Managing Difficult Conversations

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Managing Difficult Conversations

• Social Psychology 201
• For EDs

Stephen H. Anderson M.D., FACEP President, WA
State Chapter ACEP
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Seven Conversations

• Grieving
• 1) Someone is dying/ died.
• 2) Your child is going to have a bad outcome.

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Seven Conversations

• Sheriff/ Parenting
• 3) I think you have a drug/ alcohol problem.
• 4) I think youre here too often.
• 5) Why are you REALLY here?

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Seven Conversations

• Colleague/ Political
• 6) I disagree with you as a colleague.
• 7) Thats not how administration foresees it.

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Overlying Principles

• There are rules/ givens.
• You have to listen.

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Principles

• Know your allies
• Know their allies.
• Find your support
• Find their support.

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Principles

• Believe in WIN- WIN.
• To thine own self be true.
• Document.

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There Are Rules/ Givens

• Some are hard
• Some are soft.
• Some are ours
• Some are only mine.

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There Are Rules/ Givens

• The Key
• Ownership

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You Have To Listen

• Conversations are two way.
• Find out their goals.
• Find out their fears.
• Give them enough rope

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Know Your Allies

• Rally your troops.
• Build your allies.
• Do you want to be an expert witness?

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Know Their Allies

• Introductions for EVERYONE.
• Note Alleged Allies not present
• Acknowledge as appropriate.

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Find Your SupportFind Their Support

• Key to the Grieving Conversation
• If youre headed to war
• take them with you.

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Believe In WIN-WIN

• Try never to define your win, by their loss.

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Believe In WIN-WIN

• Listen
• Repeat back
• Work toward a common goal
• Compromise?

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To Thine Own Self Be True

• Never Lie
• Never Lie
• Never LIE!

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These Are DifficultStressfulConversations!

• Debrief
• Avoid being the one with the disease

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Not All ConversationsWill End WIN-WIN

• Some wont end.
• Have an exit strategy.

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Document

• ANY conversation with potential is worth
  documenting.
• Two documented views are better then one.
• They know how to document too!

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Someone Is Dying/ Died

• Its someones job,
• take ownership.
• Find your support
• Find their support

1 Most Important
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Someone Died

• Focus on the closest,
• talk to everyone
• Listen
• Account for beliefs/ cultures
• Physical contact, the healing touch.

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Someone DiedGoals To Express

• 1) We did everything appropriate.
• 2) Address pain suffering.
• 3) Now we are here to help you
• others.

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Someone Is Dying

• Dont lie
• Dont steal hope
• Be realistic

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Someone Is Dying

• Listen ( Is the PATIENT speaking through an
  advanced directive?)
• Find your support/ Find their support
• Start the conversation
• Geography/ proximity

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Your Child Is Going To Have A Bad Outcome

• Find your support/ Find their support
• Dont steal hope
• Be honest in that moment

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Bad Outcome

• Negative attitude leads to negative outcomes
• Blame is for later

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Bad Outcome

• Childs safety first
• When do you include the child in the conversation?

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I Think You Have A Drug/ Alcohol Problem

• Society/ Legislature/ Peers now tell us
• We MUST have these conversations
• THIS is the pivotal time.

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Drug Alcohol ProblemsThe Principles

• There are rules/ guidelines
• Listen first
• Your allies/ their allies
• Their support might turn out to be your
  best ally!
• WIN-WIN
• Be true to yourself

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Drug AlcoholTools to Help

• Old Records
• EDIE
• WA state Prescription Monitoring Program
• Educate patients that these exist

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I Think Youre Here Too Often

• PRC
• Patients
• Requiring
• Co-ordination

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Youre Here Too OftenNew WA Hospital Requirements

• Identify PRC clients upfront
• Notify their PCP of visit
• Discharge patient with instructions along
• the right patient-to the right place-at the
  right time
• Shouldnt be a punitive discussion

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Youre Here Too Often

• Youre Unique, but
• Educate
• The Econ Lecture

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Why Are You REALLY Here?

• Constructively focuses the scatter.
• Gives an opening to the REAL difficult
  conversation.
• NEVER demean the answer

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I Disagree With YouAs A Colleague

• Fatal Error VS. Difference Of Opinion
• Fatal Error
• Success comes through education first

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Difference of Opinion With A Colleague

• Praise in Public/ Debate in Private
• Ask yourself going in
• Whats my goal?
• Am I a team builder?
• How can I make this WIN-WIN?
• Focus on the patient

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Difference Of Opinion With A Colleague

• Listen
• Agree on the easy, Work toward the hard.
• Set the stage for The Next Time
• If necessary, use the chain of command.

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Thats Not How Administration Foresees It
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Administrations Viewpoint

• The Golden Rule
• Do unto others, as you would have others do unto
  you.
• Those with the gold, make the rules.
• Every pathway has an economic angle.

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Administrations Viewpoint

• What brought you to the table?
• What do they need from you?
• What motivates you?
• Principles
• Priorities

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Administrations Viewpoint

• Great leaders
• get input from
• great followers

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Managing Difficult Conversations

• There are rules/ givens
• You have to listen
• Know your allies/ know their allies
• Find your support/ find their support
• Believe in WIN-WIN
• To thine own self be true
• Document