MS. SMITH is a 35-year-old admitted overnight with the very painful skin condition hidradenitis suppurativa. You’re meeting her for the first time, and you’ve already been warned by nursing that the patient is very challenging. She is asking for pain medications and insisting that nothing she’s been given has helped her pain, crying as she explains that her pain level is a 10 out of 10. She also mentions that IV Dilaudid has worked well in the past to treat her pain.
You’re probably immediately thinking that Ms. Smith sounds like a drug-seeking patient—and you are sure that if you give her anything but Dilaudid, you’re going to have a fight on your hands. You don’t want to argue about the best way to manage the patient’s pain, but you also don’t want to cave and give a powerful narcotic that the patient may or may not need. So what do you do?
According to hospitalist Diane Sliwka, MD, professor of medicine at the University of California, San Francisco (UCSF), you can avoid a fight with the patient and make sure you’re providing the appropriate therapy by asking a few well-placed questions. At last fall’s UCSF management of the hospitalized patient conference, Dr. Sliwka suggested that when caring for patients like Ms. Smith, hospitalists first ask themselves a few questions about their own emotions, then try to gather more information before jumping to conclusions that may serve to only escalate potential—and unnecessary—conflict.
Don’t jump to conclusions
Dr. Sliwka, who is director of UCSF’s Center for Enhancement of Communication in Healthcare, said that conflicts with patients like Ms. Smith are especially hard on hospitalists, who typically have no former relationship with patients to fall back on.
“We often think ignoring the issue is less confrontational, but that approach can create just as much chaos.”
~ Diane Sliwka, MD
University of California, San Francisco
“We’re seeing patients at their very worst,” she explained. “So when something difficult crops up, we don’t have a leg to stand on or decades of good experiences as their primary care physician.” When hospitalists run into conflict, “we’re automatically the evil people working for the hospital who don’t know the patient. We haven’t established a relationship where people trust us, so we need to develop that very quickly.”
Dr. Sliwka urged hospitalists walking into situations where conflict is likely to be careful about jumping to conclusions. “Your assumptions are really important,” she said. “Try as much as possible to not come to conclusions beforehand, despite your history of experiences with patients who fit this persona.”
She also warned hospitalists to not shy away from conversations that can be difficult. “We often think that getting into a fight is undesirable, and that quietly going away and ignoring the issue is less confrontational, less loud,” Dr. Sliwka noted. “But I’ve found that this approach can create just as much chaos. When we have constructive conversations about conflict, we often end up in a more positive place with people because we’ve been through something together.”
Personal awareness
So how do you deal with a patient who you think might be drug-seeking? Before making any decisions, Dr. Sliwka told audience members to start by taking their own emotional temperature.
“How are you feeling when you hear that a patient is challenging?” she asked. “What can you do to make sure you stay open to the conversation with the patient?” Because it’s hard to think rationally when you’re having an emotional response, start by identifying the emotions you may be feeling.
“I’m probably feeling really frustrated because I don’t have a lot of time,” Dr. Sliwka said. Naming your own current emotional state “allows you to shift back into a more cognitive place where you’re thinking about the problem, as opposed to being wrapped up in an emotional response.”
Dr. Sliwka said she also tries to understand factors that trigger her own emotional response.
“I personally get triggered when patients seem very entitled, when they expect that you’re going to do something for them because everyone does things for them,” she noted. Other physicians may feel put off or overwhelmed when patients are crying or in acute pain. “When you become aware of what gets you going, you can then step away and take a mental timeout. Look at the situation like you’re watching a movie, not as a person who’s in the movie being wrapped up in the situation.”
Ladder of inference
If you don’t take a step back, you risk building assumptions based on cherry-picked data— what Dr. Sliwka referred to as climbing a “ladder of inference” — that can quickly escalate conflict. That concept was developed by a former Harvard Business School professor Chris Argyris, PhD.
“When we’re presented with data in any given situation,” she said, “we tend to select data. We don’t view all data as equal. When we collect data, we make assumptions, draw conclusions and take actions based on only a few data points.”
By way of illustration, she mentioned this example: A friend named Michelle was waiting for her husband to get home from work on a Friday night. Michelle had received a promotion at work, and the couple planned to go out for drinks to celebrate. When her husband didn’t come home on time, Michelle (wrongfully, it turned out) assumed that he had chosen instead to go out with his work colleagues, something he’d occasionally do.
By selecting that single piece of data about her husband (that he sometimes went out with coworkers on Fridays), Michelle had begun to climb the ladder of inference. She quickly concluded, for instance, that her husband either didn’t value their relationship or care about her promotion. But when her husband finally got home, it turned out that he had been stuck in traffic and his phone had died.
“You can see what happens when you climb the ladder and start acting on assumptions without first checking in with the other person,” Dr. Sliwka said. “That can quickly lead to misguided judgments that create problems because others feel judged by us when we don’t give them a chance to explain.” When people feel they are not being heard and relationships breaks down, “that can have very insidious and long-term consequences.”
