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Using improv techniques in a health care setting, Episode 2: Dealing with difficult patients

In the second episode of this series on using improv techniques to improve medical conversations, Shana Merlin discusses how to deal with difficult patients, including how to set boundaries, reflect positive intent, and use such improv techniques as “blending.”



Also available on Apple and Spotify. A transcript of this podcast is found below.



Additional episodes in this series:

Episode 1: Fundamentals of medical improv
Episode 3: Improving patient interactions
Episode 3 bonus: “Signposting”
Episode 4: Interprofessional medical communications



Transcript

Shana Merlin (preview):
“So, we have a basic rule, which is that no one cooperates with anyone who seems to be against them. So, if the patient thinks the doctor is not on their side, not on their team, doesn't understand them, doesn't get it, they're not going to be open to those suggestions and they're not going to want to be compliant or listening.”

Tony Passalacqua: 
Hello and welcome to TMLT's podcast, TrendsMD, Answers for health care's digital trends. I'm your host, Tony Passalacqua. This is the second episode in our series on using improv techniques to improve communication. In our last episode we discussed the fundamentals of improv – the whys and hows – with our speaker, Shana Merlin. Today, we will discuss how to deal with difficult patients and learn how to use such techniques as “blending,” reflecting positive intent, and setting boundaries. 

Shana is an improv instructor who has worked with such organizations such as the Dell Medical School at UT Austin, the Methodist Medical Center, and TMLT. She also founded her own improv school, the Merlin Works Institute for Improvisation in Austin. You can learn more about Shana and Merlin Works at www.merlin-works.com.

Today, we are joined by Stephanie Downing, an education coordinator in TMLT’s Risk Management Department. To learn more about TMLT’s CME offerings or to schedule any future CME activities, such as one where Shana is involved, you may contact Stephanie at 1-800-580-8658.

So, Shana, how should we think about dealing with difficult patients?

Shana Merlin:
I have a model I like to think of when I talk about dealing with difficult patients and trying to get them to move to where you want them to be. So, for this idea of meet and move, Stephanie's going to help me with this kind of exploration.

So, let's think about back in the day, in those beauty days of the 90s. So, say in the 80s and 90s, you wanted to go to your friend's house. What would you do? How would you get directions and get there successfully? 

Stephanie Downing:
So, being Gen X, the best generation for analog and digital, so we can compare how we were doing this back in the day, I would call my friend and I would get a piece of paper and a pen and she would give me street-by-street directions and then would have to figure it out as I drove. And then also, once we did have computers, we could go online and print out a map on MapQuest and then have like 20 pages of maps that we'd have to look through while we're driving. It's pretty dangerous, but we did it. 

Shana Merlin:
Yeah, we did it. We figured it out and we had kind of a long list of turn-by-turn directions that we had our map, and you'd set out on the road, and what would happen if you took a wrong turn or missed your turn or something like that and you got off course? What would you do back in the MapQuest days?

Stephanie Downing:
Just have to backtrack go back where we came from because we didn't have something telling us you can take this alternate route because then we just get lost 

Shana Merlin:
Right, so you'd have to backtrack you'd have to get off the map and figure it out. Uh, you might have to stop at a gas station. Do you remember that?

Stephanie Downing:
For sure. 

Shana Merlin:
Or a payphone. And get help. And so, the downside to that kind of solution is that it would, you could get lost. It would take a long time. It was really difficult when you got off course. The plus side of that is that you could get lost and discover things and have adventures and that was cool and that doesn't happen as much anymore.

Now let's fast forward to kind of today where all of us have this kind of super powered GPS in our pocket. So, when you want to go to your friend's house now, you open up your phone, you open up the Maps app. What's the first thing that happens? 

Stephanie Downing:
It says you are here. 

Shana Merlin:
Yeah, it gives you that nice blue dot that says where you are. And then what's the next thing that happens? 

Stephanie Downing:
Then it asks you where you want to go. 

Shana Merlin:
It asks you where you want to go, and you might type in the address or the name of the location where you want to go. And then it gives you a few options, right? What, it tells you one way to go that might be the fastest way.

