Modules

Selected communication challenges

This section is comprised of situations that many physicians find difficult. There are two versions of most of the interviews. They do not illustrate a right and/or wrong way of interviewing, but are intended to illustrate responses that range from physician-centred to more patient-centred approaches. The differences might seem subtle but as you will observe, you can have a marked influence on the clinical outcome of the interview.

The communication challenges interview examples include:

  • Sexual history
  • Interprofessional conflict
  • Boundary crossing
  • Ethical dilemmas
  • Cross-cultural interviewing
  • Breaking bad news

Sexual history

MCC role objectives

Communicator

  • Use appropriate non-verbal communication (positioning, posture, facial expression) (1.2)
  • Elicit patient information through active listening and the appropriate use of open and closed questions, as well as using clear language appropriate to the patient’s understanding (2.1)
  • Identify the personal and cultural context of the patient, and the manner in which it may influence the patient’s choices (3.2)
  • Provide information using clear language appropriate to the patient’s understanding, checking for understanding, and clarifying if necessary (3.3)
  • Effectively present information about clinical encounters and management plans to patients and their families (5.1)

 

Professional

  • Practice the profession with due regard for basic human rights (the right to privacy, freedom from discrimination, autonomy) (3.6)

Introduction

This is a topic that makes many physicians uncomfortable and is one of the most culturally laden aspects of any society. Sexual customs and taboos are ingrained in us and some people respond to “different” sexual practices and orientations with strong emotion. Physicians raised in more conservative cultures may have difficulty dealing with topics like abortion, homosexuality or sexual violence.

While we might adapt our actions to the local context, attitudes often remain because they form an important part of an individual’s moral approach to life. Does this mean that, as physicians, we have to give up our beliefs and adapt to the beliefs of others? How can we find common ground if our beliefs are at odds with those of our patients? To address these issues, read the “Attitudes” section of the Observation Guide. You can also review the self-assessment exercises in Module 2. Honesty, self-awareness and genuine respect for people help the physician to be non-judgmental and to be patient-centred when discussing topics relating to sexuality.

There are two basic types of sexual history. One is part of a general interview and consists primarily of screening questions. This is usually done during the first visit with a new patient and can consist of a form or checklist to fill out. Even if a form is completed, it is wise to explore the topic briefly to make sure there are no issues the patient might want to bring up. The second type of sexual history is when a patient comes with a sexual problem or the physician has reason to explore this topic because of a related health issue. In these cases, the context is quite different and the amount of information obtained is usually greater and specific to the problem.

Regardless of the situation, the major barriers involved for the physician are likely to be:

  • Discomfort with the topic
  • Difficulty in finding appropriate words and phrases to use in the conversation
  • Making assumptions about sexual orientation, level of activity, practices or attitudes
  • Focusing on the sexual orientation of the patient rather than risk behaviour
  • Difficulty in remaining non-judgmental

Such barriers make it more difficult for the physician to explore the topic and for patients to respond completely and honestly. There are three interviews that illustrate a general approach to obtaining the sexual history of a new male or female patient. The physician uses some of the words and phrases that might be useful in these situations. The interview with the woman has two versions — one is a basic screening and the other is more detailed. The basic interview with the male patient is also more detailed and is related to Module 1. There are two other examples of patients presenting with a sexual problem as the main complaint. Each has two versions, reflecting both physician-centred and patient-centred behaviours.

Sexual history, female

  • Version 1

  • Physician: Okay, I think we’ve covered most what we need to discuss together. I know your past health, your current situation, we’ve talked about your work and family. Do you have anything else you’d like to talk about with regard to those areas?

    Patient: No, I think you’ve covered it all.

    Physician: Now to complete your personal history I need to ask you a few questions about sexual activity if you don’t mind. I know you’ve filled out the patient questionnaire, but that doesn’t always cover it. So can we go over a few points?

    Patient: Okay.

    Physician: Great, first are you currently sexually active?

    Patient: Yes.

    Physician: Could you tell me a little bit about your partner, or partners, men or women or both.

    Patient: Just one partner now, my husband.

    Physician: Okay, you said now, have you had other partners in the past?

    Patient: Before we got married I had several boyfriends, I had sex with some of them but that was a long time ago.

    Physician: Okay. Now you told me earlier that you’re on the pill, do you also use condoms?

    Patient: No.

    Physician: Have you ever had any infections, unusual discharges or pain in your pelvic area? Or, have you been treated for sexually transmitted infections?

    Patient: No, nothing like that.

    Physician: Okay. Alright, thank you, I think those are all the questions I have for you at this time. Do you have any questions about what I’ve asked you or any other questions?

