Kimberly Clark

Not only are disagreements between physicians and patients uncomfortable, they also can negatively impact health outcomes and patient satisfaction. It’s no surprise, therefore, that most physicians would rather avoid conflict than engage with patients to overcome it.  

But being able to navigate conflict is an important skill for physicians. When handled correctly, conflict can lead to positive change, says Rebecca A. Andrews, MD, FACP, general medicine clinic director and associate program director for categorical internal medicine at UConn Health in Farmington, Conn. The key, she adds, is knowing how to communicate effectively when emotions run high. 

Equipping physicians with the knowledge and communication tools to do so is the goal of the session Andrews and Auguste H. Fortin, VI, MD, MPH, MACP, professor of general medicine at Yale School of Medicine in New Haven, Conn., will present at this year’s ACP Internal Medicine Meeting in Philadelphia.

They will begin the session with a discussion about implicit bias, or the unconscious attitudes and beliefs about an individual or group that impact decisions and actions. “You might have thoughts or opinions developed by your experiences, your gender, your culture growing up that might affect how you approach a different situation,” Andrew says. 

Andrew emphasizes that having implicit bias does not mean that an individual is bad or has done anything wrong, but it can compromise patient care. So it’s crucial that physicians identify the issues they are overly sensitive about and make a conscious effort to check those views or feelings at the exam room door. 

Once they are in the exam room, Andrew says there are three communication models that physicians can use when conflict and strong emotions arise. 

1. NURS = Name > Understand > Respect > Support 

The NURS model illustrates how to empathetically address emotion. The physician will 

the emotion that the patient is expressing (“You’re worried.”), convey 

of why that emotion is present (“I can see why you’re feeling this way. Many people in your situation would feel like this too.”), demonstrate 

for the patient’s experience (You’ve been through a lot.”), and offer 

(Let’s see what we can do to get to the bottom of this.”).  

2. ADOBE = Acknowledge the difficulty > Discover meaning > Opportunity for empathy > Boundary-setting > Extend the system 

The ADOBE model delineates how to effectively communicate when there are a lot of strong emotions present. The physician will 

the emotion out loud (“You seem angry.”), request more information to 

the cause (“Help me understand why you’re angry.”), find an 

to display empathy (by using the NURS model), set 

to the conversation (“I’ll work with you as long as you exhibit the same respect towards me that I am giving you.”), and 

the care if the patient has needs that the physician cannot address (refer the patient to a specialist).  

3. Non-violent communication = Observe > State > Connect > Make

The non-violent communication model demonstrates how to express and receive emotions with empathy. A physician will 

objectively (“I see that you’re frustrated because your current medication is not alleviating your pain.”), 

that the situation is causing (“I understand how difficult this is, but I am uncomfortable prescribing medication that is not recommended for your condition.”), 

(“I need to balance helping you feel better and prescribing a safe treatment.”), and 

(“Why don’t we look into approved treatments and create a plan?”).  

These models are effective when used alone or in conjunction. “A doctor might find that one approach might work better for them than another approach. Another might find that they like to do the different approaches depending on what they’re talking about,” Andrew says. “But as long as you’re using empathy and [patients] can understand that you’re caring, you can’t help but get to a good place.” 

Andrews’ ACP 2019 session, “Communicating Effectively When You Don’t Want To,” will take place on Saturday, April 13 at 9:30 a.m.

Articles

Communication tools physicians can use to manage conflict during patient encounters.

ACP 2019: How to overcome conflict with patients 

As the prevalence of physician burnout rises, so too might the occurrence of medical errors. A recent 

 by researchers at Stanford University School of Medicine found that physicians with burnout were more than twice as likely to commit medical errors, even after adjusting for specialty, work hours, fatigue, and workplace safety. 

But the relationship between physician burnout and medical errors may be more cyclical than linear. “We value our relationships [with patients], so when someone dies or an error occurs … not only does it hurt the patient and the family, but we are upset as well,” says Tracey L. Henry, MD, MPH, FACP, assistant professor of medicine at Emory University in Atlanta. When left unaddressed, this emotional or psychological stress can further contribute to burnout.

Despite this issue, Henry says most institutions do not have a system in place to support physicians and other healthcare professionals in the event of a medical error or adverse patient outcome. As a result, many physicians avoid disclosing errors and end up internalizing their emotions because “there’s this machismo culture in medicine, and so a lot of times we are ashamed to ask for help,” she explains, noting that early career physicians tend to struggle the most with error-related stress because their clinical self-confidence is still developing.