One way to go that might be the least toll roads. One way that might be the most fuel efficient. You get to pick which way you want to go. You press start and then what happens? 

Stephanie Downing:
You just .... It tells you where to go and magically just says, turn here, like, Oh, got to turn here. 

Shana Merlin:
Yeah. It tells you the next thing you need to do to go in the direction of where you want to end up.

We can think about this as a model for persuasive communication. Are you MapQuest or are you a GPS, when you are talking with your team members, when you're talking with patients? If we think about, for one thing, am I like MapQuest? Are you saying all the directions at once and giving a huge list of things to do and then they're on their own?

Are you not really finding out, um, anything about them before you tell them what they're supposed to do? The GPS, it's a lot of work up front. Because what the GPS does, the first thing it does is it joins you where you are, and it starts to see things from your point of view. It understands your motivations, where you want to go, and it also understands the obstacles in your path.

It gives you directions, a step at a time, of what you can do. And if you get off course, remember how they used to say "recalculating?" They don't even say that anymore because that was too rude, right? It's like, how dare you? It just says, okay, now do this, right? It just gives you the next right thing you can do if you're off the course.

So, we can think about how can we be more like a GPS as health care providers? How can we both meet people where they are, understand things from their point of view, understand their motivation and their obstacles, give them a right size step and information to get things in the right direction. So, this way of communicating can help reduce the amount of those difficult conversations or those high conflict because we're not talking at people, we're not overwhelming people, we're guiding them side-by-side to where they want to go. People are going to be much more likely to join you where you want them to go if you are walking side-by-side with them as opposed to going from the other side going, "Hey, over here, do this, do that, do that."

So, we can use this meet and move model as a way of having better communication. And this can be something, this is something you can do with your kids. I'm going, "Hey, I know you want, you want to use the blue cup. I get it. You want the blue cup. The blue cup is dirty. You can use the purple one or the green one."

That is a simple kind of meet and move instead of going, "Take the purple cup," you know, right? Um, and we can do that in a lot of, of ways with our patients. Even if it's, you know, I work with a lot of orthopedics where someone comes in and they want surgery. And the orthopedic knows, uh, doctor knows that's not the best treatment for the condition, and you can meet them where they are.

"I hear you're in pain. I know you want the surgery. If this surgery would solve your problem, I would do it in a heartbeat. Unfortunately, it's not going to be helpful. So let me talk about the options. We've got physical therapy. We've got this medication. We've got this you know, treatment plan. We've got to wait and see."

That's a meet and move conversation and a real simple model for kind of navigating persuasive communication and difficult conversations.  

Tony Passalacqua:
You just gave us that example of a patient's going in and they would like to have a specific procedure done and the physician identifies that the risk benefits ratio isn't great enough to justify that surgery. What are some tips and techniques that a physician could use in that specific situation?  

Shana Merlin:
Right. So, we have a basic rule, which is that no one cooperates with anyone who seems to be against them. So, if the patient thinks the doctor is not on their side, not on their team, doesn't understand them, doesn't get it, they're not going to be open to those suggestions and they're not going to want to be compliant or listening.

So, one of the first things we can do is blend. So blending is a technique that we do all the time to help us quickly get on the same page with other people. Blending is sending signals of similarity and reducing differences. And that gives our patients or our colleagues a sense that we're on the same page, we're on the same team. Um, in the most basic sense, I think this is why people talk about the weather. They're like, "It's hot outside." And you're like... 

Stephanie Downing:
"Sure is." 

Shana Merlin:
Boom, we are in the same reality. Okay? Why else would people talk about that? It's hot outside, right? It's just an easy way to get on the same page and get to that first, yes, that level of agreement.

But there's lots of ways we can blend, so we can think about, um, providers doing this. Every time they open the exam room door, they're getting a quick read of their patient, and they are looking for ways to blend and send signals of similarity. So that could be, if the patient is seated, the provider is seated to get on that same level.

