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Discussing Tough Issues With Patients: Managing Unreasonable Requests, Mistakes, and Conflicts of Interest

Developed by: Thomas Gallagher, MD Assistant Professor of Medicine Washington University School of Medicine Dr. Gallagher is the lead author of a recent JAMA article on medical error disclosure that suggests that when harmful errors occur, physicians may not be communicating the information and emotional support that patients need. For more information see: Gallagher, et al. Patients’ and physicians’ attitudes regarding the disclosure of medical errors. JAMA. 2003; 289: 1001-1007.

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Format

Two half-day workshops or four two-hour modules, employing a mixture of learning strategies including didactic presentations, interactive group discussions, trigger tape reviews, and role-plays. The workshops are intended for groups of physicians ranging from 12 to 30 participants.

How Will Clinicians Benefit?

This curriculum promotes stronger doctor-patient relationships. Physicians will be prepared to respond to requests for unindicated tests or services, to address patients' concerns about managed care conflicts of interest and to talk with patients about medical errors.

Curriculum Description

This two-part workshop focuses on the skills needed to communicate effectively when disagreements arise with patients. Participants create a list of common sources of disagreements between doctors and patients, and identify the factors that make them challenging. A video trigger tape portraying an interaction between a physician and a young patient requesting an unindicated mammogram focuses on communication skills of engagement, empathy, enlistment, and education. Core skills of negotiation and conflict resolution are introduced and applied to a videotaped vignette of a patient with back pain requesting additional pain medication. The first workshop concludes with participants practicing these skills with a standardized patient.

The second workshop focuses on disclosing an error to a patient and discussing financial conflicts of interest. A communication model for resolving such situations is presented. Trigger tapes are used to stimulate group discussion on both topics. Participants practice new communication skills with a standardized patient and receive feedback on their performance.

Learning Objectives

At the conclusion of these two half-day workshops participants will be able to:

1. describe the range of common disagreements between doctors and patients, and identify factors that make some doctor-patient disagreements more challenging than others;

2. identify core communication skills for negotiation and conflict resolution;

3. describe a conceptual model for disclosing medical errors and discussing financial conflicts of interest;

4. demonstrate ability to effectively negotiate disagreements and resolve conflicts with patients.

Intended Audience

This workshop is intended for all physicians who provide clinical care.

Pilot Testing

This curriculum has been pilot tested with general internists. Standardized patients were used before and after training to assess physicians' communication skills. Standardized patients rated each physician's use of specific communication skills for resolving disagreements. Physicians completed an assessment of the impact of this training on their communication skills.

Resources Needed to Use This Curriculum

• Facilitator: The workshops should be led by physicians who have experience teaching doctor-patient communication. It is estimated that facilitators will need approximately 20-30 hours for preparation prior to the workshops.
• Standardized patients: The curriculum is designed to include a standardized patient for the role-plays, but the materials can be used even if one is not available. Facilitators using standardized patients can estimate that they will need one for approximately 11 hours (3 hours for preparation and 8 hours for workshop participation).
• Support staff: Assist with workshop logistics, publicity, registration; duplicate workshop materials, evaluation forms; summarize evaluations.
• Equipment: Facilitators will need curriculum materials, which include workbooks and videotapes. Presenters should also have access to a computer and LCD projector for the PowerPoint presentation and a VCR with monitor for the videotapes.

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