The success of physician-patient relationships is predicated on effective communication. This is especially important when physicians must deliver bad news to a patient or family, deal with patients who are angry or seeking drugs, or handle patients who don’t adhere to treatment due to financial concerns.

During an instructional course on “Difficult Conversations in Orthopaedics,” held during the AAOS 2012 Annual Meeting, members of the AAOS Communication Skills Mentoring Program (CSMP) project team shared tools and techniques that can be used to ease difficult interactions with patients.

The 4 Es model
“Developed by the Institute for Healthcare Communication (IHC), formerly the Bayer Institute, the
4 Es model—engagement, empathy, education, and enlistment—provides a framework for successfully dealing with difficult situations,” said Dwight W. Burney III, MD, CSMP chair.

“Orthopaedic surgeons are great at ‘finding it and fixing it,’ but very often we fall flat on the communication tasks,” he said. “The 4 Es model helps us form a complete model of care that leads to increased patient satisfaction, increased adherence to treatment, and better health outcomes.”

Engagement involves creating and maintaining the doctor-patient relationship. To engage effectively, physicians should make eye contact with patients. An appropriate touch on the arm or hand is also helpful.

Empathy, not to be confused with sympathy, plays a critical role. For example, when dealing with an angry patient, recognizing that the basis of a patient’s anger is often fear is important, said Dr. Burney. “You can draw out the specifics with calm, empathic statements, such as ‘I know that this is very upsetting to you.’ You have to acknowledge the emotion even if you don’t fully understand it.”

Education is a critical aspect of care. Physicians must customize their message to fit a patient’s concerns and ability to understand. Enlistment involves negotiating with the patient to tailor a treatment plan that best fits the patient’s unique situation and beliefs.

Additional strategies
For volatile situations, Dr. Burney recommends using the HARD protocol, developed by Robert A. Buckman, MD, PhD:

• H: When the stakes are High, or when a physician is Harried or Hassled, he or she runs the risk of mirroring the patient’s response. Physicians need to be patient, calm, and mindful of their actions.
• A: Acknowledge that the situation is difficult for both the patient and the physician.
• R: Set Rules and boundaries as calmly as possible.
• D: Deescalate and find a “middle ground.” Negotiate a mutually agreeable resolution to the problem, taking the patient’s values into account.

Dr. Buckman also developed the following six-step protocol for delivering bad news to patients, which Frances A. Farley, MD, a CSMP mentor, recommends:

1. Getting started, which involves planning ahead, assembling the information, and creating an environment conducive to discussion
2. Finding out how much the patient knows about his or her health and current situation
3. Finding out how much the patient wants to know or who should be told about his or her condition and options
4. Sharing the information in a straightforward, but sensitive, manner
5. Responding to the patient’s feelings by listening, acknowledging, and supporting the patient
6. Planning for next steps and follow-through

“The bottom line is that delivering bad news is, and has always been, our job as physicians; therefore, we need to learn how to do it well,” she said.

Drug-seeking patients
Dealing with drug-seeking patients is a growing problem.

“As orthopaedic surgeons, we are inadequately trained for managing pain, especially long-term pain,” said CSMP mentor Andrew M. Wong, MD. “Basically, we were taught to prescribe a certain amount of narcotics, and we do it routinely, but we expect that everyone is going to respond the same way, and they don’t.”

According to Dr. Wong, drug-seeking patients fall into the following three categories: those with physical pathology, those with no physical pathology who are dependent on narcotic pain medication, and those who distribute or sell narcotics for nonmedical purposes.

“Understanding a patient’s underlying motivation enables us to tailor our discussions accordingly,” he said.

Dr. Wong recommends having a plan in place for dealing with drug-seeking patients and offered several strategies, including establishing a pain medication policy, documenting any discussions on pain medication, and requiring patients to turn in unused medication before refilling or changing prescriptions.

He stressed the need for empathy, tempered with honesty, particularly about any discomfort in being pressured to prescribe narcotics. “Make the issue of drug misuse the priority of the clinic visit. Don’t argue with the patient about his or her pain level, but do enlist the patient’s help and cooperation in carrying out any agreements that are made,” he said.

The difficult interaction
According to the IHC, the term “difficult” pertains to the interaction—it is not an inherent property of the patient, said David A. Halsey, MD, a CSMP mentor. To help physicians experience fewer difficult interactions with patients, the IHC has developed the following ADOBE rubric:

• A: Acknowledge and be Aware—Attitude makes a difference. It just takes a moment for the physician to tune his or her internal message to respond to the patient more constructively.
• D: Discover meaning—When physicians develop self awareness, their patients also become more self aware. It’s important to find out what the patient is experiencing and feeling.
• O: Opportunity for compassion is part of every interaction—Physicians should take a moment to be compassionate, to convey empathy and understanding.
• B: Boundaries are needed—Clearly, in some instances, physicians will need to establish boundaries regarding the amount of time spent with the patient, content of the visit, rights and responsibilities of all parties, or physical boundaries. In most cases this can be accomplished by being direct and honest with the patient.
• E: Extend the system—Physicians should rally all of the resources (financial, social, mental health services) available outside of their practice that can assist them with difficult patient relationships.

“The cost of health care is a growing societal problem,” said Dr. Halsey. “As physicians, we want to do the best that we can for our patients, but clearly barriers to access exist. Unplanned expenses relating to treatment are frequently a source of added stress for the patient that can interfere with physician-patient communication.

“When you can’t move forward with a patient—you’ve tried all the tips and techniques, but the relationship is still not working,” continued Dr. Halsey, you need to take some very important steps. Offer the patient appropriate care, inform him or her of the consequences of no treatment intervention, and when appropriate, help him or her connect with another physician or team.”

For more information on the Communication Skills Mentoring Program, visit www.aaos.org/csmp

Maureen Leahy is the assistant managing editor of AAOS Now. She can be reached at leahy@aaos.org