If the patient has an expression of worry on their face, you might blend and also give an expression of worry on your face. Now, you're not going to start sobbing. That doesn't make sense. You're not going to have more, more pain, but just having that expression. That's why you don't want to be like, "Hey, great day today," when someone's got a concerned look on their face, right? You want to blend and match that, that emotional blending, that energetic blending. So, if they're quiet, if they seem, you know, then you're going to make your voice quiet and match their tone and their energy. And that's happening in a split second, when you go in that room. And this is why a lot of times when I teach with Dr. Millman, he talks about providers being actors in some way, that every room you go in, it's a different performance of kind of reading the room and blending with that room. Now, I want to say a caveat on that is that you don't need to be phony, right? You don't need to be fake to blend with somebody. I like to think about it that we all have lots of versions of ourselves.

And we can pick which version of ourselves might be most helpful to blend in, uh, that situation. So, I might be coming in as a health care provider, but I'm also a mom, or I'm also, uh, someone who has the same condition, or I'm also an Austinite. Whatever. I'm also a Longhorn. That's a great thing to do in Austin, to blend with people.

Uh oh, I got a, I got a head shake over there. Yeah, that’s what I'm saying. You got to pick; you got to pick the moment. If you have Aggie in the room, know your audience. That's right. If you got Aggies in the room, don't even bring it up. Um, but those are simple ways to blend. So, one of the great ways that we can do this and right from the top is, uh, this, we're going to do an activity right now called two things in common.

And this is a great way to kind of quickly blend with someone and get on the same page with them. And this is a great thing to do at the top of a physician interaction before we get to that difficult conversation. Because if we can build relationship and have a strong rapport, it's going to make it easier for whatever difficult conversation is to come.

And by the way, if you know someone long enough, the difficult conversation will come eventually. So, investing in that relationship will always kind of pay off. So, Stephanie, I'm going to put you on the spot here. Um, we're going to play two things in common. So, we're going to talk as ourselves as Shana and Stephanie, and we're going to try and find two things we have in common that we don't know already.

So that's the tricky part. We're going to find, because each time you play this, we're going to have to find new things that we don't know about each other. So, what I'm going to do strategically is I'm going to ask a nice open-ended question so that we can hopefully find common ground. And I'm also going to have my "yes" goggles on.

I'm going to be looking for areas of agreement. So, my, my opener is, I like to say, you know, what do you like to do for fun? Or what do you like doing in your free time? If you had free time.  

Stephanie Downing:
It's very few and far between these days, but I do love to go see live music. 

Shana Merlin:
Oh, I like to see live music too. Boom. Okay, great And, we might just uh, if we like to high five on that. We found that thing in common. Or might dig a little deeper. I might say like oh what what's the last show you saw? Or what's a venue in Austin that you like? Or have you been to the new Moody Center to see a show? 

Stephanie Downing:
I have. I've been to all the Moody places. There's so many of them now. Yeah, I’ve been to the Moody Center. The last show I went to was um, I live in South Austin and now we have venues down there playing live music. So, I went to the Far Out Lounge and saw, I like, I like a lot of different genres of music, but this one was like heavy metal music. I like to rock out.  It's my therapy. 

Shana Merlin:
That's awesome. Okay, great. So, um, and this is a great moment because I don't, I don't like heavy metal music, and I don't like to rock out. But I'm not gonna, I'm not gonna highlight that in the conversation. I'm not gonna go, "Oh, I don't." 

Stephanie Downing:
Right. Yeah. 

Shana Merlin:
"I think it's terrible." Like, that's not, because I'm trying to blend with her, right? So, my thought is, "Oh, my partner loves heavy metal music. Oh, y'all should hang out sometime or whatever. Or he went to see the Misfits at the Moody Arena." 

Stephanie Downing:
"I saw that show." 

Shana Merlin:
“You saw that show? I was at that show. Okay, great. You both were people that were at that show."  So now you can see it's been, I'm guessing less than a minute and we found two things in common, um, and we've really got some specificity to it, some connection to it. And so now if we have to deal with a more difficult conversation, we've got some nice common ground and groundwork to come back to. And if I make a note in my chart, "heavy metal fan," then that is going to be even great when I come back the next visit. 

Stephanie Downing:
When her neck hurts.  