    Patient: No, I can’t think of any.

    Physician: Good. Thank you.

    Patient: Thank you.

  • Version 2

  • Physician: Alright, I think we’ve covered most of what we need to talk about. I know your past health and your current situation and we’ve talked a little about your work and family. Is there anything else you’d like to add about those topics?

    Patient: No, I think you’ve covered it all.

    Physician: To complete your personal history I do need to ask you a few questions about sexual activity if you don’t mind. I know you filled out the patient questionnaire, but that doesn’t always cover everything. So there are a few points I’d like to go over, is that okay with you?

    Patient: Okay.

    Physician: First, are you currently sexually active.

    Patient: Oh, yes.

    Physician: And could you tell me a little bit about your partner or partners? Whether men or women, or both?

    Patient: Just one partner now.

    Physician: And you’ve had previous partners in the past?

    Patient: Oh, I’ve had several girlfriends in the past, but Jan and I have been together for a long time now.

    Physician: So, you are lesbian, that’s right?

    Patient: Yes.

    Physician: Okay. And have you had relationships with men previously?

    Patient: No.

    Physician: No, okay. Now, with anyone who is sexually active I’ll ask about practices and precautions. Are you or your partner seeing anyone else at the moment?

    Patient: No, we’re quite faithful to each other.

    Physician: And do you practice safer sex? Um, which might mean protection during oral sex or making sure toys are clean.

    Patient: No, we know about all that and we’re very careful.

    Physician: Now have you ever had any infections? Unusual discharges, pain in your pelvic area or have you ever been treated for sexually transmitted infections?

    Patient: No nothing, nothing like that.

    Physician: Okay, great, those all the questions I have to ask right now. Do you have any questions about what we’ve talked about, or do you have any other questions of your own right now.

    Patient: No, can’t think of any.

    Physician: Thank you.

    Patient: Thank you.

Commentary on: Sexual history, female, versions 1 and 2

Note how the physician bridges to the sexual history part of this new patient interview. The timing is such that he already knows quite a bit about the patient and can adjust his vocabulary and approach to how the patient might be expected to respond. The differences in age and gender between physician and patient, which could prove embarrassing, are handled sensitively. The physician is matter of fact and professional, indicating that this is routine for all patients, but still asks permission. In version 2, he responds to the patient’s cue, noticing there is some discomfort with the topic and explains why he needs the information. The physician thoughtfully uses neutral terms in asking his screening questions. For instance, he inquires about activity with men or women instead of asking: “Do you ever have homosexual relations?” As well, he asks “Do you use condoms?” and not “Do you practice safe sex?”

The important topics of sexual activity, contraception and sexually transmitted infections are screened in just a few questions. A final open question: “Do you have any concerns you want to talk about?” allows the patient to bring up issues of importance to her, such as sexual function. Note that in version 2, the sexual orientation changes some of the questions, but the physician is not judgmental and probes only to determine safer sex practices.

Sexual history, male

  • Physician: Okay, I think we’ve covered most of what we need to talk about. I know a bit about your past health and your current situation and we’ve talked a little about your work and family. Is there anything else about those topics that you’d like to discuss?

    Patient: No, I don’t think so, it’s all good.

    Physician: To complete your personal history I do need to ask you a few questions about sexual activity if you don’t mind. I know you filled out the patient questionnaire, but sometimes that doesn’t always cover everything. So is it alright if we go over a few points?

    Patient: Um, yeah, I guess so, yeah.

    Physician: Now I can see that makes you a little uncomfortable, um, that’s okay, it’s alright, we do need to ask these questions of all our patients, it’s important for your health and for our ability to care for you as your physicians, but um, if you’d rather discuss …

    Patient: You know what, it’s okay, we can talk about it.

    Physician: Okay. First, are you currently sexually active?

    Patient: Yes.

    Physician: And can you tell me a little bit about your partner or partners? Men or women, or both?

    Patient: I, well, that depends.

    Physician: That depends …

    Patient: Yep.

    Physician: Do you mean that you have both men and women partners?

    Patient: Well, okay, just for the record here, I’m faithful, to my wife, so I don’t sleep with other women, ah, and I love my son, my family is very important to me.

    Physician: So let me get this straight, that your wife is your only female partner.

    Patient: My wife is my only female partner.

    Physician: But you are having relations with other men? Is that right?

    Patient: Yep.

    Physician: Thank you for telling me, I appreciate your honesty. Now in the past have you had multiple partners?

    Patient: (nods)

    Physician: And have you used protection? Used condoms?

    Patient: Ah, um, sometimes.

    Physician: And do you engage in oral or anal sex?

