The Difficult Clinical Conversation

Abstract

Dr. Wang's first patient of the day is a 39-year-old woman, Tonya Miller, who has vaginal discharge and a weight loss of 70 pounds (from 178 pounds to 108 pounds) over 2 months. She is divorced and has no children. She lives alone, and has no family members in town. Dr. Wang begins to ask about her past medical history, which includes a tonsillectomy as a child. The patient reports nothing unusual in her history except recently persistent fatigue. EDUCATIONAL OBJECTIVES1. 2. 3. 4. 6.Describe situations or topics that may contribute to difficult clinical conversations Describe possible helpful responses to difficult conversations with patients Describe and demonstrate insight regarding patients or situations that are difficult because they evoke particular responses from the student, which may be related to difficulties or family issues of the learner Describe resources for managing the feelings patients evoke in the student Describe common patterns in difficult encounters Define content and relational aspects of communication processes THE DIFFICULT CLINICAL CONVERSATION DR. WANG: I'm curious about what you think might be causing you to lose weight. Do you have any ideas? MS. MILLER: No. I'm eating the same as I have been. I think maybe it's because I've been nervous lately. WHAT MAKES AN ENCOUNTER DIFFICULT?An interaction between patient and physician can become difficult when both parties feel (or are) unable to understand the other (Starfield et al., 1981); when there is incongruity between the patient's and physician's goals or values (Taylor, 2000;Waitzkin, 1991); or when the patient and the physician battle for control (Suchman, 1998). Sometimes difficulties arise because patients and physicians treat each other as though they were significant people, such as parents or teachers, from each of their past experiences, rather than as the people they are now. Such difficulties related to countertransference (the physician's feelings toward the patient) or transference (the patient's feelings toward the physician) can distort the relationship and create difficult communication (Stein, 1985). This phenomenon may mean that caring for an elderly female patient is more difficult for a physician who had difficulties with his grandmother, and easier for a physician whose grandmother died at a younger age. The physician's own life cycle stage may also affect her ability to care for patients, either because the experience is "too close to home" or because of inexperience with the stage the patient is in at the time (see Chapter 20). Each physician will find different types of patients who push his or her buttons: One of the key skills to managing difficult encounters is to use self-awareness of what kinds of patients or problems are likely to "push one's buttons" (see Table 13.1), and then to employ strategies to use that knowledge for the patient's improved care and one's own professional development (Ellis, 1983). This self-knowledge and the skill to use this self-knowledge does not happen automatically: Real improvem...