At this year’s ACP Internal Medicine Meeting in Philadelphia, Henry will moderate an interactive panel discussion focused on helping physicians recover and grow from medical errors. The panelists will use programs currently in place, such as 

, to provide physicians with resources and best practices for coping with medical errors that they can take back to their organization or practice. 

Specifically, leaders should create awareness that medical errors happen and can happen to any physician, and then ensure that physicians are able to process their emotions in a healthy way. Henry recommends developing a protocol that includes nonpunitive teams debriefs following an error or adverse event and a peer-to-peer support network. She notes that it’s important for the individuals leading the debriefs and peer support groups to receive training in order to ensure they understand how to discuss the error without pointing blame or re-traumatizing the physician.  

“We’re all human. Everyone makes medical errors at some point in their career,” Henry says. “This is how you deal with it. This is how you move forward.”

Henry’s ACP 2019 session, “Medical Errors and How to Grow From Them,” will take place on Saturday, April 13 at 11:15 a.m.

When medical errors occur, patients suffer-but so do physicians.

ACP 2019: Caring for the caregiver after a medical error

When Matthew Taylor, MD, PhD, began the process of choosing a medical specialty, he made a list of the disciplines he thought would evolve significantly during his career. Of the various areas he considered, the one he kept coming back to was genetics. 

Clearly, he was right. The breadth of genetic knowledge and its applicability to patient care is expanding rapidly. “We have many, many more [genetic] tests, and often those tests lead to confirming a diagnosis, providing some prognostic information, accessing a clinical trial, and in some cases, actually accessing some disease-specific therapies,” says Taylor, who is double boarded in internal medicine and clinical genetics and is the director of the adult medical genetics program at the University of Colorado Denver. 

Patients’ interest in their genetic information has increased as well, and the growth of the direct-to-consumer genetic test industry means a physician is no longer required. Patients do, however, expect their physicians to help interpret the results and determine appropriate treatment.  

The problem is that there are far too few geneticists to meet this demand, which means that primary care physicians must be prepared to integrate genetics and genomics into their daily practice. But many primary care physicians are not fully confident in their abilities to have genetic conversations with their patients, Taylor says.

“It’s quite frequent for us to see patients come in who have read a lot about what has been suggested they have, and they want to talk about what their mutation will or won’t be,” he says. “That can be daunting for the physician who realizes that the patient may know more about [a genetic condition] than they do, and you can’t always assess whether the patient has it right or not when you don’t really know what they’re talking about.”

At this year’s ACP Internal Medicine Meeting in Philadelphia, Taylor will lead a session focused on what internists need to know about genetics. 

He acknowledges that genetic diseases tend to be rare and unfamiliar to internists, so it’s difficult to have a comprehensive discussion about genetics without a disconnect from clinical practice. However, he will cover areas that most internists should expect to encounter, including what to do if a patient requests interpretation of genetic test results, how to determine if a patient might have a condition for which genetic testing is available, and how to assess if testing would have any utility for a patient and/or the patient’s relatives. 

Beyond attending this session, practicing internists looking to strengthen their competency in genetics may have to turn to a self-study approach, unless they want to go back to medical school. Taylor recommends guiding CME to focus more on genetics, attending genetics conferences, and reading the literature. 

And while it’s understandably difficult for internists in busy practices to devote additional time to learning more about genetics, Taylor believes it’s imperative. “If you’re an internist who is looking at retirement in the next couple of years, no problem. But if you’re just starting out or you’re in the midst of it … genetic and genomic medicine has arrived,” Taylor says. “And internists have a really critical role to play.” 

Taylor’s ACP 2019 session, “Genetics: What the Internist Needs to Know,” will take place on Thursday, April 11 at 7:00 a.m.

Internists have a major role in helping patients understand and manage their genetic conditions.

ACP 2019: What internists need to know about genetics 

A growing number of physicians are leveraging Twitter not only to connect with patients but also to engage with colleagues and share their perspectives on current topics. Here are 10 Twitter accounts to follow for timely and relevant content about healthcare and the world of medicine.Click here to download a PDF of this slideshow.

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Looking for professional insight, opinions, and even a little humor from your peers? Start by following these internal medicine docs on Twitter.

Author | Kimberly Clark

Articles

ACP 2019: How to overcome conflict with patients

ACP 2019: Caring for the caregiver after a medical error

ACP 2019: What internists need to know about genetics

10 internists to follow on Twitter