TrendsMD podcast: How to de-escalate disruptive patients safely and effectively

January 10, 2022

Dr. Brian Sayers and attorney Stacy Simmons offer useful and practical strategies for de-escalating patient conflicts over the phone, in person, and online.

 



Also available on Apple, Google, and Spotify.

TRANSCRIPT

Anthony Passalacqua, 0:11: Hello and welcome to this edition of TMLT's podcast TrendsMD: Answers for health care digital trends. I'm your host, Tony Passalacqua. Today I have special guests, attorney Stacy Simmons of Ballard Simmons and Campbell LLP, and our returning guest, Dr. Brian Sayers. Today, our topic is going to be de-escalation. Stacey, can you go ahead and tell me a little bit about yourself?

Stacy Simmons, 0:35: Sure, so I'm a medical malpractice defense lawyer here in Austin. I've been defending doctors in malpractice cases in cases before the Texas Medical Board, or that's what I do. I've been doing that since 1993. Our firm with four other lawyers and that's exclusively what we do.

Anthony Passalacqua, 0:55: Dr. Brian Sayers, can you tell us a little bit about yourself?

Dr. Brian Sayers, 01:00: Sure. I'm a rheumatologist in a small private practice here in town. I've been in practice for 35 years. I spend a lot of time working with physicians in a physician wellness program through our County Medical Society, and I'm just really interested in the topic today.

Anthony Passalacqua, 01:18: Well, thank you both for joining me. One of the things that I wanted to let our listeners know is that the specific format we're using today is actually based off of one of our resources that we have on TMLT's website, it's called the De-escalation techniques and resources. And one of the first things that we think about is that de-escalation for each individual has like a very unique identity. But Dr. Sayers, what's your idea of what de-escalation looks like from a physician's perspective?

Dr. Brian Sayers, 01:46: Right. So, the situations it comes up in, in a medical practice, can take a lot of different forms. The most common one that we deal with actually is patients who are irate on the phone. And it's something that our staff [member] who's handling the call can't really resolve and often shouldn't resolve. And, so we have protocols for the physician, preferably to engage with that situation to de-escalate. And then sometimes we'll have folks that are disruptive, and sometimes physically so, very rarely, in the waiting room which we have completely separated from our back office that needs to be dealt with from a safety standpoint sometimes. And then sometimes we have angry patients who are in exam rooms or in the back part of the office and we have to de-escalate that. And you know, fortunately, these situations, other than the one with the phone - that's the most common one - the other two are much less common but potentially have bigger consequences. So, those are sort of the three general scenarios we're dealing with.

Anthony Passalacqua, 03:01: Stacy, how about you? Have you ever experienced any de-escalation events?

Stacy Simmons, 03:05: I guess my experiences are obviously different from Dr. Sayers, because I'm not working in doctor’s clinic everyday. But yes, de-escalation is a common thing, I guess. Mine is usually de-escalating a lawyer on the other side of case from me, which occasionally happens. We mostly have professional, good lawyers on the other side of cases, even in Austin. But that occasionally happens. There's sometimes the de-escalation in mediation. Where, I mean, in a lawsuit, we're not usually, you know, alone with the plaintiff, right? We're not, because we're usually represented by counsel. So, there's not usually the one-on-one with the plaintiff. But at mediation, you are talking to the plaintiff. And so, there's de-escalation that goes on, for me, at least, as part of the mediation process of trying to get people to kind of let down their guard, and in that process for it to work. And then sometimes there's de-escalation of my own client. Who is mad about getting sued. Doctors not typically in love with lawyers, even their own lawyers.  There's that process sometimes, and so, my scenarios are probably a little different than Dr. Sayers.

Anthony Passalacqua, 04:15: Well, we're going to examine those as we continue to move throughout each one of these steps that we have highlighted on our Resource Hub. One of the first things that we suggest is to move to a private area. So, we kind of talked about as it seems safe to do so, you'd want to take it away from a public space and move it to a private area to talk. From an attorney's perspective, do you see anything there that could potentially cause any issues for a physician or staff member?

Stacy Simmons, 04:37: So, you're talking about taking an irate patient to a private area to talk?

Anthony Passalacqua, 04:43: Yes, it could be any different type of situation. So, you can go ahead and frame it however you'd like. If it's if it's an irate patient, it may have a different response than maybe someone who's going through some sort of emotional trauma.

Stacy Simmons, 04:54: Yeah, there's the safety perspective, right? Which I think Dr. Sayers may speak to a little bit, [it] has some protocols for, and if what that looks like is depending on the level of “irateness” of the patient. Maybe you don't want to be alone with the patient, maybe you need to have another staff member in there. But from a legal perspective, rather than sort of a safety perspective, the thing that jumps out at me first is, you know, is when we now have the inevitable lawsuit afterwards and you've had some sort of heart-to-heart with this patient. The patient says that you said all these things that you didn't say, you know, and it was just you and the patient. There’s the have someone else there with you, then you have a witness to what you talked about. Maybe that makes the patient uncomfortable, but maybe not. Maybe that's okay. I've had a couple of cases where doctors have tape recorded the meeting with the person. In Texas, you've got to tell the person that you're dealing with, you gotta’ let him know. And I mean, if you're going to do that, I would just be like, “Are you okay with this? This will help us both remember what we said later.” Make it a shared memory thing, not a “I don't trust you so I'm going to record this.”  But for a shared memory, it would be good for us both to be able to remember what we talked about later, because we're both pretty emotional right now. So, I've had a couple of doctors do that. Sometimes that's been very helpful, to have that later. But actually, most times, it's very helpful. Sometimes you kind of wish they hadn't recorded the conversation. So, it really, there's no black and white answer. But I think from a legal perspective, there are a couple things that come up.

