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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

Join ACP and your colleagues in New Orleans at the annual marquee educational event for internal medicine physicians and subspecialists around the globe. Together physicians will share in three days of unparalleled professional revitalization and learning within the internal medicine community.

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

ACP 2019: How to overcome conflict with patients 

As more physicians become employed, learning how to successfully negotiate an employment contract becomes a crucial skill to learn. 

A common issue is that many physicians simply don’t negotiate, and just sign what’s put in front of them, says Michael S. Sinha, MD, JD, a Regulatory Science Fellow at the Harvard-MIT Center for Regulatory Science.

Sinha, who is presenting a session on negotiation basics at the American College of Physicians annual conference in Philadelphia, talked with Medical Economics via email to discuss some of the key aspects of negotiation vital for physicians to learn.

 What is a common mistake physicians make when negotiating contracts?

: Often, physicians will eagerly sign a binding letter of intent or agree to terms of a contract with little or no negotiation-in some cases, they aren’t even aware of what can be negotiated!

The key is to consult a healthcare lawyer early in the process. Find someone who specializes in physician employment contracts in that state. They will have a lot more insight as to what can, and should, be negotiated.

Ultimately, if you don’t negotiate, you’re only cheating yourself.

 What areas in an employment contract are most important to focus on?

 The first thing to do, before any financial compensation is discussed, is to clearly define the duties and responsibilities in the contract. Get any promises that are important to you in writing. Only when those details have been hammered out can you get an estimate of your true market value.

It will also affect the salary structure that works best for you. Perhaps you have a lot of administrative responsibilities that would cut into meeting pre-defined relative value unit (RVU) thresholds-this may mean you’ll miss out on bonuses under an incentive-based contract, and a fixed salary would make more sense.

Flexibility and vacation time may also be up for negotiation, but at the expense of your base pay. Here, an incentive-based contract may mean that, as long as you’ve hit appropriate metrics, you’ll have more time off with no salary repercussions.

That said, be sure that you have access to the performance reviews or quality metrics that are being used to determine bonuses. Get it in writing!

 One area we regularly hear about from physicians is restrictive covenants/non-compete clauses. What do physicians need to know before signing a contract containing one of these? Is there anything they can do to protect their post-employment career opportunities if they sign a contract containing a restrictive covenant?

 State-level legal expertise is particularly important here. Some states, like Massachusetts, ban restrictive covenants in physician contracts. Others have limits on what these clauses can entail. The lawyer you hire should know the standard for a particular area and can push for compromises in duration and geographic distance.

That distance can be very important. For instance, a 20-mile restrictive covenant may be reasonable in rural Tennessee but would be unreasonable in New York City. Negotiate favorable terms for a restrictive covenant prior to signing the contract; if you don’t, disputes over restrictive covenants could take a few years and several thousand dollars in litigation fees to resolve. Don’t ignore the clauses just because you think you’ve found your “dream job.” And don’t be afraid to ask around. Other physicians in your practice group may have a covenant of shorter duration or distance-or may not have one in their contract at all.

 What are some items physicians can/should negotiate for that many physicians tend to overlook?

 I would start with student loan repayment. Some newly-minted physicians are coming out of residency with $200,000 to $300,000 in student loan debt. There are usually ways to get the hospital to pay some of it off. They may be reluctant to pay a lump sum directly to you, but may be happy to write a check straight to the lender. They’re also less likely to pay any of it up front, but may agree to annual installments, payable after each year of service.

As more physicians become employed, learning how to successfully negotiate an employment contract becomes a crucial skill to learn.

ACP 2019: Contract negotiation: What physicians need to know

Loneliness: It is a growing societal challenge that can dramatically influence patient and physician health.

In a keynote presentation April 11 at the American College of Physicians (ACP) Internal Medicine Meeting 2019, former Surgeon General Vivek H. Murthy, MD, MBA, told about 4,000 attendees that the country’s state of emotional health remains an important driver of health.

“If you told me five years ago that I would be talking to physicians about the subject of loneliness, I would have been surprised,” Murthy said. As he travelled the country as the 19th Surgeon General of the United States, he began to hear more patient stories related to addiction, violence, mental illness and other behavioral-based health conditions. There was an undercurrent, Murthy says, that connected many of these prevalent social issues to loneliness. “Many patients are struggling with it,” he adds.

Healthcare professionals are starting to recognize its impact on adherence to physician treatments and recommendations, lack of exercise, smoking, and other unhealthy lifestyle behaviors and other social determinants.

It is estimated that as much as 20 percent of the population struggles with loneliness, and additional research in this area is starting to offer stronger linkages to health consequences associated with loneliness including depression, dementia, cardiovascular disease, and anxiety.

“It affects physicians too. We talk about burnout in our profession,” Murthy says, but healthcare is not a profession that often promotes self-care.

Physicians work long hours, which can definitely contribute to feelings of isolation and a kind of physical and emotional barrier to making stronger connections with friends and family.

When your professional lives take over, Murtha says, you need to adopt strategies that can help you stay connected with your love of medicine and maintain a healthy balance outside of busy schedules.

During long shifts, try to add a micro-dose of self-appreciation, Murthy says. For example: Take five extra seconds when you are washing your hands to reflect on the ways you have helped patients that day. Do that three times a day.

“We are not designed to work alone,” he says. “We need each other, and we need to support each other.”

Murthy called on attendees to imagine a time in healthcare where physicians have built a culture that supports each other. “The lives of the people in this room matters.”

“Our country is in this struggle between love and fear,” he says. “People are worried about the kind of environment their children are growing up in. They see the polarization of politics. They look at the meanness on social media. People are worried. How are we going to create a better world for ourselves? Where will that leadership come from? Our profession has to lead.”

Loneliness is a quiet epidemic causing loud health impacts on patients and physicians. 

ACP 2019: How loneliness affects patients-and their physicians 

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.

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