    Patient: Yes.

    Physician: And with your wife, are you using condoms right now?

    Patient: Ah, no, we’re trying to have another child.

    Physician: I see.

Commentary on: Sexual history, male

In the interview with the male patient, the physician recognizes and acknowledges the patient’s non-verbal cues of discomfort with the topic. He gathers more information in this case since it might become important in later management (see Module 1). He uses more closed-ended questions, possibly because he feels that the patient might not wish to elaborate, at least in this initial interview. Note that he also chooses not to pursue at this time the obvious health implications of the patient’s sexual activity. While it is important to establish trust and confidence in the relationship, the physician must also consider and respond to the risks involved for the patient and others.

A sexual complaint

MCC role objectives

Communicator

  • Use appropriate non-verbal communication (positioning, posture, facial expression) (1.2)
  • Elicit patient information through active listening and the appropriate use of open and closed questions, as well as using clear language appropriate to the patient’s understanding (2.1)
  • Identify the personal and cultural context of the patient, and the manner in which it may influence the patient’s choices (3.2)
  • Provide information using clear language appropriate to the patient’s understanding, checking for understanding, and clarifying if necessary (3.3)
  • Effectively present information about clinical encounters and management plans to patients and their families (5.1)

 

Professional

  • Practice the profession with due regard for basic human rights (the right to privacy, freedom from discrimination, autonomy) (3.6)

The following interviews illustrate ways of dealing with patients, male and female, presenting with a sexual complaint. They also illustrate the impact that patient personality can have on an interview. Each has two versions.

A sexual complaint, female, version 1

  • Physician: Hello.

    Patient: Hi.

    Physician: You’re Patty French?

    Patient: Yeah.

    Physician: Hello, I’m Dr. Novak, nice to meet you.

    Patient: You too.

    Physician: Is it your first time in the clinic?

    Patient: Yeah.

    Physician: Okay, and how would you like me to address you, is Patty okay?

    Patient: Oh yeah, Patty’s fine.

    Physician: Okay so what brings you in today?

    Patient: I, I think I might be pregnant.

    Physician: You think you might be pregnant. And what makes you think that?

    Patient: Well, we had sex and you know, we didn’t use anything.

    Physician: Okay and when did this occur?

    Patient: Oh it was like 18 hours ago.

    Physician: Eighteen hours ago, okay. Okay, so you had unprotected sex 18 hours ago, can I assume then that you’re not on any sort of birth control?

    Patient: Oh yeah, no I’m not.

    Physician: Were you using anything, contraceptive foam, anything like that?

    Patient: No.

    Physician: Okay, and in terms of having sex, 18 hours ago, is this the first time?

    Patient: No, I mean, we’ve had sex before but, yeah, we didn’t use anything, this time.

    Physician: Okay, so previously when you’ve had sex, you have used a condom?

    Patient: Yeah.

    Physician: Okay, alright, and is this a new relationship?

    Patient: Um I guess kind of, we’ve been together, you know, four months.

    Physician: Four months, okay. And you’ve had sex in the last four months, and just last night you didn’t use a condom. Previously you did use a condom.

    Patient: Yeah.

    Physician: Okay and have you ever been on birth control in the past?

    Patient: No.

    Physician: Okay. So you know the thing about using a condom, is that it can prevent pregnancy but also sexually transmitted diseases.

    Patient: Mhmm.

    Physician: Okay. Have you ever had a problem that way?

    Patient: No.

    Physician: No. Okay alright, well do you have any ideas about where you’d like to go with this?

    Patient: Um, I mean I’ve heard of something called the morning-after pill.

    Physician: The morning-after pill. Okay so you have heard of that. And is that what you’re interested in?

    Patient: Yeah, I mean like if it’s not too late, maybe.

    Physician: Okay the thing about the morning after pill is that it’s good within 72 hours …

    Patient: Okay.

    Physician: So you’re well within the time limit, so you can relax about that. Okay and maybe I need to ask you a few more questions about your health in general, just to make sure that the morning-after pill is really good for you.

    Patient: Okay.

    Physician: Are you taking any medications right now?

Commentary on: A sexual complaint, female, version 1

In this interview with a young woman, the physician utilizes a number of techniques. Can you find examples of summarizing, paraphrasing and gathering information? What kind of questioning style does he have? How would you describe his attitude toward the patient? Note how his body language and tone are gentler than with Jack. He is adjusting to his patient and trying to put her at ease. However, how would you assess his adjusting to the patient’s understanding, his gathering of information and making assumptions? These three areas are especially important in exploring the patient’s sexual practices. Is there anything in this interview that you might have done differently or any information that you would have tried to obtain?