Anthony Passalacqua, 06:22: One of the questions we sometimes get is, does the patient have to notify the physician that they're going to record them?

Stacy Simmons, 06:28: In Texas, that's a one party, it's a, it's a one-party tape recording. So, as long as I know I'm tape recording it, it's legal to tape record it. It's just, you can't wiretap or like, neither party to the conversation knows that they're being recorded. But if I want to record my conversation with Dr. Sayers, and I don't want to tell him about it, I can do that. So that you now probably, that you're trying to play that before a jury later. And you did that surreptitiously and didn't tell the other person. They don't think that is very doctorly. Right? So, I think as a doctor, you're going to want to be on the up-and-up and say, “I think this would be good for both of us. Are you okay with it?”

Anthony Passalacqua, 07:05: Dr. Sayers? How about you, from a physician's perspective, move into a private area? What are some potential benefits and risks that you identify?

Dr. Brian Sayers, 07:13: If it's an event that sort of starts in the waiting room, the way our waiting room is configured is that there's a long counter with a lot of glass separating patients, and then a door. If they're in the waiting room and they're angry? I'll usually go up front, slide back the glass, and visit with them for a minute. It's all about upfront assessing safety. Is it safe for them to be in the office at all? Do we need to call for help? Is it safe to take them to a private area? In the back of the office? Or is it better for me to walk into the waiting room and visit with them there? I think that it's sort of an intermediate thing. But you know, if they're, if they're mad, but it, you know, seems very unlikely it's going to be something that's physical, and you can't easily de- escalate in speaking with them there, or if there's other people in the waiting room, and sure, you know, if I feel like it's safe, I'll take them to the to the back of the office to make it more private. When I do that, we'll go into an exam room. I don't shut the door. I leave the door cracked a little bit.  The staff’s aware that there's an issue going on, and they're standing by, you know, listening to see if it's escalating. And then I'm careful when we go in the room, that, you know, I don't push the patient into a corner or something like that. Everybody feels like they can exit the room easily. And we can have a conversation from there. There are some advantages absolutely to speaking with them in a way that's less public, particularly because your de-escalation techniques, I think are easier to do, if it's one person with one person. Now, if it's someone who's pretty angry and it's a female patient, I'll usually ask one of my medical assistants to step in with me. And that may or may not be necessary most of the time, but that's kind of a routine that we do there.

Anthony Passalacqua, 09:02: Did you have anything else you wanted to add maybe to that, Stacy, from an attorney's perspective?

Stacy Simmons, 09:07: Yeah, I think that's, I think that's smart. Especially if it's a male doctor with a female patient, it’s is probably a pretty smart thing to do. When you invite another person in, right, he leaves the sort of a little bit of the personalness of it that I think on the whole, (unintelligible).

Dr. Brian Sayers, 09:25: Sometimes I have them come in and then as the conversation goes along, if it looks like the temperature is going down a little bit, I'll say we can go ahead and step out, the two of us at that point. But you’ve just kind of got to get a feel for where you're going with this one.

Stacy Simmons, 9:40: (Unintelligible) are better. I think if it's a female patient. They probably they might be more comfortable if there was a female staff member in there. And maybe they have the complete opposite effect.

Anthony Passalacqua, 9:50: So Dr. Sayers, you were talking a little bit about moving to a private space. So, can you kind of describe to me what that space looks like?

