Modules

Communicating with adolescents

Part 5

Kelsey is assessed at the Eating Disorders Clinic at the medical centre and returns home. Following the assessment, a team meeting is held to decide on the recommendations for Kelsey’s management.

  • Anne Gregory, a pediatrician specializing in adolescent eating disorders
  • Phil Hofmeyer, a pediatric psychiatrist
  • Gary Collins, a social worker
  • Mary Welbourne, a dietician
  • Ben Taylor, a pediatric resident doing a rotation in adolescent medicine
  • Jennifer Bryant, a nurse practicioner
  • Jennifer: Alright, um, our next patient is Kelsey Cournoyer, a referral from Dr. Burnside in Humphrey’s Harbour. Seen last week. Ben, you did the initial history, do you want to give us a background?

    Ben: Yeah, yeah sure. Uh, Kelsey Cournoyer. She’s a 15 year old girl, presented to her family doctor about six months ago. At that time she weighed 50 kilograms and her BMI was calculated at 19. She was having regular periods … she was having regular periods, which started at 13 years old, but she became amenorrheic about two months ago. She was in denial, seems to have features of weight phobia presentation. She was sent to a dietician, then she was sent to a family therapist but without really much response. She’s continued to slowly lose weight, has admitted to episodes of bulimic behaviour, as well. I would say her risk factors are pretty typical. She did well in school, she’s a high achiever, she restricts her diet, a mother who diets. Family conflict with a recent divorce proceeding. Um, she was also kicked off the cross-country team for not maintaining her weight.

    Anne: Okay so Ben, do we have a definite diagnosis of anorexia here?

    Ben: Yes yes. She seems to fit the criteria. She’s got a subtype of bulimia as well.

    Anne: Okay and no features of depression or any other major psychiatric disorders?

    Ben: Uh, no. Not so far.

    Anne: Any substance abuse or any evidence of metabolic or cardiac abnormality? Besides the amenorrhea.

    Ben: No no.

    Anne: Okay. Sounds good Ben.

    Jennifer: Does anyone else have any questions about the diagnosis?

    (no response)

    Jennifer: Okay. Who wants to go next?

    Gary: Well I can certainly agree with Ben on the family conflict piece. Um, yes, the parents are getting a divorce but I think the problems started before that and had an impact on Kelsey’s behaviour. She doesn’t get along with her father. And um, her mother just unfortunately doesn’t seem to be very strong emotionally, so depression probably wouldn’t surprise me with that. There’s a lot of work to be done I believe with Kelsey about her family.

    Phil: Yeah, I agree … I agree. I think we can definitely be looking into depression, certainly with the mom.

    Gary: Absolutely.

    Phil: Um, Kelsey’s eating disorder behaviours really started with typical teen rebellion and a vulnerable personality. There have been some mild features of obsessive compulsive behaviours but it’s mostly been anxiety. And she’s angry. I mean, she’s angry at everybody. She’s, there’s no signs, though, of depression in Kelsey, and certainly no signs of suicidal ideations. So at this point I wouldn’t, I don’t think we should be treating with meds.

    Gary: No, I agree. She might respond to counselling and behavioural therapy a lot better.

    Phil: Yeah.

    Gary: I think that’s probably a good way to go.

    Phil: Mhmm, yeah.

    Mary: I’ve been thinking about her diet. Now, she’s limited herself to a couple of vegetables at the moment. However, I think we can work around this to improve her caloric intake. My main concern is inpatient, or day care. Now the family’s such a mess, it might be helpful to have her admitted for a while. I don’t see the appropriate resources at home.

    Anne: Oh there may not be, but right now we have kids a lot sicker than Kelsey. And, clinically, she’s a candidate for outpatient treatment.

    Gary: Yeah, but how can we consider that though when she lives 200 kilometres away and her mother has two other children. She can’t possibly make it to daily treatments. Mind you, if she’s inpatient, now we’re taking her away from school and friends, so I mean that’s important too, isn’t it?

    Mary: Mhmm. They’ve had no success with the dietitian at home.

    Ben: So there’s no actual medical reasons for admission. But then there are no local resources. So what do you do in that situation?

    Anne: Well, any ideas?

    Jennifer: She has already seen a local social worker who does family therapy. The family doctor seems interested. Maybe they could work together to manage her there? Especially if the family dynamics are such a major factor in the case. Or what do you think Phil?

    Phil: Yeah, no I’d be happy to talk to the family physician. I think I could probably get something going there.

    Anne: Okay so we’ll look into that.

    Jennifer: Alright, our next patient is …

Commentary

Inter-professional relationships and conflict resolution

“Unfortunately, healthcare organizations have not evolved as quickly as clinical advances, and the environment of care has evolved into a difficult and complex setting filled with poor communication, unclear policies, role confusion, turf battles, and stressful interpersonal conflicts.” (Gerardi, D., 2004)

Every physician working in Canada will work in a team at some point, either during training or practice. In the past, team work was generally thought of, if at all, in terms of the other health-care workers carrying out the physician’s orders. This is no longer the case. Skills in working in inter-professional teams are now expected of all health-care professionals, including physicians. The reasons for this are obvious:

  • Health-care systems are complex.
  • No one person can a) know it all, b) do it all for the individual patient or the health of society.
  • Evidence shows that good team functioning leads to better outcomes in both patient and staff satisfaction.