Shana Merlin:
Yeah, that might be a clue, but I go, okay, "What's, what's the last heavy metal show you saw?" And you're going to be so impressed that I remembered that you like heavy metal. So that sense of blending, asking questions, quickly building rapport, and getting on the same page is really a great way to win over and build relationships. So, we talked about these improv skills we're using of positivity.  And we're also using an improv skill of curiosity.

So, we know when we want to win people over, it's more important to be interested than interesting. So, I'm shifting my focus away from myself and onto my partner. At the same time, I have to be a little open and vulnerable and share of myself that I like live music too, right? A lot of times in health professionals, we're asking a lot, a lot, a lot of questions about our patients, a lot of really intimate questions.

And if we give nothing of ourselves, it can be a very imbalanced relationship. So, we have to find obviously appropriate and accurate ways to share of ourselves and build that connection. So, we have that curiosity, we have the positivity, we have the flexibility of kind of going letting the conversation go where it leads us.

I was not expecting you to say heavy metal, so I have to be open to that as well. So, these are improv skills. These are relating and rapport skills. And these are also skills that can help us prevent conversations from getting too tense and for help us be more persuasive whenever conversations arise. 

Tony Passalacqua:
Well, that brings up a great point about a tense situation. I mean, what are some really good techniques that someone could use for de-escalation? 

Shana Merlin:
Yeah, um, I'm gonna, we're gonna do an activity, uh, called Reflecting Positive Intent. And this one is a really powerful activity on many levels. But the first reason is that it's a de-escalation, uh, technique.

So, this is something you can use when people are upset. When they are ranting. When they come in, you come in the room, they come in hot, they are complaining, they've got an agenda, right? It's really easy to get defensive. It's really easy to want to shut it down. "Hold on here, hang on, stop, calm down." But we know if we do that, what's going to happen?

They, that just adds fuel to the fire. They're going to get even more upset. So, I'm going to ask Stephanie, I'm going to put a minute on the clock. I'm going to ask her to rant about something for a minute. Something that. It bugs you; it bothers you, it's not just like the weather, something vague like that, but it's something that's kind of closer to your heart, something important.

And I'm gonna just listen for a minute without interruption. I'm not gonna ask questions, I'm not gonna interrupt, I'm just gonna purely listen. But I'm listening for something specific. I'm listening for positive intent. I'm listening for what she cares about, because after she's done, I'm going to reflect back that positive intent.

And I actually invite you to, we might, we might both take turns in reflecting back that positive intent and see what kind of lands with you, Stephanie. But you don't have to worry about that. You just get to rant, which is fun in itself. Okay. Are you, you've got your topic, you know what you're going to rant about?

Stephanie Downing:
Yes. 

Shana Merlin:
Okay. Minute on the clock. Begin. 

Stephanie Downing:
Okay. So, on my way here, this is perfect, because on my way here, I don't drive as much as I used to because I work from home four days out of the week. But driving on Mopac earlier, I was going the speed limit and going around cars that were going below the speed limit in the passing lane, the far-left lane.

And it's so frustrating. And I have read studies where it's more dangerous to pass a car on the right than on the left. So that's why the left lane is for passing only. And so, uh, you know, I get right up on them, which I shouldn't and try to show them, you know, you're going too slow and then they never pull over into the middle lane.

So, then I have to go around them, risking my life and other people's lives that are on the highway. And it's just, it's so frustrating. And it happens so much in this town. I don't see it in other cities. It's really just in Austin. I don't know if it's because it's like a melting pot of people from other places, but for some reason, it just annoys me so much. 

Shana Merlin:
Okay, that is time. Well done. 

Stephanie Downing:
It was only a minute? I could have kept going! 

Tony Passalacqua:
Students are so close to your heart, Stephanie. 

Shana Merlin:
I think a lot of listeners were right there with you, um, and understood that. So, before we get into reflecting positive intent, I want to point something out, which is, you might've noticed, we got around 40 seconds in, Stephanie is starting to calm down herself.

So, she started kind of running out of steam and she slowed down, her voice got lower. So, one of the first takeaways is that most people when they want to rant or vent will in a minute, kind of start to run out of steam. So, we're often afraid that they're going to go on forever and it's going to be uncontained and we can't deal with these emotions.So, we try and squash it, put it out. But that actually is part of what makes it go on longer. And of course, some people will go on long and you have to reign those people in. 