Climbing down the ladder
Instead, Dr. Sliwka suggested taking a step back and making sure any assumptions you’re making are accurate. “Start with a blank slate,” she said. “Walk in as though you’ve never seen this problem before. Even though the nurse just told you this patient is challenging, you’re going to let that go.”
Instead, try to view the patient in a positive light. “If you’re going to make assumptions up the ladder of inference, you’re better off to making positive ones. Try to assume the best of people when you don’t know them and give them the benefit of the doubt.”
One tip: “Ask yourself, ‘Why would a reasonable person behave this way? Why would this patient say that nobody is treating her pain and that she needs Dilaudid?’ ” By choosing to approach potential conflict with curiosity, Dr. Sliwka added, “saying, ‘I want to understand what is happening for you, tell me because I’m here listening, I’m present with you,’ changes the tone every time.”
It’s also good to remember that people who use opioids feel stigmatized. If you can instead approach a conversation with them “with positivity and trust and make people feel like you believe them, patients can respond very differently—and positively in kind.”
Interests vs. positions
Another tip: Don’t head into a potential conflict by taking a position, which can automatically put you on a crash course with your patient. Instead, Dr. Sliwka suggested that hospitalists try asking patients about their motivations.
“Taking a position can be polarizing,” she said, “but asking about motivations or patients’ interest in a given situation can open up a lot of opportunity for discussion—and room for compromise.”
To help understand patients’ perspectives, Dr. Sliwka suggested asking “ICE” questions, an acronym that stands for ideas, concerns and expectations. What ideas do they have about why this pain regimen isn’t working? What concerns them the most? As for expectations: What are they hoping for with pain control?
When talking to Ms. Smith, for example, you might explain that you can’t give her any Dilaudid—or any more, if she’s already receiving it. “But you might ask her to tell you about her pain and how the medication is working,” Dr. Sliwka said. “You may find out the Dilaudid is running out after three hours, even though it’s being given every six hours.” Or you may find out that at home, Ms. Smith is taking a much higher Dilaudid dose and that she’s now suffering more from withdrawal than pain.
“You’ll find out all kinds of things that people are thinking about,” Dr. Sliwka said. “You might learn they’re just really scared, and it might not be about the pain at all.”
Taking this approach can be helpful when it comes to tapering down opioids. “You can explain that a patient’s pain control seems better with a new regimen—and that the next day, you’ll need to begin transitioning to using only the pill form of Dilaudid,” she said. ” ‘What thoughts do you have about how you’d like to ramp down IV dosing? How would you like to decrease the frequency? When are you ready to start?’ Let people know your time frame, that by 48 hours from now you want the patient to be taking pills.” Patients not only may be amenable, but “they may give you ideas about how to do it.”
Edward Doyle is Editor of Today’s Hospitalist.
Then there’s conflict with colleagues …
WHEN NAVIGATING CONFLICT, hospitalist Diane Sliwka, MD, urges physicians to give people the benefit of the doubt. Don’t pass judgment until you have all the facts, and try to view the other person’s motivations in a positive light. Such strategies can help bring clarity to otherwise difficult situations.
But when it comes to conflicts with certain colleagues—people with whom you have a long history of problems—that advice may not necessarily apply. “It can be tough when you have a long line of repeated offenses,” Dr. Sliwka told a group of hospitalists at last fall’s UCSF management of the hospitalized patient conference.
While Dr. Sliwka tries to give people the benefit of the doubt, “some people will prove you wrong,” she said. “They won’t always be coming at you with the best intentions or with good reasons for doing what they do.”
That requires a different approach. “You might have a conversation that gives feedback about how certain actions have an impact on you and how they affect your work, and when things need to change.”
This strategy may be a bit more confrontational than the one she prescribes for patient conflicts that crop up. But it may be necessary to drill down on the issues that are the real problem.
As with all conflicts, Dr. Sliwka urged physicians to be careful about making assumptions about workplace conflicts without good data. “Because this person doesn’t respond to your e-mails, you think she must not care about the relationship or like working with you on this project. That can create a lot of problems for you when you don’t check in with the people in question.”
And coming to a conclusion without talking to the other person can make the situation worse. “Others feel judged by us, because we haven’t given them a chance to explain what happened, and they feel not heard,” Dr. Sliwka said.
But sometimes enough is enough, and there are situations that cross the line. “What if somebody is bullying you or actually harassing you? Those situations require different approaches than what we’re talking about.”
One tactic is to use what she called feedback mode: “Say something like ‘Here’s what I’m seeing happening.’ You’re giving people feedback on how their behavior is affecting you. I would use this type of conversation to address situations that keep recurring and are really causing problems.”
The good news is that by addressing problems head-on, you may be able to turn a relationship that’s full of anger into something stronger. “That feeling of ineffectiveness, frustration, and turmoil and angst that we carry around can be turned around by skillful communication,” she explained.
Dr. Sliwka also acknowledged that while this approach can help resolve many long-term conflicts, it won’t work in every situation. “You’re going to have differences that you can’t reconcile,” she pointed out. But “letting people know what’s going on with you can elucidate a lot of the things you’re in conflict with them over.”
Published in the March 2020 issue of Today’s Hospitalist