Dr. Brian Sayers, 9:59: Yeah, exactly. Well, so you know, everybody feels like they can exit the room and as I mentioned. But, then it's really, you're going to set the tone for what the private space is like, and, you know, it's all about how you posture yourself. You want the patient to be able to see your hands. And so I usually lightly put my hands together and kind of hold them up on my chest, because that's kind of an empathetic posture. And they know you're, you're not clenched up and, and facial expressions are really important. Right now, we're wearing masks, but one day, we won't, and it's, you want a pleasant expression on your face; you want a compassionate look to your face and eye contact is really important. But you have to be super careful with this. You don't want to stare him down, because that's, that's aggressive and intimidating and escalating. And, so, I'll look at them while they're talking. And then I'll kind of look down and nod or say, “Yeah, I get that” or “Yes” or something. You want to let them know that you're, that you are listening. And, then your attitude going in there. You have got to take a deep breath as you enter that room and go in with the idea, “I'm just going to try to get through this and let them say what they need to say. I'm not going to argue with them.” This is not the time to be arguing, this is the time to listen. And so with that sort of atmosphere available, you don't usually have to prompt them, but if you need to, just say, “Tell me what's going on.” And in a, in a conversational voice. And then you need to  - other than just acknowledging that you're listening -  keep quiet. Let them talk themselves out, just let them go as long as they need to go and say as much as they need to say. And at some point, eventually, they're going to talk themselves out. And if you get to that point, you're 90 percent home and de-escalated. They want to be heard. And they want to be acknowledged that they've been heard. And silence is okay. If there are pauses, just let there be silence. You don't want it to get too long or too awkward, so it seems confrontational. But let there be some silence. And that's okay. And once they talk themselves out, that's the point where you show respect, you acknowledge, and you're empathetic. And that doesn't mean you have to agree with them, it doesn't mean that you have to endorse anything that they've said. But somehow you need to acknowledge the fact that you know they're upset, and you don't want them to be upset. And it can be something like, “Well, I'm really sorry that you're angry,” or “I'm really sorry that you're upset, we just don't ever want that to happen around here, we try to have an atmosphere around here where people feel safe and feel cared for and feel that there's some good care going on. So I'm really sorry that it got to this point.” And you know, from there, you have to kind of read the signals. What can we do to to help resolve this? Sometimes it’s appropriate, sometimes it's not. But at this point, you're trying to wrap things up. You don't need this to go on a whole lot longer than this, if if the temperature has gone down with them. And at that point, you really kind of want to figure out a way to go ahead and get them out of the office. You don't want to be making any long-range plans with them; don’t necessarily offer to make a follow up appointment; and you absolutely don't make any decisions or say anything to them about them needing to go to another practice or get care somewhere else. I terminated some patients early in my career who were, you know, disruptive like that. And I came to learn later, that much more commonly, these folks, once they leave and reflect on things, a lot of times they'll call and apologize. But as often as not, they will just sort of drift off and go to another practice without you having to go through the risk of formally terminating them and all the things that that can bring up. Where am I right, and where am I wrong here? This is just sort of my thoughts.

Stacy Simmons, 14:01: Well, first of all, there's a few things that are sort of universally right or wrong, Right? But there's not a perfect way to handle this, but it sounds to me like you handled it beautifully. And probably most people would love it if you would come handle it for them! What I find when I'm talking to the doctor about the situation, hearing the retelling of the situation, the doctor is mad. I think if you're in the situation that you were talking about, Dr. Sayers, if you, as the doctor, can focus on: This is not my opportunity to be right. Right? Because as a doctor, you're supposed to be right all the time. And patients come to see you and they want answers. And they want you to be right. And, so you're sort of used to being in that role and giving responses and giving answers. So, you're going to have to, like, really shift gears. I think that is the first thing to acknowledge to yourself, if you're just not in the situation very often, that you are shifting gears from what you usually do,

Dr. Brian Sayers, 14:54: It's really in our nature to defend ourselves and to dispute facts and to be in charge of the conversations. To go in with the idea that you're just not going to do that right now.

Stacy Simmons, 15:06: You're going to totally put on a different hat. And, and I think if you walk in there with that, acknowledging, that you are going to go into giving answers, telling people, and being right, you know? Because that's what you're supposed to do! So anyway, I think, I think if you can sort of say to yourself, “This is not my opportunity to be right; this is my opportunity to listen.” You know, and even if the other person says things that are stupid, or silly, or, you know, accusatory, or whatever - and that's hard, that's easier said than done - but especially if the person says things that are accusatory, there's no good that’s going to come of arguing, right?

Dr. Brian Sayers, 15:41: Yeah. And don't leave out the possibility that you might be wrong, or your staff member might be wrong. And as you were mentioning before we started taping, sometimes this is a very appropriate time to apologize. And it may be just apologizing that they're upset without taking any blame for it. But sometimes, you really might need to apologize for something that happened or something that one of your staff members did.

Stacy Simmons, 16:07: That's exactly right. And again, the distinction that you're making there, I think is important, is sometimes, I think doctors learn in medical school and I'm not sure who teaches them this, but universally when they come to me, they will say, “I thought we weren't supposed to apologize.” So somewhere along the way, doctors get told that, and the nurses get told if it wasn't written down, it didn't happen. So, somebody tells people that in school, I think! (Laughs.)

Dr. Brian Sayers, 16:30: An admission of guilt. Yeah, it isn't.

Stacy Simmons, 16:33: And it's not. It's not an admission of guilt. As I said before, sort of jokingly, if you say, “I'm sorry, I totally screwed up. It's all my fault.” I mean, that's yeah, that's not good. That's hard to deal with later, right? But if you say “I'm so sorry that you're upset, or unsafe. Sorry that we didn't handle this in a way that makes you happy or makes you feel comfortable” or whatever, I'll defend that 100 times out of 100. I mean, if you're sitting before the jury, and the plaintiff's lawyer is saying, “Well, doctor, you are guilty, because you are, you're negligent because you apologized.” I don't think anybody thinks that. I think they think that you're a good human being because you apologized. And, so I think as we said before, [if] you have somebody who's on fire, right? And you go in there and argue with them and try to be right, you might as well just throw gasoline on that plane. Whereas if you go in there and take the oxygen out of the room and apologize, and say “I'm here to listen” and you really do it, you don't just say it and then interrupt them constantly and try to be right, you really do listen, I think that really takes the wind out of people's sails and they're not expecting it.

Dr. Brian Sayers, 17:36: Right, it can be really hard.