A sexual complaint, female, version 2

  • Physician: Hello.

    Patient: Hi.

    Physician: You’re Patty French?

    Patient: Yeah.

    Physician: Okay, my name’s Dr. Novak, nice to meet you.

    Patient: You too.

    Physician: How would you like me to address you, is Patty okay?

    Patient: Oh yeah, Patty’s fine.

    Physician: Okay, so Patty, what brings you into the office today?

    Patient: Um well, I think I might be pregnant.

    Physician: You think you might be pregnant, okay alright. Um, how do you feel about that?

    Patient: Um well it’s not really, what I want, you know what I mean. I don’t really want to have kids right now.

    Physician: So can you tell me what happened?

    Patient: Um, well like we didn’t use anything, you know, so I’m just worried that maybe I’m pregnant.

    Physician: So you didn’t use anything …

    Patient: No.

    Physician: Meaning that you had unprotected sex, you didn’t use a condom?

    Patient: Yeah.

    Physician: Are you on any sort of birth control at all?

    Patient: No.

    Physician: No okay. So when did this happen?

    Patient: It was like 18 hours ago.

    Physician: Eighteen hours ago. So last night some time. Okay. And, is this a new partner, a regular partner?

    Patient: Um I don’t know, like four months.

    Physician: So you’ve been seeing him?

    Patient: Yeah.

    Physician: For four months.

    Patient: Mhmm.

    Physician: And have you had sex in the four months, or was this the first time?

    Patient: Yeah, we’ve had sex before.

    Physician: Okay. And were you using protection before?

    Patient: Yeah like generally we, you know, used condoms.

    Physician: You used condoms. So last night you didn’t use a condom, is there any reason for that?

    Patient: Yeah well, you know, it was just different.

    Physician: It was different. What do you mean it was different?

    Patient: Well, um, like he was behind me?

    Physician: Okay so when you say that he was behind you, do you mean, did you have, was it vaginal sex behind you or was it anal sex that we’re talking about here?

    Patient: Um, it was anal.

    Physician: Anal sex. Okay and was this the first time you’ve had anal sex?

    Patient: Yeah.

    Physician: Okay. Alright. And is this the reason why you didn’t wear the condom?

    Patient: Yeah like I didn’t, you know, I didn’t really think about it, you know?

    Physician: So what concerns you about having anal sex and being pregnant?

    Patient: Well like I said I don’t really want to have a kid right now.

    Physician: Okay. So do you think that you can get pregnant through anal sex, is that … ?

    Patient: Well, I mean, yeah I don’t know.

    Physician: Okay.

    Patient: Can’t you?

    Physician: Um well it’s highly unlikely. After you had the anal sex, did your boyfriend perform vaginal sex?

    Patient: No.

    Physician: No, okay so strictly anal sex, no vaginal penetration after that. Alright so I think the good news is, in all likelihood you’re not going to become pregnant from having anal sex.

    Patient: Oh.

    Physician: Okay. We could talk about, you know, what could happen in the future if you’re having unprotected sex, but I think you’re aware that unprotected sex can lead to pregnancy.

    Patient: Yeah.

    Physician: Vaginally.

    Patient: But not, the other way?

    Physician: Not, not anally. Not unless, like I say, possibly if you had anal sex and then had followed it with vaginal sex, unprotected, then, that’s a possibility, but …

    Patient: Oh, okay.

    Physician: The chances are very remote that you’d be pregnant this way. Now I think that we should do an exam on you and make sure that everything’s okay. Generally speaking, how is your health?

    Patient: Generally I’m pretty healthy.

Commentary on: A sexual complaint, female, version 2

In this interview, the physician employs many of the techniques used in version 1, but with subtle differences. Once again he uses open questions, but instead of asking: “Why do you think that?” in response to her opening statement, he says: “How do you feel about that?” This change in one word allows the patient to tell her story more openly, which is especially important since the physician does not know her. He follows that question with another good open question: “Tell me what happened.” Compare the listening style with that used in the Jack Simpson interviews, especially with respect to responding to cues and use of silence/interruptions. What other techniques and styles does he employ to gather information? Note how he even subtly checks the gender of Patty’s partner. Repeating the patient’s words (“different,” “behind me”) is particularly effective in bringing out important information about the sexual encounter. He adjusts to the patient’s level of understanding in his explanation, treating her obvious naivety with respect.

A sexual complaint, male, version 1

  • Physician: Okay Jack, so according to the chart it’s about three years since you’ve been by, what’s …

    Patient: Yeah it’s about that …

    Physician: What brings you in today?