But the first tip is, give it a minute. A lot of times people just need to get it out. And that's And a big and important step and get it out without interruption. That we got to see that a little bit. I know you said you could have gone longer, but you were starting to slow down.

Stephanie Downing:
That’s true. Yeah. 

Shana Merlin:
Okay. So now we're going to get into reflecting positive intent. So, what we're going to use is we're going to use a script based on what you said I think you care about blank based on what you said. I think you care about blank. What I’m not going to do, I'm not going to summarize your problem. I'm not going to say, based on what you said I think you care about drivers that drive too slow and that they should drive faster. That's not what I'm going to do.

I'm not going to solve the problem. "Based on what you said, I think you should take I-35 instead of Mopac because the drivers are much better." That's not what we're doing. All we're doing is reflecting what's underneath. Why is this upsetting her? Usually when someone is upset, it's because there's something they care about, something they're afraid of losing, they're scared of losing, something they want that they're not getting.

Um, and so we're going to kind of target that. So, we're going to take a few turns using this phrase to kind of reflect back, your positive intent, your values, your motivations, what you care about, and then you're just going to tell us what resonated with you. So, I'll go first. "Um, based on what you said, I think you care about safety."

Now it's your turn. 

Tony Passalacqua:
Stephanie, it sounds like you care about, safety was totally the one I was thinking of. So now I'm sitting here, I'm like, oh, safety was the easiest one. Yeah, but I mean, it sounds like you also, um, would like that you care about your community operating the same way as it should in other areas. 

Shana Merlin:
Based on what you said, I think, yeah, you care about people following rules and things being orderly. 

Tony Passalacqua:
Stephanie, it sounds like you care about the fact that you're working more from remotely and that you don't have to deal with that as much. 

Shana Merlin:
Based on what you said, I think you care about efficiency. 

Tony Passalacqua:
Based on what you said, it sounds like you would wish that these people would probably shift out of that left lane and maybe go more to the right. 

Shana Merlin:
Okay, so, so any of those resonate with you? 

Stephanie Downing:
For sure, definitely the safety, because it is definitely more dangerous to pass in the middle of the highway than where you're supposed to, and um, also people following the rules on the road. Because if everybody didn't follow the rules, there would be anarchy, there would be crashes everywhere, and so yeah, safety and following rules.

Shana Merlin:
Yeah, and how does it feel to hear us reflect that you care about safety, and you feel that you care about everyone following the rules? 

Stephanie Downing:
Well, I felt heard and, um, maybe you feel the same way. So, it's like some commonality, community and yeah. So, um, I feel better about it cause I'm not the only one, maybe? 

Shana Merlin:
And this is interesting. We're having this duality of Stephanie, the heavy metal rocker who wants everyone to follow the rule of the road. 

Stephanie Downing:
And then I drive all the way home.  

Shana Merlin:
So, we're talking about this as a de-escalation technique. So, both letting someone give them some time to blow off some steam, reflecting back what what's positive in them, what they care about, often makes them feel heard, feel validated in a way that helps you, helps them calm down because they're seen for what they care about and what's good in them.

And for us as listeners, it also changes us because instead of being like, here goes Stephanie, I'm complaining about this thing again, blah, blah, blah. Um, instead I'm going, “Oh, this is someone who's passionate, who cares deeply about things, who cares about our community and about safety and about civility and all these things that, um, that I might care about too.”

That helps me feel better about the people that I'm dealing with every day, and we've talked about burnout. So, this is something that can help with reducing my burnout by listening for what people care about and seeing them as individuals who care deeply. And, like Stephanie was pointing out, oftentimes we have agreement where we can find that common ground, which is so important in difficult conversations, is in motivation, in what we care about, what our values are. 

I often will use the example of vaccine hesitancy.  So, when there's a parent that is hesitant to get their kid vaccinated, they often share the value of the doctor, which is they're both care about the kid's health and safety. They have different ideas about how to keep that kid healthy and safe, but that's, they have that shared value.