Stacy Simmons, 17:40: It's very easy for me to say that you should do that. But if you go in there and start arguing with someone, that's kind of what they want. They want to argue. if they're already in there, they're already taken back to your office because they were making a big stink in the waiting room, they want to fight. And ultimately, you are not going to win that because all they have to do is go file a board complaint, you know? Which is, not what you want to happen, and/or a Yelp review, or whatever social media things happen. I mean, doctors are a little bit at the mercy of the public in those ways. I think everything you're saying is great. I think you just have to put on a different hat. The other thing that I think is like people come to us for answers, right? And for solutions. And what do I do about this? So, I tend to, in situations where people are upset, tend to want to come in and solve it. Here's what you should do. Here's what we should do. Here's the answer. “They don't want you to jump in and solve it.” They want you to listen, you know? And so an effective tool for me is to just tell myself, I'm just gonna ask, “Well tell me more about that. Tell me more about that.” That's the only thing I need to say. “Tell me more about that.” Then that saves me from going, “Okay, well, here's the solution,” you know, which is sometimes not helpful in the situation. So, it doesn't allow them to do what you were referencing, which is talk themselves out, you know, but if you sort of say, “Tell me more,” they'll keep going.

Dr. Brian Sayers, 19:00: It's a good, it's a good way to do it in an open-ended way so that it goes in the direction that they want it to go in, and you're not forcing anything. They just need to know it's a safe place to just let it out.

Stacy Simmons, 19:12: Yeah, if they started, like, hurling criticisms at your staff or hurling criticisms, you know, there's a certain amount that you don't have to take, but you're going to take it in an effective de-escalation, I think you're going to take more than you think you should. And that person is going to be de-escalated and interestingly, it would be, it'd be interesting to know how many of these situations, where you actually end up having a better relationship going forward with the patient. I mean, some patients, you hope they just go off and you never see them again. But sometimes people get their noses bent over something stupid. And if you're like that, like you're describing, and you end up having a really good relationship with the patient going forward.

Dr. Brian Sayers, 19:54: Yeah, I think you make a good point there. Because sometimes it does go over the line, and it gets into personalities. And, I do think it's okay to, to say something like, “Well, you know, we need to try to take out personalities, as we're problem solving here,” or something like that. Because sometimes it can get very personal and either towards you, or more often a staff member. You kind of want to steer away from that and talk more about a behavior that's disturbed them rather than the person that's disturbed them.

Stacy Simmons, 20:29: That's a really good distinction. And you know, as a person, he probably has stepped in things before, in this scenario, where I'm intending to be a good listener, be a good empathizer. And I jumped in and tried to solve it if you do that. I mean, you're, you're not going to be perfect at this, right? Because it's not what you do. Hopefully, it's not what you do very often; it doesn't come up that often. And so if you do find yourself doing something that's not helpful, it's completely fine to say, “I am clearly doing something here, but it's not helpful.” Like out loud to the patient and acknowledge, “I don't usually find myself in this situation. And really what I intended is to listen, so let me close my mouth and start listening again.” You know, it's completely fine to acknowledge that you have said something that maybe is not helpful, and you didn't intend to - so let me sit down and listen, or whatever. I mean, whatever the circumstance, yeah, redirect.

Dr. Brian Sayers, 21:21: And I think in that acknowledgement stage, at the end, when they've talked themselves out, I do think it's also okay, if it's kind of personal about a specific staff member’s actions to say, like, “You know, that's really not like her. She usually doesn't behave that way with patients. I need to talk to her about that and see exactly what has happened here and try to sort this out on our end.” You're not acknowledging that they did anything wrong, but you are acknowledging that there's a specific person that they're concerned about. And because if that's their main thing, you want to get away from the name calling and go into a little bit of problem solving in the end, or at least a plan that you're going to talk to that employee. And they don't know what that means. And depending on the situation, it's okay to acknowledge that there was a problem between them and one specific person. And you are going to look into that.

Stacy Simmons, 22:16: Yeah, and I think too, you gotta’ remember that everybody's bringing into the room, that you may not know that they're bringing into the room. Maybe the patient is mad about something something really traumatic going on in their life. I mean, who knows, right? And I'm not saying you need to, like, analyze that and spend too much time talking to him about it. But then again, when you're putting on your different hat, maybe that's something to think about is, there can be something completely that you have no idea going on with this person. Let me shift into a lawyer thing, when Dr Sayer said the thing about not feeling like you have to tell them that, “Well, I'm glad we've had this conversation but we won't be seeing each other again, because I’m terminating you.” I can't imagine a situation where you're gonna ever want to say that to a patient who's mad. But I will say, I agree with you, a lot of times it just fizzles out. In their head, they're gonna go somewhere else anyway. But you do have, you do have those situations where you have a 30-day obligation to refill medications and all that. And if you've got a situation and it's just it's not going to work — “I don't ever want to be dealing with this patient or refilling a medication or any anything again”—you may need to terminate that patient. And I think those are the situations where if you’ve got a relationship with the lawyer, or kind of does what we do or even TMLT, you call the Risk Manager at TMLT and you tell them your particular scenario. And what do you think I should do? I think almost universally, you should not tell them in the meeting that you're going to terminate them. But if you need to send them a letter soon after, there could be situations where I have had situations like that, and I'm not quick to tell a doctor to fire somebody, but I've had situations where I'm like, “You need to fire that person.”