    Patient: Well you know, I’ve been to a hospital since six months ago, I had to walk in to a place in Sudbury because some lady I met left me with a nice little gift and I had to get some stuff, and get it taken care of. But they told me then I should go in for a checkup. And you know my mom’s been sort of on my case about it, so here I am.

    Physician: Your mom’s been on your case about?

    Patient: Oh, just going in and having a checkup you know.

    Physician: Oh about a checkup.

    Patient: Yeah yeah yeah.

    Physician: Okay.

    Patient: She said “You go in and get it checked out, they say you should go.” So, fine, whatever you want.

    Physician: So, she knows that you caught something, from some woman, in Sudbury?

    Patient: Well I mean, I don’t tell my mother everything, you know.

    Physician: Okay.

    Patient: She knows, I told her I had a bit of difficulty there, we didn’t have to go into the specifics really …

    Physician: So, that was six months ago.

    Patient: That was six months ago.

    Physician: So what happened …

    Patient: It’s all cleared up now …

    Physician: It’s all cleared up.

    Patient: They gave me the stuff they give, you know, the Tetra whatever.

    Physician: The what?

    Patient: Tetra something, they gave me.

    Physician: Okay. Antibiotic?

    Patient: Yeah yeah that’s what it was, yeah.

    Physician: Alright and you say it’s all cleared up?

    Patient: All cleared up, good as gold.

    Physician: Okay. Well that’s good okay. Anything else, bothering you?

    Patient: No, no, see, I feel fit as a fiddle. You know, except you know sometimes I get a little stiff.

    Physician: Okay right. And you said your mom’s concerned.

    Patient: Yeah but you know, she gets concerned right.

    Physician: Okay. Alright.

    Patient: She probably thinks I’m going to drop dead of a heart attack or something like that, you know.

    Physician: Why would she think that?

    Patient: Oh, you know, it’s just, it happened to dad, so she’s a little bit jumpy.

    Physician: How old was your dad when he died?

    Patient: Oh he was 70 though.

    Physician: He was 70. And you?

    Patient: I got lots of time!

    Physician: And when did that happen?

    Patient: Oh that was a little bit over a year ago.

    Physician: A little bit over a year ago. Okay so he was 70. How old are you now Jack?

    Patient: I’m 30.

    Physician: And, so your dad was seventy when he died of a heart attack, and your mom’s concerned. Has anything been happening, have you been getting any pain in your chest, anything like that?

    Patient: No sir.

    Physician: Any shortness of breath?

    Patient: No no no, everything’s great.

    Physician: What about, are you sleeping ok?

    Patient: Yeah yeah yeah, I sleep fine.

    Physician: How many pillows do you use when you sleep?

    Patient: How many pillows? Jesus, it depends on how many she has.

    Physician: Okay. Generally, when you’re sleeping alone?

    Patient: Oh when I’m sleeping alone, just like one, maybe, two I guess.

    Physician: Do you have any problems like when you’re lying down flat, do you have any problems breathing?

    Patient: No.

    Physician: Okay. Anything else, feeling any pain in your legs anywhere?

    Patient: No, you know, sometimes my knees get a little bit, you know as I say, a little bit stiff from sitting and pushing gas peddles and clutches and such all day.

    Physician: So what do you do for a living now?

    Patient: I’m a trucker, a long-haul trucker.

    Physician: A long-haul trucker. Okay, when did you start that?

    Patient: Oh I started that three years ago. Remember that’s the last time I saw you, I had that checkup then.

    Physician: Oh that’s right, you came in for the full checkup.

    Patient: Yeah, you remember me!

    Physician: Yeah. And there was no problems then?

    Patient: No no.

    Physician: Okay, okay.

Commentary on: A sexual complaint, male, version 1

Jack’s reason for the visit is a follow-up on his sexually transmitted infection (STI), as suggested by the physician who treated him six months ago. This physician starts with appropriate open questions, but when Jack says his STI is all cleared up, the physician drops the topic (comes to premature closure). He then inquires: “Anything else on your mind?” It is a good open question, but it leads to a detailed, although not complete, inquiry into heart disease, using primarily closed questions.

Why do you think the physician chose not to inquire further into the STI?

  • He did not need to as it has been treated.
  • The physician does not understand the importance of follow-up on STIs.
  • The physician feels uncomfortable with the subject and/or Jack’s presentation.

Jack might leave satisfied, but has he received appropriate follow-up and counselling with regard to high risk sexual behaviour?

A sexual complaint, male, version 2

  • Physician: Okay Jack, I was just looking at your chart here and I see you were in about three years ago, is that right?

    Patient: That is a fact, yeah.

