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Communication Expertise: Eliciting the Patient’s Perspective

Teaching About the Challenging Patient Visit:
Focus on Perspective
Tracy Kedian, MD
Alexander Blount, EdD
• By the end of this session participants will be able to:
– Recognize the techniques used by experienced providers in
challenging encounters.
– Identify barriers to teaching perspective taking with in a
challenging patient encounter.
– Describe 2 techniques for teaching perspective taking in a
challenging patient encounter.
– Apply the RAP strategy in a difficult patient encounter.
Chief Concern
“The chief complaint is merely the
opening to the physician-patient
Desmond, 2003
Challenging Visits
• We all have been in patient visits which:
– Hang us up
– Frustrate and anger us
– Make us think “there is no hope for this one”
• As experienced providers, we may have
more strategies for finding the kernel of
potential in the relationship with our
challenging patients
When is this difficult?
When do we find perspective taking most
Personality Disorders
Narcotic Seeking
Disability Seeking
When we cannot bridge the gap between our
perspective and theirs
What Do You Do?
Your patient is a 35 year old mother of three who
is parenting alone. She has quit her job because
she is overwhelmed by the responsibility of
caring for her children with no help and working.
She says she is not depressed but needs you to
tell the state she is disabled because she cannot
manage to work. She won’t go to counseling.
She won’t visit with the social worker in your
office. She just needs you to fill out this form.
She knows if she can just stay home from work,
she will be able to cope.
But as a teacher?
A first year resident comes to the library to
precept this visit.
Taking Care
• Of our Learner
– Reflect
– Validate
– Instruct
• Of our Patient
– Reflect
– Validate
– Negotiate
What Does Your Learner Need To Know?
The value of listening
Insight into one’s own biases
How to express a caring attitude
How to form and communicate a
consistent plan
What are the patient’s expectations?
How do you forge a relationship
while saying no?
A Story about Perspective
Once upon a time in Austria, a group of
school children came upon a large house
with an iron fence around it. In the front
yard, they could see an old man crouched
down waddling in the tall grass and
quacking like a duck. They stopped to
watch the strange sight and the crazy old
man. The information that would have
changed the meaning of the scene was
hidden by the tall grass.
Konrad Lorenz, Nobel laureate in Medicine,
was being followed by a group of ducklings.
Here he is studying imprinting in geese.
Turns out geese imprint by sight, ducks
imprint by sound. For geese to think he was
their mother, he had to be there at the
hatching. For ducks to do the same, he had
to be the first thing that said “quack” to them
after they hatched.
Perspective Taking on Sesame
“Oh, the big becomes the little
If you take it back a bit.
That’s about the size of it.
That’s about the size,
Where you put your eyes,
That’s about the size of it.”
Exercise in Perspective Taking
• Tell me a story of a case, a patient where you
were pretty sure you knew what the patient’s
situation was and then something happened
that made you understand their situation in a
completely different way.
• Let the stories get going. Many will have
one. Then get them to design a plan or a
process that will be more likely to find out the
perspective changing information earlier on.
• When we ask our learner about nonadherence, what is their perspective?
If the patient is not on board with the
plan, why doesn’t that story come
• The Classic Reasons
– Subject too sensitive
– Lack of established relationship
– Insufficient time
More Subtle Reasons
• Missed Non-Verbal Hooks and Cues
– Look of surprise/fear
– Sighs
• For many patients is it not OK to question
or give voice to doubts and fears
– They don’t want to insult you by challenging
your medical competence.
Words have different meanings
• Shock
– Circulatory collapse
– An upsetting surprise
• Depression
– Sadness and Anhedonia
– Crazy – Abnormal - Unfit
True Cultural Divide
• The Body
– Confluence of energies?
– Humors?
– Discrete organs with
biochemical communication?
Eight Questions
• What do you call your illness? What name does it have?
• What do you think has caused the illness?
• Why and when did it start?
• What do you think the illness does? How does it work?
• How severe is it? Will it have a short or long course?
• What kind of treatment do you think you should receive?
What are the most important results you hope to receive
from this treatment?
• What are the chief problems the illness has caused?
• What do you fear most about the illness?
Arthur Kleinman, MD Department of Psychiatry
Harvard Medical School
Expectations Differ
• Patient desires an “MRI to look for cancer”
– Presents with a symptom which we spend
time exploring rather than their concern and
desire for the MRI
• What are you worried about?
• Do you know anyone who has had this before?
• What do you think might be going on?
• What do you think might help us to find out?
Techniques to Teach Perspective Taking
• Where do we start?
An exercise to teach using positive
attribution to improve the doctor-patient
Ask the learner to list the attributes of patients they
don’t like to work with in one column and the
attributes of patients they do like in another column.
The list usually look like this:
• Patients we don’t like
Don’t care
Lots of issues
Drug seeking
• Patients we do like
Clear issue
Takes care of self
Involved in own care
If attribution is the most effective
form of influence (and it is):
• Think of how patients you have described in the
left hand column could be described by the
words in the right hand column.
• Practice describing the behavior that was
troublesome to you using the new adjective with
the person next to you.
• Notice how it changes the dynamic for the doctor
and patient.
A Matter of Perspective?
• Can working with the ever challenging
“chronic pain patient” be considered an
exercise in perspective taking?
The Perspective Divide
• Do:
– Learn about their illness
– Make a contribution to pain
– Make them feel
heard/attended to
• Don’t
– Make bad decisions
regarding pain
– Contribute to an addiction
– Feel/be “used”
• Do
Find a provider who listens
Get relief
Get support/paperwork
Feel validation
• Don’t
– Feel disrespected
– Leave without what you
Bridge the Gap:
Elicit their perspective
Bridge the Gap:
Elicit their perspective
• Reflect
– On their own biases/experiences
– On how the patient arrived at this perspective
• Assess
– What can actually be done and what cannot
• Plan
– Negotiate shared goals
Our Learners Can
• Elicit the patient’s perspective
• Validate their symptoms
• Affirm their commitment to helping
• Assure the patient of our concern
• Offer other possibilities
Small Groups
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