Dr. Brian Sayers, 23:54: Yes, it absolutely comes up. So, I was talking at lunch the other day with some colleagues about this podcast, and one of the things that came up is sort of an intermediate scenario, there were, I think, the wording one of them used was in a situation like that, that really abusive and antagonistic, they might say something as the patient's exiting like, “Well, this just might not be the practice for you to come to.” And so then it seems to me that you've kind of got the worst of both worlds. They may think they've been terminated in a legal way. You haven't terminated them at all; it was more of an offhanded comment. They don't know what to do with that. You don't really know what to do with it, for that matter. I think that's probably the more likely scenario in the heat of the moment that might happen, rather than saying, “Don't ever come back here.” Yeah, something more vague like that.

Stacy Simmons, 24:45: That's a good point. I was saying earlier, sort of have that, that, that have thought through the, “What am I going to say?” Rather than trying to jump in and solve the problem. “Yeah, tell me more about that.” If you have something, you know, you're going to say, maybe think through like, “How am I going to end this? How are we going to separate from each other?” And you don't always know, because you don't know what they're going to say and how the meeting is going to get. But, but maybe you have kind of a plan for “How am I going to end this without saying, never come back?” Or maybe “This isn't practice for you” or any of those scenarios. It's hard to know, unless you're in this scenario.

Dr. Brian Sayers, 25:16: Exactly. Right. If there's not an urgent medical problem that has to be addressed right then, that's a great way to end it. So, that they can drift off if they're going to, or call and apologize if they're going to. Most of the time, by that point, they're kind of ready to get out of there. You know, they, they really are not about their future relationship with you. Unless they're just verbalizing it, they kind of want to go as much as you want them to go at that point.

Stacy Simmons, 25:40: I can only think of scenarios like at mediation. I mean, I've never had to deal with an irate, real irate, patient in the moment. I mean, that doesn't come up for me. But in mediation, you know, we're sitting across from the plaintiff who's now seen the doctor, and they've got all their feelings right out there. And they're wanting to talk about it, usually. And, and we have to tell them all the reasons why they really either should walk away or take a very small amount of money for this thing that they think is a very big deal. And sometimes it is, right? And, and it's hard to hear that, I mean, it’s hard as “the other side” to hear that. I'm very tuned into that. But the thing I always say, after I have said all the things, the hard things that I need to say, is that I appreciate you listening to me. And it's gotta be hard to do that in a scenario. And I appreciate you listening to me. And so, you could maybe say something like that, like, “I really appreciate you being brave enough to share all this with me,” you know, or “trusting me to share all this with me” or something like that. I think that's a good way to end it. And then you're not really talking about “Never come back” or “Let's make an appointment.”

Dr. Brian Sayers, 26:45: Yeah, and there is a scenario, and this has been really I only had this happen one time in my office, in the back office, where they just are there to argue, and you can't, you can't talk, they won't talk themselves out. There is, there is a point that comes up in some situations where you finally, you're just going to have to say, “I think that we're probably not going to resolve this and maybe you should leave the office” or something. I don't know. How do you handle a situation like that? Where they just go on and on, until, without really responding to the normal procedures?

Stacy Simmons, 27:23: I think you just have to say something like what you just said, “I really appreciate you sharing that with me. And obviously I may have some views that are different than yours. And I feel like we've kind of talked this out as much as it's productive to do so. We're kind of getting past being productive at this point.” You know? I think if you go in with an attitude, you as the doctor who are usually in the position of being sort of in control of this visit, the conversation, the scenario - what you're supposed to do as a doctor – you’ve got to take that hat off, and suddenly be rolled over on the path. And I'm here, I'm here to listen, you know, and sort of almost imagine that. Or else, it's the body language, the things you say, the way you look, the things you're doing with your hands, it's all going to come across that way.

Dr. Brian Sayers, 28:17: I think one thing that we need to acknowledge here also, especially in light of what has happened here in Austin within the last year or so with one of the practices, is that we're talking about, you know, uncomfortable situations, but not typically real dangerous situations. And so, I don't want this conversation to minimize the possibility for patients to become violent in the office particularly if they're in a patient care area. And you think that there's really a physical threat that's present.

Stacy Simmons, 28:53: Yeah, and I think and hopefully, that's exceedingly rare. But but if it is, if you have any inclination that that's the direction that that's going, you just err on the side of calling the police. Call 911. Or, again, whatever we need to do.

Dr. Brian Sayers, 29:09: And I think staff training and protocols really come into effect then for something you hope you'll never have to use. But there does need to be an understanding with your staff about what triggers, I mean, in our building, we don't have security, we have to call 911. But what triggers a call like that, and that in situations that they have the okay to do that, if they think there's a situation that's escalating to the point that that needs to be done.

Stacy Simmons, 29:36: You actually have a protocol in your office where like, you have some signal, you can send some staff member. . .?

Dr. Brian Sayers, 29:41: You know, we don't. We don't have like a safe word or something like that, that we use. We have had meetings where we have sat down twice now as a group and talked about disruptive patients, and especially patient safety after that, that what happened in Austin last year. And the staff members, they all understand that it's okay to call 911 If there's a situation that they think is escalating, and if I'm in the room with a patient, even with the door cracked, you know, unless I start hollering, they're not going to really know that that situation has come up. But they know that they need to be in a position to where they can exit the office easily. And that they can call 911.

Stacy Simmons, 30:22: Yeah, that's, that's scary that there needs to be right? A protocol.