    Physician: Okay so it’s been quite a while, what’s been going on? What brings you in today?

    Patient: Oh well you know I’m just taking care of business. I had a little thing happen in Sudbury about six months ago. This nice, nice lady, I thought she was a nice lady, gave me a wee little present. And I went in to get her taken of, not her, but the present, and they gave me some antibiotics and told me, you know, you should go in for a checkup. And so you know, I mentioned to my mom that I’d been in there, and they told me I should get a checkup and she’s been on me to go and get a checkup, so here I am.

    Physician: Okay so when she gave you a little gift, what do you mean by that Jack?

    Patient: Well, you know, I don’t know what you want to call it, clap, VD, whatever they’re calling it now …

    Physician: Yes, sexually transmitted disease or infection.

    Patient: … a little of dose of something. Well I guess that’s the scientific term, sure.

    Physician: And you said how long ago was that?

    Patient: Six months ago.

    Physician: Six months ago.

    Patient: The stuff they gave me cleared it right up.

    Physician: So, and do you remember what they gave you?

    Patient: Tetra something.

    Physician: Okay.

    Patient: Tetra.

    Physician: Some sort of antibiotic?

    Patient: Yeah yeah yeah. That’s what it was, antibiotics. You took it 10 days …

    Physician: Okay so you took it for the full 10 days.

    Patient: Oh yeah yeah yeah.

    Physician: And everything cleared up.

    Patient: Yeah.

    Physician: And where did you say this happened?

    Patient: This was, well, I went in in Sudbury, it was probably, but it was probably when I was in the Sault. Well I know for sure it was when I was in the Sault.

    Physician: And you mentioned something about you were supposed to have a checkup …

    Patient: Oh yeah yeah, they said you know you should really go in for a checkup, for a full checkup, and I said yeah, yeah, that’s a great idea.

    Physician: But you didn’t do it.

    Patient: No, not right away, like I’ve got shit to do in my life, and the thing cleared up right away so I wasn’t too worried.

    Physician: Okay, so what exactly happened Jack?

    Patient: Well what happens on the road sometimes?

    Physician: Well you tell me. So you were in the bar …

    Patient: Okay well I met this nice woman in the bar, and you know, you know, sometimes you meet people in the bar and you know what they’re about, and sometimes you meet people in the bar who seem just a little bit different. And this woman she was, you know you know, we were having a nice time, having a chat, and you know she told me she was, like, she’s a grade two teacher, so …

    Physician: One thing led to another and …

    Patient: Yeah we went back to her place, and I didn’t figure on anything happening that night because you know, you know how it is …

    Physician: You hadn’t met her before?

    Patient: You bank, you put some money in the bank, you draw it out later, but she was good to go. She was good to go for sure and …

    Physician: Had you met her before?

    Patient: No, this was the first time. Usually I’m a little more discerning, but you never know, she was pretty, she was pretty hot.

    Physician: And can I ask you Jack, did you wear a condom at this point or no?

    Patient: Well no no, like I’m not in the habit of doing that, I ride bareback. You see, this is the thing, eh, she was, and most of the woman I see, are married. So they’re taking care of that on their own.

    Physician: And what do you mean bareback?

    Patient: Well it means no condom, just …

    Physician: So you’re not in the habit of wearing condoms?

    Patient: No, just me and the open air. No no I like it nice and slick and shiny. You know, if she’s … I’ll move up a bit.

    Physician: But have you got a problem like this before Jack?

    Patient: No never. Never. Like I thought she’d be okay because she’s married, like, you know, it’s the middle of the afternoon, so, I have a lot of afternoon sex, yeah.

    Physician: Okay. And so generally you don’t wear a condom when you’re …

    Patient: No no.

    Physician: … having sex. And why is that?

    Patient: It’s not nearly as much fun.

    Physician: Alright. Uh, okay so you had this, meeting, with this woman …

    Patient: Yeah we had sex.

    Physician: You had sex.

    Patient: Yeah, three times.

    Physician: And what happened after that?

    Patient: Well, you know, I get this, you know, feeling in my, I get this feeling in my dick right? You know, I start having a, it starts to be uncomfortable and I got to take a leak, you know, it’s not like I’m pissing fire or anything like that, but it doesn’t feel good.

    Physician: Okay so you had some pain in your penis.

    Patient: That’s what I’m telling yeah. And I started getting these little bits of stains in my underwear, and so some of the white ones I had to throw out.

    Physician: Okay so what sort of pain was it Jack? Was it a burning pain or a sharp pain, what sort of pain was it?

    Patient: Well just like a mild sort of, I guess you’d call it a burn. Like I mean, like I say, it wasn’t like there were flames shooting out of my penis. It wasn’t that bad or nothing, but it was, it was enough for me to notice.

