Managing Difficult ConversationsSocial Psychology 201

For ED’s

Stephen H. Anderson M.D., FACEPPresident, WA State Chapter ACEP

Seven Conversations

• Grieving

• 1) Someone is dying/ died.

• 2) Your child is going to have a bad

outcome.

Seven Conversations• Sheriff/ Parenting

• 3) I think you have a drug/ alcohol

problem.

• 4) I think you’re here too often.

• 5) Why are you REALLY here?

Seven Conversations

• Colleague/ Political

• 6) I disagree with you as a colleague.

• 7) That’s not how administration

foresees it.

Overlying Principles

•There are rules/ givens.

•You have to listen.

Principles

• Know your allies…

• Know their allies.

• Find your support…

• Find their support.

Principles

•Believe in WIN- WIN.

•To thine own self be true.

•Document.

There Are Rules/ Givens• Some are hard…

• Some are soft.

• Some are “ours”…

• Some are “only mine”.

There Are Rules/ GivensThe Key

Ownership

You Have To Listen• Conversations are two way.

• Find out their goals.

• Find out their fears.

Give them enough rope…

Know Your Allies…

• Rally your troops.

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

Know Their Allies…

• Introductions for EVERYONE.

• Note “Alleged Allies” not

present

Acknowledge as appropriate.

Find Your Support

Find Their Support

• Key to the Grieving Conversation

• If you’re headed to war…

take them with you.

Believe In WIN-WIN

• Try never to define your

win, by their loss.

Believe In WIN-WIN• Listen

• Repeat back

• Work toward a common goal

• Compromise?

To Thine Own Self Be True

• Never Lie

• Never Lie

•Never LIE!

These Are DifficultStressful

Conversations!

• Debrief

• Avoid being the one with the

disease

Not All Conversations

Will End WIN-WIN

• Some won’t end.

• Have an exit strategy.

Document• ANY conversation with “potential” is

worth documenting.

• Two documented views are better

then one.

• “They” know how to document too!

Someone Is Dying/ Died

• It’s someone’s job,

take ownership.

• Find your support

• Find their support

#1Most

Important

Someone Died

• Focus on the closest,

talk to everyone

• Listen

• Account for beliefs/ cultures

• Physical contact, the “healing

touch”.

Someone DiedGoals To Express

• 1) We did everything appropriate.

• 2) Address pain & suffering.

• 3) “Now we are here to help you…

& others.”

Someone Is Dying

Don’t lie

Don’t steal hope

Be realistic

Someone Is Dying

Listen ( Is the PATIENT speaking through an advanced directive?)

Find your support/ Find their

support

Start the conversation

Geography/ proximity

Your Child Is Going To Have A Bad Outcome

• Find your support/ Find their support

• Don’t steal hope

• Be honest “in that moment”

Bad OutcomeNegative attitude leads to

negative outcomes…

Blame is for later

Bad Outcome

•Child’s safety first

•When do you include the

child in the conversation?

I Think You Have A Drug/ Alcohol

ProblemSociety/ Legislature/ Peers now tell us

We MUST have these conversations

THIS is the pivotal time.

Drug & Alcohol Problems

The 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

Drug & AlcoholTools to Help

• Old Records

• EDIE

• WA state Prescription Monitoring Program

Educate patients that these exist

I Think You’re Here Too Often

PRCPatient’s

Requiring

Co-ordination

You’re 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”

Shouldn’t be a punitive discussion

You’re Here Too Often

“You’re Unique, but…”

Educate

“The Econ Lecture”

Why Are You REALLY Here?

• Constructively focuses the scatter.

• Gives an opening to the REAL difficult

conversation.

NEVER demean the answer

I Disagree With YouAs A Colleague

Fatal Error VS. Difference Of Opinion

Fatal Error

Success comes through education first

Difference of Opinion

With A ColleaguePraise in Public/ Debate in Private

Ask yourself going in:

What’s my goal?

Am I a team builder?

How can I make this WIN-WIN?

Focus on the patient

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.

That’s Not How Administration

Foresees It

Administration’s ViewpointThe Golden Rule

1)Do unto others, as you would have others do

unto you.

2)Those with the gold, make the rules.

Every pathway has an economic angle.

Administration’s Viewpoint

What brought you to the table?

1)What do they need from you?

2)What motivates you?

Principles

Priorities

Administration’s Viewpoint

Great leaders

get input from

great followers

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