Dr. Brian Sayers, 30:26: And I never really thought about that until that happened last year. And it's, it's, it's hard to have that conversation with staff members, although that was an easy time to have the conversation, because everybody was really, really upset about it.

Stacy Simmons, 30:40: I don't know if it's a good time or not, but I wouldn't mind, since you're bringing up staff and sort of, you know, their involvement in, in this whole process, because it's not always just you with a patient, right? It's quite often involving people in your staff. And in my role, it's not uncommon to see something, too, has escalated to a lawsuit, a board complaint, you know, whatever. And the doctor never even knew there was a problem. Like, this is something that's going on with the patient and the staff. And as you know, I'm irritated because it takes me lots of minutes to get through the phone tree. I'm irritated because when I get finally get to ‘push one, push five,’ I finally get to the phone tree, it's not even a human being who answers the phone and I gotta leave a message, you know? And then how long does it take for somebody to call me back? I think that happens in a lot of practices these days, as practices get bigger. And, and I will quite often talk to a doctor that's like, I didn't even know there was a problem. You know, and so I think it's important. A couple of things in that regard. And this is sort of, again, just a human being kind of thing. Try your best to be the kind of doctor in your office, where your staff is not afraid to bring something to you, you know? And I know that seems kind of obvious. But if you're kind of grumpy with the staff all the time, when the staff brings things to you, like, you know, trying to deal with with Ms. Simmons and she's really being a pain, and this is what's going on, and she wants her $100 back, or whatever. If you're always grumpy about that, they are going to go to great lengths to try to deal with it themselves rather than involve you. And it's totally understandable why you're grumpy about it with all the responsibility that you have. But it's gonna’ blow up in your face because they are going to try to deal with something that should have been escalated to you or to a competent office manager to deal with. And quite often they do it well. But sometimes, no matter how well they do it, they can't make the patient happy, the patient wants your attention. And so, I think it's good to have at least conversations with your staff, about letting you or an office manager know when things get to a certain point. And then being, you know, grit your teeth and be nice about it when they do.

Dr. Brian Sayers, 32:59: They need to be trained not to engage for too long when it's, you know, an abusive patient or an angry patient. But if you're not having staff come to you, at least occasionally, and telling you about a bad encounter they've had on the phone, then they're just not telling you because it is absolutely happening. And, you know, they're supposed to pass off the calls if it gets antagonistic to a co-worker, preferably the practice manager. But they're supposed to let me know if I'm available. And if I'm not available, as soon as they can tell me about it, they do. And I'll usually wait a few minutes and call the patient back, let him cool down for a while. A call from the doctor in that situation is just gold because you weren't involved in the call. They're rarely going to be complaining about you. It's really usually about office procedures or a bill or something. And that's when the you know, apologies for you know, whatever's going on, or their feelings, it really diffuses the situation. All of these are great points because this happens much more frequently than a patient in the office who's really irate and angry and possibly even threatening. The phone thing is much more common, and in a way, much more solvable. You lose the body language and things that are an advantage in person. But you know, a call back from the doctor usually means a lot to the patients, just the call itself acknowledging that there's been a problem. And, you know, they'll be a little cooled off at the time. But you absolutely should be hearing from your staff that calls have been a problem, or your practice manager. And they need to know it's an atmosphere where not only is it okay to tell about it, but you expect them to tell about those calls.

Stacy Simmons, 34:34: That's such a good point. And here's another thing from a lawyer perspective is, and again, write everything down. I mean, nobody has time to do that. And y'all are going to be saying to yourself that it would be great if we had time to do that. But if you can sort of train your staff or at least try to get them, when they make these phone calls, when they call someone back because someone's upset about whatever, if they get the voicemail still document it. I called them back left a voicemail, you know. I called, tried really hard, even if it's a one liner. Because then when I, as a lawyer and am dealing with the, whatever, the board complaints or whatever, that “I called, and they never call me back.” You know, then I've got a page from your EMR, you know, that says, “Sandy in my office called on this date and left a voicemail” and “Somebody else in my office called on this day and left a voicemail,” and that is gold.

Dr. Brian Sayers, 35:37: Yeah. And with clinical staff, that's that's expected - that kind of documentation. The scenario that might be a little more problematic is when your front office staff or bookkeeping staff or whatever is interacting with the patient in that way. I need to do it, too. Yeah, I mean, it tends to, but I guess that's you need to figure out how that might work. Because I know even in my own office, they'll jot things down on a post-it note or something, so that they can remember when they call them back and that but as far as entering that in the clinical record . . .

Stacy Simmons, 36:08: Your point is well taken. I think in the best-case scenario, you write all that down, right? The front office people are documenting that too. But that would be impossible for them to deal with all the stuff they've got to do, that once the front office knows that we are now having a problem with this patient. I mean, this patient has been pissy on phone and we're having a problem and you know, and then the front office needs to jump in there and document you know, when they call back. And literally, even if it's just a post-it note that you scan, if they write things on a post-it note or on a spiral notebook or whatever, scan that in your EMR because, you know, six months from now, you won't be able to find it.

Dr. Brian Sayers, 36:41: Right. I think most practices don't really think to do that when it’s nonclinical staff involved.

