music editor Solon Kelleher, our illustrator Michael Shen, moral and executive support from Shreya Trivedi, and most importantly thanks to you, our listeners!
- Abbasi J. Pushed to Their Limits, 1 in 5 Physicians Intends to Leave Practice. JAMA. 2022 Apr 19;327(15):1435-1437. doi: 10.1001/jama.2022.5074. PMID: 35353134.
- Blackler L, Scharf AE, Chin M, Voigt LP. Is there a role for ethics in addressing healthcare incivility? Nurs Ethics. 2022 Sep;29(6):1466-1475. doi: 10.1177/09697330221105630. Epub 2022 Jun 20. PMID: 35724428.
- Fiester A. Contentious Conversations: Using Mediation Techniques in Difficult Clinical Ethics Consultations. J Clin Ethics. 2015 Winter;26(4):324-30. PMID: 26752387.
- Fiester A. The “difficult” patient reconceived: an expanded moral mandate for clinical ethics. Am J Bioeth. 2012;12(5):2-7. doi: 10.1080/15265161.2012.665135. PMID: 22548510.
- Fiester AM. What mediators can teach physicians about managing ‘difficult’ patients. Am J Med. 2015 Mar;128(3):215-6. doi: 10.1016/j.amjmed.2014.09.017. PMID: 25707885.
- Nigam JAS, Barker RM, Cunningham TR, Swanson NG, Chosewood LC. Vital Signs: Health Worker-Perceived Working Conditions and Symptoms of Poor Mental Health – Quality of Worklife Survey, United States, 2018-2022. MMWR Morb Mortal Wkly Rep. 2023 Nov 3;72(44):1197-1205. doi: 10.15585/mmwr.mm7244e1. PMID: 37917563.
- Shanafelt TD, West CP, Dyrbye LN, Trockel M, Tutty M, Wang H, Carlasare LE, Sinsky C. Changes in Burnout and Satisfaction With Work-Life Integration in Physicians During the First 2 Years of the COVID-19 Pandemic. Mayo Clin Proc. 2022 Dec;97(12):2248-2258. doi: 10.1016/j.mayocp.2022.09.002. Epub 2022 Sep 14. PMID: 36229269; PMCID: PMC9472795.
- Sun M, Oliwa T, Peek ME, Tung EL. Negative Patient Descriptors: Documenting Racial Bias In The Electronic Health Record. Health Aff (Millwood). 2022 Feb;41(2):203-211. doi: 10.1377/hlthaff.2021.01423. Epub 2022 Jan 19. PMID: 35044842; PMCID: PMC8973827.
- Valtis YK, Stevenson KE, Murphy EM, Hong JY, Ali M, Shah S, Taylor A, Sivashanker K, Shannon EM. Race and Ethnicity and the Utilization of Security Responses in a Hospital Setting. J Gen Intern Med. 2023 Jan;38(1):30-35. doi: 10.1007/s11606-022-07525-1. Epub 2022 May 13. PMID: 35556213; PMCID: PMC9849525.
- Wong AH, Whitfill T, Ohuabunwa EC, Ray JM, Dziura JD, Bernstein SL, Taylor RA. Association of Race/Ethnicity and Other Demographic Characteristics With Use of Physical Restraints in the Emergency Department. JAMA Netw Open. 2021 Jan 4;4(1):e2035241. doi: 10.1001/jamanetworkopen.2020.35241. PMID: 33492372; PMCID: PMC7835716.
Music Credit: Cach PKL by <a href=”https://app.sessions.
blue/browse/track/222493“>Blue Dot Sessions</a>
Music Credit: Brek PKL by <a href=”https://app.sessions.
blue/browse/track/222494“>Blue Dot Sessions</a>
Tags: At the Bedside, difficult patients, managing conflicts, mediation