And as a provider, starting with that, that's a great meet and move example, right? "I hear you talking about your concerns about these vaccines and that they don't seem safe or tested. I hear you caring about your kid. I see you care deeply and you're working hard to make sure that your kid is safe and healthy, and I feel the exact same way."

And that's a great way to get in alignment, blend, mirror, uh, get on that common ground and then you can start to move in that direction. "What I know will make your kid the safest is X, Y, and Z. Can we talk about that or talk about Y," right? And that can be a nice framing for that conversation. 

Tony Passalacqua:
I know we were talking about de-escalation, but in some instances, it does feel like that there are things that you are unable to de-escalate, you know, effectively from by just saying, okay, you know, we're going to utilize this technique. Is there another technique that you could use that, that, that works good, where maybe there's a wish the patient has that you're unable to fulfill?  

Shana Merlin:
Yeah. You know, I did, uh, training for TMLT recently, um, with a local health care group, uh, around difficult patients and difficult conversations. And the first thing I had them do was kind of all write down the situations that come up again and again for them that have these difficult conversations. And well, what I have them do is I have them write them all on a piece of paper and then I have them wad them up and then I have them throw them at each other.

Stephanie Downing:
I was there. It was so fun. 

Shana Merlin:
It's very therapeutic.

Stephanie Downing:
Everybody had the best time too. It's such a great...

Shana Merlin:
It's like a somatic therapy experience where you're like, write down your trouble and wad it up and throw it around. But then we unrolled the paper and read them out and read them together as teams and shared them.

And what really struck me was I would say four out of five of the difficult conversations were patients complaining about things that the provider has zero control over. And I think that's part of what makes these conversations so difficult. You know, I think providers are often kind of seen by patients as the top of the chain, right?

You're the, the buck stops here. You're the person I can talk to address this problem. But as most providers knows, they're just a cog in a giant...health care machine. Um, and so a lot of those complaints are about billing and insurance. And wait times, and “I've scheduled this appointment for X, but I want you to help me with A, B, and C as well.”

These are all things that the provider has almost no control over, but they are something that they'll need to get addressed. The provider needs a way to address those situations, and that's where we get into this strategy of agreeing in wish form. So, say, um, you know, it's interesting because wait, wait times is something I think we all experience.

I wanted my kid to see a pediatric ophthalmologist and I, I had to wait four months before we could get in with that doctor. There's not a lot of them here in town. So, uh, when I called to make that appointment and I'm going, I mean, this was in June, they're going October, like October? Are you kidding? Uh, and what they can say is "I wish. I wish I could get you in tomorrow."

And especially if that's genuinely a shared wish, I wish we had, we could see all the patients as quickly as they need to be to be seen. You can share in that desire in an honest way. "I wish I could get you in tomorrow. The soonest I have on the calendar is October." And that's a way to quickly express empathy, compassion, get on the same page, and deal with reality.

So, this agreement and wish form actually comes from the book, "How to Talk So Kids Will Listen and, How to Listen So Kids Will Talk," which is a classic, um, uh, parenting book. But I always say if it works with toddlers, (laughs) it'll work with everybody! Because basically, difficult patients, if we have a really basic kind of model of our brain and neuroscience, difficult patients, when they're upset, we say they have flipped their lid, which means their thinking brain, their neocortex, I'm pointing to kind of the knuckles of my …  of my fist here, that, that part that gets flipped up and it's offline. And so, they're not able to do logical thinking when they are upset. So, the first thing we have to do is deal with this emotional brain. Try and calm this emotional brain down so that the prefrontal cortex, the thinking brain, can come back online.

So that's why when we reflect positive intent or agree in which form, it helps calm the brain down so they can start to get back to normal, rational problem-solving conversation. When someone is irrational, when they are upset, talking logic to them will not help. We all, we all know what that is like.

Um, so sometimes just validating, finding alignment, you know, telling your kid, I wish we could stay up all night and watch TV, but it's nine o'clock and you have to go to bed. That also keeps you from being the enemy, right? The enemy is the calendar. The enemy is the clock. The enemy is something else…the enemy is Insurance codes whatever else you can deflect on so that you can stay in a positive relationship with that person.