Stacy Simmons, 36:47: That's a good point. And not all the time. I think that would be unreasonable for me to expect that anybody would be able to do that. I mean, with the run of the mill phone calls, all day long. Don't do that. But when you can tell, we’ve got a problem. You know, and you're making phone calls and now your office manager is involved. Jot it down, put them in the EMR. There's some like initials, use callback, left voicemail. I can't remember what it is, but I love it, from one of my kids “called back, left voicemail,” and, and even if you put that in, put the date, then it helps later to show we were responding to that you called five times and we never called you back. So, if you can, that's, that's the A+.

Dr. Brian Sayers, 37:28: We're just we're interacting with insurance companies over pre-authorizations and stuff that aren't going well. And so they're, they're used to documenting things of just insert in situations like this, I think that does take some coaching.

Stacy Simmons, 37:41: And again, make sure they know it's not expected all the time. That would be too hard. But when you can tell something's going wrong, right? Let me just say this, sometimes you don't know something's going wrong. Like you’re making those phone calls, you don't necessarily know it's wrong. But then there comes a point where you do. And at that point, even you could, while you still remember it, you being the front office girl that I talked in front, obviously, woman, you know, her man, whatever, I talked to her two times yesterday and one time the day before. Even if you didn't document it right then because you didn't know there was a problem, once you realize there is you can say, “I talked to her two times on Tuesday, one time on Monday.” You can do that in your note, and it's better than nothing.

Anthony Passalacqua, 38:23: So, we're kind of talking about, like, the different, like states for emotions for a lot of patients. And so, I know, for a lot of us, we think, okay, you know, like aggression, like that's the first one that always seems to kind of come to mind. But I've noticed with like this pandemic, there's these two other emotions that we have coming out. One of them is a topic that Dr. Sayers and I talked about, which is burnout. I know right now, we're seeing like a huge turnover in staff, just in multiple locations, because of just the level of emotional stress that individuals are handling. And then as well, with this public health, health crisis, we've also seen, like a loss of life, which is something that I think a lot of people have to deal with. And it brings up a whole slew of different emotions. And so, one of the things that I was kind of wondering from just the risk management perspective, is, you know, how do you handle all of those different situations with all of those different emotions that are that are coming out, especially for de-escalation?

Dr. Brian Sayers, 39:24: Well, I think everybody's emotions are kind of on edge. I mean, we don't know what all is going on with people these days. We never do, but it's even it's even harder now. And, you know, the best, just easy example of that, that that most of us as physicians have learned to deal with, is the vaccination thing. I don't ever confront people about vaccinations anymore. I'll ask them something like, “What did you decide about getting vaccinated?” Things like that. Because it is, you know, you want to get the right information across to people. You want to take care of them in a way that's safe. But there are, there is just this stew of emotions going on with staff and patients right now. And it's easy to step back. So, we just need to give each other a little slack now. Not everybody feels that way. Not everybody comes into your office that way. But it is a mindset that we need to remind ourselves about in our staff about that there is so much going on with patients right now, with their jobs and their families and their worries, that it is a whole new ballgame as far as how we how we approach people.

Stacy Simmons, 40:34: I think that's a very good point. Somebody told me a long time ago that like anger, sadness, all the emotions typically, like fear is behind all of it, right? There's some fear that's behind it. I can tell you that, even though I deal with doctors every day and three of my immediate relatives are doctors, I mean, I have intense amount of like anxiety and fear of going to the doctor. I can sit in a doctor's office and wait to meet with them, doesn’t bother me at all – workwise - not bother me at all. But if I'm sitting there waiting to be seen there, it's a different feeling. You know, so even just a patient being at your office, they're sick, maybe there's a finding out if there sick. They're worried about how much it might cost. I don't know there's 100 things they are worried about. Fear right now is amplified by everything else that's going on. So I think too, when your people are quick to be irritated by dumb little stuff - that’s true of patients. That's true of staff. That's true of the doctor. That's true of their lawyer. That’s true of everybody. You know?

Dr. Brian Sayers, 41:42: Your fear triggers reflexes that you can't always control, and sort of a reptilian part of your brain that gets activated. And, so there's a lot of that going on.

Stacy Simmons, 41:52: And people act in ways that you're not used to seeing them act, and act in ways that are silly and unpredictable. And I think that's kind of rampant right now. And, and everything we can do to recognize that, and if you are the type of person that is good at putting people at ease, is good, because it's easy to get irritated when somebody acts weird or upset or hyper emotional about something in your office. But if you can step back from it and get [that] everybody really is under a lot of pressure right now and scared about stuff and worried about their jobs and our families.

Dr. Brian Sayers, 42:23: That's true. And it takes, if you're in a big hurry, none of this works, you've got to slow down and try to figure out what's going on with them and how to address it. And that's hard. When we're behind at the office and in a big hurry to get from A to B, taking that extra time and recognizing when you need to, that's a that's a real skill you have to develop and nurture it.

Stacy Simmons, 42:46: I think that's exactly right. But I think it's also so important to know that if you step into it, and you didn't really do that, you acted on impulse and somebody’s mad because you’re running late, and you’re like, “I’ve got to see 50 patients where I used to see 15 – and overhead and whatever. That’s all true. But if you find yourself saying the wrong thing, like your attitude is wrong, or you weren't empathetic to the person, you can stop. And you can acknowledge, I'm not acting in a way that's very productive. And I'm gonna start over, you know? And sometimes, if you acknowledge that out loud to the other person even? That's okay. And people are like, very forgiving when. . . I mean, you know, you find yourself irritated at the guy at the drive thru because they got your order wrong, and you're being annoyed. “No, what I said was three large fries!”  Don't mean and then you're like, wait, “I'm so sorry. You know, what am I doing? I'm so sorry.” I mean, it's, it's that's just an example. It is okay, to stop and say you're sorry. And recognize you're not acting in a way that you need to, let me start over. I mean, I don't know. I feel like that's kind of basic human. Exactly. But it helps.