    Physician: There was some burning.

    Patient: Yeah.

    Physician: And you said your underwear was stained.

    Patient: Oh sure, sure it was.

    Physician: So there was some discharge?

    Patient: Yeah yeah yeah.

    Physician: Okay and what colour was it?

    Patient: It was like green yellow stuff.

    Physician: What is thick?

    Patient: Possibly yeah.

    Physician: Okay so how long did you wait before you went to see the doctor?

    Patient: Oh not too awful long, that’s not something you want to mess around with, if you’re in my position.

Commentary on: A sexual complaint, male, version 2

In this version, the physician keeps the focus on the reason for the visit: follow-up on Jack’s STI. The mother’s concerns do not come out. Is this important in this context?

Note how the physician obtains appropriate details of the sexual encounter. He asks three times about condom use. The physician is likely trying to send a message to Jack about the importance of safer sex practices.

Note how he clarifies Jack’s jargon and paraphrases into language that he is sure he understands. Throughout the interview, the physician is professional and non-judgmental. In contrast to the previous interview, how will the information obtained here lead to appropriate care? What do you think the physician should do?

Interprofessional conflict

MCC role objectives

Professional

  • Be respectful of colleagues (4.3)
  • Recognize personal limitations and respect the expertise of others (5.2)
  • Communicate with other health-care professionals clearly, in a timely manner, and with due regard to their point of view (5.4)
  • Be sensitive to, and do not abuse, the power relationships within the health-care system (6.4)

 

Collaborator

  • Demonstrate respect for team members without bias (e.g., bias related to gender, ethnicity, cultural background or health-care role) (3.3)
  • Use strategies to deal with conflict through negotiation and collaboration, while respecting the views and positions of others (4.2)

Entrustable professional activities

  • Lead and work within interprofessional health care teams (8)
  • Improve patient safety and the quality of health care at both the individual and systems level (10)

 

Critical competencies

  • Accurately elicits and synthesizes relevant information and perspectives of patients and families, colleagues and other professionals accurately (9)
  • Works with other health professionals effectively to prevent, negotiate and resolve interprofessional conflict (14)

Introduction

Patients are not the only people we communicate with in our professional life. Much of what we do involves interactions with other health professionals. One of the major differences between physician-patient and interprofessional communication is the power differential. Patients come to physicians for help because of the physicians’ expertise. Because of this differential, patients have less control over the conversation than they would in other situations. This is not the case between health-care professionals. Interprofessional communication frequently occurs around problems about patients or the functioning of the health-care system. When there are disagreements, they are often related to the different ways health-care professionals view the system or interpret their role. But poor communication can lead to the escalation of a minor issue into an emotionally-charged conflict. The power relationships among different professions are more uncertain and complex than between physician and patient. However, the principles of communication remain the same: active listening, being non-judgmental and gathering information.

Watch these next conversations between a physician and nurse. Note how many of the items on the Observation Guide apply here as well. There are two versions and the second one is divided into three parts to better illustrate person-centred behaviours.

Interprofessional conflict: Introduction, version 1

  • Physician: Excuse me are you Molly Brown?

    Nurse: Ah yes I am.

    Physician: Oh hi, I’m Dr. Green, I’m the attending I haven’t actually met you but I need to talk to you if that’s okay with you.

    Nurse: Actually I’m just having my coffee break so if it could wait that’d be great.

    Physician: Do you know what, I just got paged and I’ve got to go down to the ER and it’s something I’ve got to deal with right away. I’m going to be straight with you, I’ve had a complaint about you.

    Nurse: I’m sorry?

    Physician: Yeah, one of the patients down the hall has reported that he’s heard some, what he thought was abusive behaviour happening, down to Mr. Jones in 4A, so I need to talk to you.

    Nurse: Um, I’m sorry, Mr. Jones complained …

    Physician: Yeah.

    Nurse: … complained about me?

    Physician: No no, it was another patient, who heard something going on. I’m wanting to check this out with you because I’ve got to find out what actually happened.

    Nurse: Have you met Mr. Jones by any chance?

    Physician: Yes I actually have met Mr. Jones, yeah. Mhmm.

    Nurse: So which patient was this, that complained?

    Physician: Do you know what, I’m not going to worry about telling you that. I just need to check out what happened this morning. Can you tell me in your own words what happened.

    Nurse: Yeah, I was getting Mr. Jones ready for you guys to come around, for grand rounds.

    Physician: Right yeah okay.

    Nurse: So if you had met Mr. Jones, you probably have an idea of what I was up to.

