Physicians frequently start uncomfortable discussions in the exam room about topics that patients would rather not discuss – topics like vaccinations, firearm safety, religious objections to medical treatments, and concerns about discrimination.
While intense dialogues with patients have always been a part of medicine, some physicians feel this part of their job has become more challenging thanks to the emergence of COVID-19 in the U.S. during March 2020.
“It has changed,” El Paso infectious disease specialist Ogechika Alozie, MD, told Texas Medicine. “A lot of things have sort of evolved, and we’re a more contentious society than we were two or three years ago. It feels like patients and even clinicians are a lot more stressed and anxious. There is a kind of underlying angst. So, people are a lot less able to deal with difficult situations and conversations than they were previously.”
Dr. Alozie was part of a five-physician panel gathered by the Texas Medical Association at TexMed 2022 to discuss how physicians can address these and other potentially problematic encounters in clinical work as skillfully as possible. CME based on that panel discussion is available to members at tma.tips/CommBarriersCME.
The rise in social media and the internet also have played a role in adding to the stress physicians face when they address troublesome issues with patients, especially the topic of vaccines, Austin pediatrician Kimberly Avila Edwards, MD, another panel member, told Texas Medicine. Young patients and their parents frequently ask questions based on misinformation they have gleaned from online sources. (See “Getting Another Shot,” page 45.)
Social media “increased the speed with which myths or misinformation are perpetuated,” she said. “But even before social media, there were opportunities to have alternative frames of reference around public health.”
So, what are the best ways for physicians to work with patients through these demanding interactions? Here are a few suggestions offered by the TexMed panel.
Size up your own feelings on a controversial topic before discussing it with a patient, and prepare for skepticism, misinformation, or difficult questions.
To effectively counter myths or incorrect information, physicians must understand that the patient’s response might make them frustrated or angry. “Have self-awareness about your own strong emotional responses or triggers for when parents share their viewpoint,” Dr. Edwards said. “It’s important so that it doesn’t become a personal conflict but instead a productive conversation.”
Think about your language and try to ensure it is diplomatic and empathetic.
Effective communication is just as important for physicians as knowing how to stitch up a wound or other basic aspects of medicine, says San Antonio palliative care specialist Jason Morrow, MD. “The reason why we are obligated to invest in effective communication strategies and practice them over and over is because that’s how we get good at what we do. We don’t get [good] outcomes without communicating effectively. We can’t just mind-warp the person in front of us and make them take their medications and make them do what we think is the right thing.”
Group potentially controversial questions with ones that are less controversial.
Ten years ago, Dr. Edwards took a direct approach to gun safety, asking the parents of her patients if they had any firearms in the house. That made some parents defensive, she says. Over time, she learned to instead include questions about firearms as part of a checklist covering several important child-safety measures.
“[Each physician] needs to, from the beginning, acknowledge to parents that you’re there to partner with them, not to judge them,” she said. “For example, when it came to firearm injury prevention, [I learned] to sandwich that conversation between other preventative anticipatory guidance. ‘Does your child use a helmet to ride the bike? How do you store firearms safely in your home? Do you buckle up your child every time you get in the car?’”
Focus on preserving the relationship, not necessarily winning over the patient to your view right away. One way to do that is to ask open-ended questions such as, “What do you think?”
Recommending certain vaccines or medications can prompt patients to question their physician or even become angry, says Galveston endocrinologist Kevin McKinney, MD. In his practice, many patients resist the idea of taking insulin because family members or friends who had diabetes have died while taking that medication. To address their concerns, he uses a series of open-ended questions or statements: What do you know about insulin? Do you know someone who takes insulin? Tell me about your experiences.
“That’s something that in general brings out a flood of emotions,” Dr. McKinney said.
When patients refuse to use insulin, he provides them with trusted sources so they can do research and promises to discuss the subject with them at later visits. Sometimes, convincing them can take several visits. “You have to really take your time with a patient and remember the patient-physician relationship.”
That can be difficult to accept for results-oriented physicians, says Tyler pediatrician Valerie Smith, MD. “As physicians, we are doers. We like to accomplish things; we like to provide health and intervention. But our role here is really to defuse that situation. And then we can maybe bring them from the precontemplative to the contemplative [stage], where they’re willing to have that conversation [about the vaccine or medication].”
Even though it’s difficult, try to make time in the exam room when patients are likely to become hesitant or upset.
Encouraging patients to air their concerns about a treatment often takes time – a luxury most physicians don’t feel they have in the exam room, Dr. Morrow says. But it’s most important in those cases when patients are likely to feel judged, hesitant, stressed, angry, or bereaved. “I’m doing the best I can with the seven minutes I’ve got [with the patient],” he said. “If I’m spending that time building the relationship and not blowing the trust – like, I want to get them coming back – that’s time really, really well spent.”
When patients become personally insulting, it’s OK to acknowledge that you’re angry. But it’s still important to remain calm and professional.
Recently, Dr. Alozie walked into the intensive care unit at a hospital in El Paso, and a patient’s family members said they didn’t want a Black doctor. “I was like, ‘Well, half of us who are [in infectious disease] are Black, so you’re going to have a small problem here,” he said.
The family members laughed at that, helping Dr. Alozie start a conversation that eased the initial tension. “They eventually did fire me, and it was fine. It’s OK to get fired. There are a lot of patients out there. The important thing ... is don’t make this a contentious situation.”
Tex Med. 2022;118(6):42-43
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