Effectively Managing Difficult Conversations with Patients

One of the areas of greatest satisfaction for physicians comes from interacting with and making a difference in their patients' lives.  And most of the time, patients are appreciative of the care and concern that they receive from their doctors.  However, there are times when the interaction between patient and physician goes awry.

These difficult conversations can be a source of great frustration and disappointment for both parties.  Let's explore some strategies that you can take to help transform a difficult discussion into a discussion that results in learning, for both you and your patients.  We will focus on types of conversations that can be most challenging - non-compliance and delivering distressing news to the patient. 

1. When patients are non-compliant:  A patient continues to smoke despite a diagnosis of Chronic Obstructive Pulmonary Disease (COPD)..  A patient's blood glucose levels are wildly fluctuating and he is not following dietary recommendations.  A patient refuses anti-hypertensive medication despite consistent blood pressures above 135/90.  These circumstances are not only frustrating, but can have potentially grave consequences.  There are myriad reasons for non-compliance -most of which can be classified into one or more of the three "C's": commitment (the patient does not fully believe and/or understand the reasons for their doctor's medical advice), confidence (the patient does not believe that he is capable of complying with the recommendations), control (the patient feels a loss of autonomy over his lifestyle).  The highest likelihood of getting the patient's buy-in and follow-through of medical advice is to proactively address each of the 3 "C's" before the patient is non-compliant.

Commitment:  The most effective tool a physician has to achieve commitment from a patient is to provide ample communication so the patient clearly understands why the recommendation is being made.  Focus first on the positive results the patient will experience by complying with medical advice (vs an overemphasis on the consequences of non-compliance).  Ensure that the patient understands the reasons using appropriate language and making frequent use of open-ended questions that seek to clarify the patient's comprehension and surface any misperceptions. 

Confidence:  Patients may be hesitant to express their lack of confidence for fear of disappointing their physician or feeling embarrassed at their perceived ignorance.  The only way to surface their confidence level is to ask good questions.  After addressing "commitment" (above), one very useful question is this: On a scale of 1 to 10, how confident are you that you will follow the recommendations we discussed?  Once the patient provides a number, follow-up with this question: What would raise that number for you?  Continue exploring with the patient until you feel confident that the patient is both committed and assured to the changes they are being ask to make.  If necessary, provide education, support (possibly through other health care providers such as a nutritionist) and/or reassurance.

Control:  A perceived lack of control and autonomy can feel threatening to people, causing them to assert their independence.  As much as possible, give the patient options and choices in how they will implement the medical advice.  Ask the patient what is most important to him in regards to choices and control.  Work with the patient as a partner in their health rather than dictate to them what must be done.  This will likely lead to increased trust, commitment, and follow-through.

2. Delivering "bad" news:  The first time you deliver the news to your patient (for example, a new diagnosis of cancer), recognize that as soon as the patient hears the word "cancer," it is likely that he will not hear much else of what you say.  So the focus in this first conversation is to be honest, caring, and empathetic.  Provide space for the patient's distressing emotions - they are to be expected.  By labeling their emotions, for example, I know this is scary for you, it can have the effect of decreasing the intensity of the distressing feelings and it shows that you care.  Avoid giving much detail (unless the patient asks) and do not expect that the patient will remember much of what you have said, beyond the diagnosis.  That is why it is critical to schedule a follow-up appointment soon after delivering the news so you can provide more details about the medical treatment plan and to answer the patient's questions.

To sum it up - effective communication is often just as, or more important than your medical knowledge and skills.  Be proactive in addressing the patients' emotional needs and in gaining their commitment so that they will achieve optimal health outcomes.