Tony Passalacqua:
I understand that a lot of people um have difficulties with this. I am definitely one of them. How do you know it's time to stop the conversation? Like what's a really easy way of doing that? And you were talking earlier about, you know, you put your hand on the doorknob, you're getting ready to head out. And then all of a sudden someone starts to talk to you. Any sort of tips and tricks on that?

Shana Merlin:
Yeah. And, um, And I think we're talking about, you know, these, these difficult conversations when a patient is really upset. So, we've got our strategies we just talked about of blending with them. So, sending signals of similarity. We've got our strategy of reflecting positive intent and trying to really understand what's underneath their complaint.

We've got our strategy of agreeing in wish form to really get an alignment, but those might not be enough. That might not work. And the patient is still upset. And then it's really important to be clear with yourself beforehand about what are your boundaries. Boundaries are a challenging thing. There's something I am still learning about, but what I've learned so far about boundaries is boundaries are what I'm going to do.

They're not about what you're going to do, or what I tell you to do. They're about what my plan is. So, for example, you might want to get clear with yourself, if you deal with a lot of difficult patients, of what behaviors are going to be reason for you to end the visit? Or to leave the room? So, I might say: if someone continues to raise their voice after I've asked them to lower the voice and heard them out.

If someone is physically aggressive. If someone is physical with some objects in the room. Those are signs that they're, they might be unsafe to be around. So, making sure that I'm clear about when is it time to, to leave the room or end the conversation. Some strategies can be, one, leaving the exam room door open if you feel like that person is not safe or you're, even when you're ahead of time, or opening it when you feel like that might be happening.

Another option is to say, call a timeout, um, and say, “I mean, I've asked you to calm down, I've asked you to lower your voice. I'm going to call a time out. So, we both have a little bit of time to cool back. I'm going to come back with another staff member.” Um, which is another great way to make sure you're, you stay safe. “…And we can resume this conversation, or you're going to need to make another appointment and come back.”

It’s okay if someone's upset. It's okay if they, whatever, I think they are, they can call me a name, they can whatever, but if they raise their voice, you get to decide what your boundaries are, but I'm saying this is an example of what your boundaries could be.

And then strategies. I'm going to leave the door open. I'm going to call a timeout and leave the room. I'm going to come back with another, uh, provider to help provide safety. I'm going to end the visit. I'm going to call security. These are all different like escalations that you could do depending on what it is. Now, the thing is, it's very hard. Just like you, your, your lid gets flipped, and it's hard to make those decisions in the moment. So that's why it's really important to get clear with yourself about that. So as soon as you see something that crosses your boundaries, you know it's time to respond, and you're not going, “Well, I don't know. Did I do something wrong?” Is it, uh, um…. And you can even, it's a great conversation to have with the people you work with, with your staff. So, everyone can get clear on what their boundaries are and what the practices, you know, the baseline boundaries are. Other people might have, you know, higher ones, but getting clear on that can really prevent things from getting out of hand. And also add an element of safety for the provider because they know they have a plan. They don't just have to stay in that room and take it, if things feel uncomfortable or unsafe. So, we've got strategies for if we think we can calm that person down and have a productive visit and we've got strategies for if it's time to go to plan B, which is to ensure your own safety and the patient's safety.

Tony Passalacqua:
Shana, what's one piece of information that you would like our physicians to leave with when they're dealing with difficult patients?

Shana Merlin:
Well, let me speak to the physician in you, which is to say, uh, an ounce of prevention is worth a pound of cure, right?

So, just like we want to practice, uh, preventative medicine as a best practice. Um, conflict prevention is a best practice. So, making sure that we are building relationships, that we are having positive interactions. So, the research says you want five or six positive interactions for every one negative interaction or feedback.

So, having that foundation of positivity and relationships, can help us weather the, um, the storms that are to come. Now I know that's not possible in, um, some medical situations. You're always going to be with a new patient. So that's taking that first 30 seconds, 60 seconds, 90 seconds to create that foundation of positivity so that hopefully you can have a better visit overall.

Tony Passalacqua:
Thank you, Shana, and thank you for listening to our podcast. In our next episode, we will continue to discuss how to improve patient interactions through improv communication.

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