Managing Difficult Conversations

1. Managing Difficult Conversations Social Psychology 201 for ED’s Stephen H. Anderson M.D., FACEP President, WA State Chapter ACEP September 24, 2012 Presented at WSHA Safe Table - ER is for Emergencies 1

2. Seven Conversations • Grieving 1) Someone is dying/ died. 2) Your child is going to have a bad outcome. Presented at WSHA Safe Table - ER is for Emergencies 2

3. Seven Conversations • Sheriff/ Parenting 3) I think you have a drug/ alcohol problem. 4) I think you’re here too often. 5) Why are you REALLY here? Presented at WSHA Safe Table - ER is for Emergencies 3

4. Seven Conversations • Colleague/ Political 6) I disagree with you as a colleague. 7) That’s not how administration foresees it. Presented at WSHA Safe Table - ER is for Emergencies 4

5. Overlying Principles • There are rules/ givens. • You have to listen. Presented at WSHA Safe Table - ER is for Emergencies 5

6. Principles • Know your allies… • Know their allies. • Find your support… • Find their support. Presented at WSHA Safe Table - ER is for Emergencies 6

7. Principles • Believe in WIN- WIN. • To thine own self be true. • Document. Presented at WSHA Safe Table - ER is for Emergencies 7

8. There Are Rules/ Givens • Some are hard… • Some are soft. • Some are “ours”… • Some are “only mine”. Presented at WSHA Safe Table - ER is for Emergencies 8

9. There Are Rules/ Givens The Key Ownership Presented at WSHA Safe Table - ER is for Emergencies 9

10. You Have To Listen • Conversations are two way. • Find out their goals. • Find out their fears. • Give them enough rope… Presented at WSHA Safe Table - ER is for Emergencies 10

11. Know Your Allies… • Rally your troops. • Build your allies. Do you want to be an expert witness? Presented at WSHA Safe Table - ER is for Emergencies 11

12. Know Their Allies… • Introductions for EVERYONE. • Note “Alleged Allies” not present Acknowledge as appropriate. Presented at WSHA Safe Table - ER is for Emergencies 12

13. Find Your SupportFind Their Support • Key to the Grieving Conversation • If you’re headed to war… take them with you. Presented at WSHA Safe Table - ER is for Emergencies 13

14. Believe In WIN-WIN • Try never to define your win, by their loss. Presented at WSHA Safe Table - ER is for Emergencies 14

15. Believe In WIN-WIN • Listen • Repeat back • Work toward a common goal • Compromise? Presented at WSHA Safe Table - ER is for Emergencies 15

16. To Thine Own Self Be True • Never Lie • Never Lie • Never LIE! Presented at WSHA Safe Table - ER is for Emergencies 16

17. These Are DifficultStressfulConversations! • Debrief • Avoid being the one with the disease Presented at WSHA Safe Table - ER is for Emergencies 17

18. Not All ConversationsWill End WIN-WIN • Some won’t end. • Have an exit strategy. Presented at WSHA Safe Table - ER is for Emergencies 18

19. Document • ANY conversation with “potential” is worth documenting. • Two documented views are better then one. • “They” know how to document too! Presented at WSHA Safe Table - ER is for Emergencies 19

20. Someone Is Dying/ Died • It’s someone’s job, take ownership. • Find your support • Find their support #1 Most Important Presented at WSHA Safe Table - ER is for Emergencies 20

21. Someone Died • Focus on the closest, talk to everyone • Listen • Account for beliefs/ cultures • Physical contact, the “healing touch”. Presented at WSHA Safe Table - ER is for Emergencies 21

22. Someone DiedGoals To Express 1) We did everything appropriate. 2) Address pain & suffering. 3) “Now we are here to help you… & others.” Presented at WSHA Safe Table - ER is for Emergencies 22

23. Someone Is Dying Don’t lie Don’t steal hope Be realistic Presented at WSHA Safe Table - ER is for Emergencies 23

24. Someone Is Dying Listen ( Is the PATIENT speaking through an advanced directive?) Find your support/ Find their support Start the conversation Geography/ proximity Presented at WSHA Safe Table - ER is for Emergencies 24

25. Your Child Is Going To Have A Bad Outcome • Find your support/ Find their support • Don’t steal hope • Be honest “in that moment” Presented at WSHA Safe Table - ER is for Emergencies 25

26. Bad Outcome Negative attitude leads to negative outcomes… Blame is for later Presented at WSHA Safe Table - ER is for Emergencies 26

27. Bad Outcome • Child’s safety first • When do you include the child in the conversation? Presented at WSHA Safe Table - ER is for Emergencies 27

28. I Think You Have A Drug/ Alcohol Problem Society/ Legislature/ Peers now tell us We MUST have these conversations THIS is the pivotal time. Presented at WSHA Safe Table - ER is for Emergencies 28

29. Drug & Alcohol ProblemsThe Principles • There are rules/ guidelines • Listen first • Your allies/ their allies “Their support” might turn out to be your best ally!” • WIN-WIN • Be true to yourself Presented at WSHA Safe Table - ER is for Emergencies 29

30. Drug & AlcoholTools to Help • Old Records • EDIE • WA state Prescription Monitoring Program Educate patients that these exist Presented at WSHA Safe Table - ER is for Emergencies 30

31. I Think You’re Here Too Often PRC Patient’s Requiring Co-ordination Presented at WSHA Safe Table - ER is for Emergencies 31

32. You’re Here Too OftenNew WA Hospital Requirements • Identify PRC clients upfront • Notify their PCP of visit • Discharge patient with instructions along: “the right patient-to the right place-at the right time” Shouldn’t be a punitive discussion Presented at WSHA Safe Table - ER is for Emergencies 32

33. You’re Here Too Often “You’re Unique, but…” Educate “The Econ Lecture” Presented at WSHA Safe Table - ER is for Emergencies 33

34. Why Are You REALLY Here? • Constructively focuses the scatter. • Gives an opening to the REAL difficult conversation. NEVER demean the answer Presented at WSHA Safe Table - ER is for Emergencies 34

35. I Disagree With YouAs A Colleague Fatal Error VS. Difference Of Opinion Fatal Error Success comes through education first Presented at WSHA Safe Table - ER is for Emergencies 35

36. Difference of Opinion With A Colleague Praise in Public/ Debate in Private Ask yourself going in: What’s my goal? Am I a team builder? How can I make this WIN-WIN? Focus on the patient Presented at WSHA Safe Table - ER is for Emergencies 36

37. Difference Of Opinion With A Colleague • Listen • Agree on the easy, Work toward the hard. • Set the stage for “The Next Time” • If necessary, use the chain of command. Presented at WSHA Safe Table - ER is for Emergencies 37

38. That’s Not How Administration Foresees It 38 Presented at WSHA Safe Table - ER is for Emergencies

39. Administration’s Viewpoint The Golden Rule • Do unto others, as you would have others do unto you. • Those with the gold, make the rules. Every pathway has an economic angle. Presented at WSHA Safe Table - ER is for Emergencies 39

40. Administration’s Viewpoint What brought you to the table? • What do they need from you? • What motivates you? Principles Priorities Presented at WSHA Safe Table - ER is for Emergencies 40

41. Administration’s Viewpoint Great leaders get input from great followers Presented at WSHA Safe Table - ER is for Emergencies 41

42. Managing Difficult Conversations • There are rules/ givens • You have to listen • Know your allies/ know their allies Find your support/ find their support • Believe in WIN-WIN • To thine own self be true • Document Presented at WSHA Safe Table - ER is for Emergencies 42