Helping physicians manage challenging patient encounters.

Helping Physicians Manage Challenging Patient Encounters Part II

Physician executives in general, and especially those who read the first part of this article, typically have a number of questions and concerns about how to get started and how to ensure the success of a program for building physician skills in dealing with challenging patients in your organization. Experience has shown the following issues and questions to be of particular concern.

Is There a Need?

The best advice for determining the need for such a program is to capitalize on your experience as a trained diagnostician. The question becomes knowing what symptoms to look for and determining whether or not they exist. So begin with a review of the problem and effects of poor physician-patient interaction discussed in the first part of this article. If those problems and issues exist in your organization, you need to do something about them. A quick review of those issues includes patient complaints about physician behavior and/ or treatment, physician burnout and lower quality of worklife, poor colleague respect and interaction, clogged organizational systems due to patients' changing physicians and repetition of work, patients/members leaving both managed care and fee-for-service settings, and an increase in legal action taken by patients against their individual and/or organizational health care providers.

Crucial information can be obtained from a number of sources. For example, you can get useful feedback from physicians, chiefs of service, "patient services" departments, patient surveys on physicians, department administrators, and the nursing staff. If you have limited time and resources for collecting data throughout your medical facility, focus on primary care departments where patient volume is greatest or where you already know there's a problem. The necessity of obtaining data from a variety of sources exists in large part because physicians are not always aware of or willing to admit to interaction difficulties with patients. In some cases, threats of or actual litigation, as well as damaged organization and professional reputations, are needed to bring a "skill difficulty" to the surface.

How to Start

This is usually of the largest hurdles for physician executives to get over, primarily because it calls upon your abilities to leverage your organizational position, raise tough issues with colleagues, and utilize effective leadership skills. It would be useful to begin by getting buy-in from your chiefs of service and staff physicians. Without that buy-in, your work will be more difficult. Discuss with them the effects of poor physician-patient interactions as well as the data you collect from the sources mentioned earlier.

Expect to meet with some resistance; your own commitment and leadership skills will determine how readily it can be overcome. Some physician executives get extra leverage in this effort by referencing the close correlation between poor patient relations and increased exposure to medical malpractice litigation.

An important way to help get a program off to a successful start is to emphasize its win-win aspects and outcomes. It's important that the program be viewed as an opportunity to enhance skills for mutually satisfying outcomes with patients. It is also important to coordinate with education chairpersons of selected department, if available, to help in scheduling and other logistical matters.

Once you have sufficient buy-in and a department or group is selected for the program, conduct one-on-one interviews with a small number of the physicians who will be participating to get a "feel" for the patient interaction and relationship issues in that department. A facilitator or consultant, as an outside party, can be helpful here and in other parts of program implementation. The interviews also provide an opportunity for the facilitator to get to know some of the participants before the program begins.

How to Keep Physicians Involved

Keeping physicians involved and motivated can be a major challenge, especially when they blame most, if not all, of their problems with patient interaction on tight schedules that the "system" imposes on them. Unfortunately, this is a fact of life for many physicians - and it should be made clear that it is not the focus of the problem at hand. If the "system" can be changed, it will. If not, all the more reason to further develop physicians' patient management skills.

Keep the program visible and actively back it. Share targeted end points and benefits with your physicians. Ensure that the program uses a mixture of learning techniques, such as direct information, discussions, and role playing. Use participants' personal experiences as examples, talk about individual successes and difficulties, and use extensive videotaping and feedback. Keep the program focused on the unique needs of each group. Use feedback from patient surveys and/or patient focus groups so that they know how they are being perceived by their patients. In short, keep the program relevant and dynamic.

Role of Participating Physicians

To get the most out of the program, participants need to be open to feedback about their styles in interacting with patients and be willing to try different approaches. Experience has shown that the most successful participants are those who are willing to take risks in giving and receiving feedback and who are willing to try new approaches in their practices.

If those who most need to enhance patient interaction skills are not really getting involved, work with the chief of service to ensure that these physicians see the full benefits of the effort and are made aware of the negative effects they are having on themselves, you, and the organization.

Individual physicians may feel that they have absolutely nothing to learn about patient interaction skills, and any attempt to make them do so would be a complete waste of time. Such physicians should be encouraged to reflect on the effects of poor physician-patient relations, as well as the benefits to themselves, their patients, and their organization of participating in the program, to see if they would be willing to at least give the program an honest try.

Chief of Service

The chief has to be major proponent of the program. He or she should be a good role model in patient interactions. It also helps for the chief to be a participant in the program for his or her department. The facilitator will rely on the chief to provide accurate and candid information about the skill levels of individual participants. Such information contributes to the facilitator's ability to ensure optimal learning for all participants.

Unfortunately, those most in need of help in developing their patient interaction skills are often not the most willing to do so. It is important, therefore, for the chief of service, and if necessary the physician executive, to speak directly with such individuals to ensure that they know how they are coming across to patients, are made aware of the impact they are having on themselves and the organization, and know the personal and organizational benefits of actively and enthusiastically taking advantage of an opportunity to enhance their skills. The personal and organizational costs of not doing so must be made clear; your goal is to convince them of both the benefits of an honest effort and the costs of not participating.

Physician Executive

The physician executive can contribute to the program's success in a number of important ways. Motivate and be supportive of your chiefs. Make the program a priority if the issues are important to you. Point out the reasons why a program can benefit individual physicians and the overall organization. Participate in your own department's program where appropriate. Physician executives need to fully utilize their leadership skills and be willing to take risks in leveraging their organizational position to motivate others.

Measuring Effectiveness

Once the program has been completed, ask participants if they feel more effective in successfully handling challenging patient encounters. Ask department administrators after the program what they see and hear regarding physician-patient interaction and how this differs from their impressions before the program. If you conducted a patient survey of physicians before the program, you'll have good baseline data to compare with a follow up survey. Also get feedback from the chiefs about their perception of participants' ability to handle challenging patient encounters. Another way to measure the effectiveness of your program is to look at the level of formal patient complaints on file in your organization. Complaints usually address only major problems, but you will still get an indication of any degree of improvement, especially about physicians with a history of patient interaction difficulties.

Follow Up

There are a number of steps you can take to help ensure long-term success. Have formal and/or informal discussions to talk about specific challenging patient encounters in selected departments. In addition, you could identify those physicians who want or require additional efforts to more fully develop effective skills. It is also useful to have your consultant/facilitator revisit once or twice a year for a concentrated effort with new professional medical staff and/or for a review with individuals needing extra support.

If you've used an outside consultant /facilitator in the implementation of the program, it helps to develop that expertise within your own organization for ongoing success. One or two physicians in each department that has gone through the program can become an in-house resource in facilitating challenging patient encounter discussions on a more regular basis. Another step that will keep the goal of good physician-patient relations relatively fresh is a twice-a-year patient survey of physicians. This provides regular and valuable feedback to physicians about how they're being perceived by their patients so that they do not rely solely on their own perceptions.

Participants in these programs have sometimes expressed a desire to use a similar format for the improvement of physician-to-physician communication. Where such a follow-up effort has occurred, participants are generally more ready to open up and share concerns about their working relationships and overall interactions with one another. Once again, the use of a skilled and objective facilitator is important for establishing a safe and constructive forum for the discussions.

THE AUTHOR

Kurt M. Shusterich, PhD, who has worked with the Southern California Kaiser Permanente Health Care Program for over five years, is a health care management consultant in Pacific Palisades, Calif.