Anthony Passalacqua, 44:07: Yeah, and the last thing that I always think of for de-escalation is online reviews. We have a lot of individuals that are really into providing their input online. But the interesting thing about online reviews versus in person as as we lose, you know, we were talking about electronic communication, I think before we started, you know, so emails, you know, there's always the potential that the emotional component of it gets lost. You were talking about how someone told you something, one of the things that one of my mentors told me a long time ago is, is that you can read the same letter in four or five different emotions, and it can completely change it. And so, with that being said, online reviews, they sometimes seem quite hostile to a lot of our physicians. Dr. Sayers, how do you handle those online reviews? Do you do get a lot of online reviews?

Dr. Brian Sayers, 44:54: No, we don't have online reviews that feed out of an EMR or something like that. So I don't, you know, have, you know, 50 or 60, probably? And I, you know, look at them occasionally because the negative ones. You know, occasionally there has been, I've been surprised at who wrote it, and what they wrote, and I’ve picked up the phone and call them and as often as not, when that happens, they'll repost something. But even when that's not the case, it's I think it's helpful to see them and a lot of them are really unfair. But, you know, that's, that's part of it. It's a, it's a thing that's really annoying and unfair, but in a way, I think it's a thing that in some ways might check behavior a little bit too. We are a little bit more careful about how we behave with patients and how respectful we are and how we try to de-escalate things. Because in the end, we really don't want that to show up in a review.

Stacy Simmons, 45:51: That's interesting. And so far, from a lawyer perspective, the online review thing is, is you know, one of the things we get calls about a lot and doctors really hide about it. And the one thing I want to say is don't respond, you know, to online reviews. As the doctor, it is probably going to be online or spied on. I was like, wow, When Dr. Sayers says that he calls them back, that's the right thing to do. Because if he responded online, it's probably going to be considered a HIPAA violation. And the weird thing is, I mean, a case years ago where this woman, you know, reviewed this doctor, and all the specifics about her care, “I came to see you about blah, blah, blah, and all the details about my personal care.” And I'm the patient, and I'm putting that out there. And the doctor wrote back and said, “Well, really what happened was, you know, blah, blah, blah.” And he had not gone at all outside of what she already said, he didn't like, turn it to some completely different thing that she didn't raise. He was talking about what she had already put out there. And in my mind, I was like, that's waivered. You've already you put it out there, you the patient, put it out there. He can talk about it. But that is not, that is not the way the Texas Medical Board will interpret that. And so, what we tell our clients and doctor friends or whatever that ask us, and we're probably way too conservative about it, but we say just do nothing online, call the person. But a lot of doctors will say that that makes you look like a jerk, because the public doesn't know that you responded, and you look like this person who's ignoring an online review. If you've got to do that, if you feel real strongly about that, we advise people to say “I can't acknowledge whether you are patient in my practice or not, out of respect for your privacy. But if you are, I will be happy to contact you. And we'd love to talk to you about your input. And we'll be very interested in your input and you know, something self-serving like that. But you don't acknowledge even that they're a patient in your practice. And you say “It's because it’s out of my respect for your privacy. And I'll contact if you are, I will be happy to contact you privately and have a conversation.”

Dr. Brian Sayers, 47:57: Yeah, that just seems like such common sense that everyone would realize, but I guess in the heat of the moment, some people don't and you have experience with that, apparently.

Stacy Simmons, 48:07: I feel real strongly, especially perhaps some practices are very driven by word of mouth like, you should go to this person, and some practices, not so much. And some practices are, and so the ones that are feel very strongly, “I don't want to leave something out there. It looks like I don't care.”

Dr. Brian Sayers, 48:23: Well, it's an inherently unfair system.

Stacy Simmons, 48:26: It is 100% unfair for doctors. The whole social media thing is 100% unfair.

Anthony Passalacqua, 48:32: So, the last thing I always like to ask each one of my guests is, what's the one thing for de-escalation that you guys would want our listeners to leave with? Dr. Sayers go ahead.

Dr. Brian Sayers, 48:43: Take a deep breath and realize, you know, this is not the time to win an argument. This is the time to listen and de-escalate. And it is not the time to argue or defend yourself.

Stacy Simmons, 48:57: That's exactly what I would say. It is not the time to be right. It's not the time. I mean, you may have to eat some crow, you know? And I'm not saying you have to admit that you've done something wrong. But you may have to listen to some stuff that you’ve got some really good responses to, but it's not the time for that. It's the time to let the person be heard, acknowledge that they're being heard, and you don't need to be right. You just want the path of least resistance.

Anthony Passalacqua, 49:21: Well, thank you for listening to our podcast. If you're a policyholder, please feel free to contact us with any questions by calling 1-800-580-8658 or check out our resources at tmlt.org and clicking on our Resource Hub. I thank you both for your time today.

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