Some teams are “permanent,” with a well-defined structure, personnel and roles (e.g., a stroke team in a tertiary care hospital) while others are more transient in makeup and dependent upon need (e.g., the health-care professionals a family physician may consult concerning home care for a patient).

How well teams function depends on several factors:

  • Team culture or norms: the unwritten rules, the expected behaviours of the members
  • Rules and regulations: the stated terms of function of the team (e.g., weekly meetings, a project to complete)
  • Disciplinary features: what type of members (e.g., nurses, social workers, etc.)
  • Personalities: leaders, facilitators, disrupters, collaborators, compromisers, etc.

 

Conflict resolution

  • Conflict is the recognition of difference.
  • Conflict is normal and need not involve anger nor obvious emotion.
  • Conflict can be either constructive or destructive.
  • Unresolved conflict leads to a toxic work environment.

 

Sources of conflict

Differences in:

  • Values and beliefs (culture)
  • Roles, including perceived disciplinary boundaries
  • Goals, both personal and organizational
  • Personality
  • Language, including non-verbal
  • Experience

 

Ways of thinking about conflict

Naming
Learn to recognize the signs and symptoms of conflict.

  • In yourself: tension, fear, anger, threat, guilt, etc. Be self-aware. What is your level of emotional comfort?
  • In others: body language, overt hostility, bullying, demanding, etc.

Learn to listen for understanding (hearing the other, gathering information). Mindful listening is non-judgmental, empathic, “in the moment” without thinking about your response to the perceived conflict, e.g., no assumptions.

Framing (or reframing)
Having heard, respond by acknowledging the speaker has been heard. Summarize what you have heard through paraphrasing, clarifying and checking in. This normalizes the conversation, reframes emotional or inflammatory remarks and tries to redirect the conversation to less confrontational levels.

Blaming
Try to establish a “no-blame,” more problem-solving atmosphere. Find even a small area of agreement or a common goal (finding common ground) from which a more rational dialogue can proceed.

Taming
Can an agreement or solution be reached? If so, what technique is used?

  • Avoidance
  • Appeasement
  • Collaboration
  • Compromise
  • Competitive
  • Zero-sum
  • Something else?

The naming, framing, blaming, taming is adapted from Gerardi, D. (2004).

 

Read the following articles:

Reflective exercise 6

Consider the team meeting you have just watched. They meet every week to review the patients they have assessed. The nurse practitioner, the pediatrician and the dietician are team members who work only in the Eating Disorders Centre; the others have hospital responsibilities in addition to their primary roles.

Commentary

In this scene we see the kinds of inter-professional interactions that occur every day in health care. These seemingly insignificant interactions colour and contribute to the environment of the team and organization.

The most likely answer for Question 1 is “D.” We all feel more comfortable when interacting with our own kind, whether our national culture or the people in the workplace. However, if this is a frequent behaviour, it may send a subliminal message to the other health-care workers: “We are different (better, more powerful) from you.”

Physicians often expect to be, and are, the leaders of teams. Here it would seem to be the nurse-practitioner, an indication of the current more egalitarian view of health-care teams. However, while the nurse-practitioner is certainly the administrative leader, how are decisions made? You might have chosen “B” rather than “A” in that case.

For Question 3, you might wonder why the decision about in-patient/out-patient treatment was a conflict, whereas the other choices were not. Clearly, all were in agreement with the diagnosis. The social worker and psychiatrist both felt comments on depression were within their area of expertise and in this case, they agreed, a decision accepted by the others. There was no discussion of severity; everyone deferring to the pediatrician’s expertise. The treatment issue brought up a difference in viewpoint that most members felt comfortable addressing. The problem of patient placement, admission and discharge is one that occurs frequently between physicians and other health-care professionals. One reason for that is addressed in the next question. The pediatrician dismisses the dietician’s concerns, saying other patients are “sicker.” What does “sicker” mean to each of the team members? The pediatrician indicates her meaning earlier, in the interrogation of the resident: “metabolic, cardiac abnormalities?” The dietician says: “the family is such a mess.” This demonstrates different ways of looking at a problem and, if this is not recognized, a simple disagreement may escalate into conflict.

In Question 5, the social worker tries to frame the problem by elevating the discussion to non-personal issues and presenting all sides of the issue — he is collaborating. If the dietician felt as though her expertise had been attacked (watch her non-verbal response to the pediatrician), this may have added tension. The resident summarizes by stating both sides of the issue). Note how a decision is reached. No-one challenges the pediatrician’s decision not to admit the patient. This is not a team in which decisions are made by vote. She does however ask everyone to problem-solve: “any ideas?” The nurse-practitioner, who may have the best overall view of the issues, suggests a compromise (Question 8), proposing collaboration between the local physician and the social worker.


 

Next: Conclusion

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