    Physician: Yeah, well I know.

    Nurse: Have you seen him?

    Physician: Yeah Mr. Jones is difficult I will give you that, but what happened?

    Nurse: Yes he is.

    Physician: What went down?

    Nurse: Like I said, all I was trying to do is clean him of all the, you know, urine that was covering him up.

    Physician: Yeah. Right.

    Nurse: His barf, everything else that was going on.

    Physician: Yeah.

    Nurse: And that’s about it, I don’t know the problem is here so.

    Physician: Well what I’ve been told is the person heard some verbal abuse and heard what he thought was a slap and. But but but, is that the truth, is that what happened? Did you actually do something to this patient?

    Nurse: So I’m sorry, you’re coming in here accusing me of abusing somebody, you haven’t even … you’re taking the …

    Physician: I’ve been told this by another patient, and you know all these patients on this ward are my responsibility, I have to check this out and I really want to find out what’s going on. I thought I’d do you a favour and talk to you first before I talk to your supervisor. But that’s what I’ll have to do if you’re not going to tell me what happened.

    Nurse: Well thank you very much, I appreciate that.

    Physician: Okay.

    Nurse: But I’m afraid that, you know, all I was doing was getting him prepared. I don’t, like I said, I don’t think you recognize who this man is.

    Physician: Look …

    Nurse: He’s a …

    Physician: Look I know he’s a difficult patient and I …

    Nurse: Excuse me do you mind if I finish.

    Physician: I can’t …

    Actually, you know what, I need to find out in your words, did you slap this patient? Were you abusive to him? Verbally? Did you swear at him? Is that what happened? Huh?

    Nurse: Can I talk now?

    Physician: Well, you know I would really like to hear what you have to say, yeah.

    Nurse: Okay. So, basically, what happened is that I was trying to get him cleaned up, he was full of vomit.

    Physician: Yeah.

    Nurse: Um, he defecated over himself, I mean have you seen this? Of course you haven’t seen this.

    Physician: Well I’ve seen patients who are difficult and were not expecting …

    Nurse: No, no, no, wait a second.

    Physician: … these people to be perfect when we come in.

    Nurse: I thought.

    Physician: What happened? Do I need to report this? Or what’s happening here? Because if that patient is in danger from the care of one of the personnel here, that’s my responsibility and I need to report that. So I got to find that out.

    Nurse: Yeah well I’m actually trying to tell you what happened, so obviously you’re not interested in hearing my side of the story, are you?

    Physician: Look I’m interested, and I think you should just calm down because I need to get the facts before I make a report about this and I just you know, like I, you know, you’re obviously not in a great space, so like let’s find out what really happened.

Commentary on: Interprofessional conflict, introduction, version 1

Why do things not go well in this version? Usually in a conversation one of the parties initiates and takes a more active role. In this case it is the physician who asks to speak to the nurse. But why does the conversation become confrontational?

The physician states several times that she wants to hear the nurse’s story.

  • How would you assess her listening style, especially in her use of interruption?
  • How would you assess her questioning style? Note how questions become focused very quickly, from “Tell me what happened.” to “Did you slap him?”
  • What happens when the nurse attempts to gather information about the accusation?

Note the difference in the power relationship. The physician says: “Can you tell me in your own words what happened?” and “I’m responsible for the patients on this ward.” The nurse retaliates with: “I’m trying to tell you.” and “Can I speak now?”, statements that patients would likely not make. The nurse’s emotions appear to be directed at the physician. Why?

  • Do you think that nurses feel any less responsible for patients than physicians?
  • Is the physician being judgmental?
  • Do you think the physician has already made up her mind (e.g., is not open-minded)?
  • Did the physician demonstrate interprofessional respect toward the nurse?

How would you assess the quality and quantity of information the physician gathered?

Interprofessional conflict: Introduction, version 2

  • Physician: Excuse me are you Molly Brown?

    Nurse: Ah yes I am.

    Physician: Oh hi, I’m Dr. Green, I’m the attending I haven’t actually met you but I need to talk to you if that’s okay with you.

    Nurse: Actually I’m just having my coffee break so if it could wait that’d be great.

    Physician: Do you know what, I just got paged and I’ve got to go down to the ER and it’s something I’ve got to deal with right away. I’m going to be straight with you, I’ve had a complaint about you.

    Nurse: I’m sorry?

    Physician: Yeah, one of the patients down the hall has reported that he’s heard some, what he thought was abusive behaviour happening, down to Mr. Jones in 4A, so I need to talk to you.

    Nurse: Um, I’m sorry, Mr. Jones complained …

    Physician: Yeah.

    Nurse: … complained about me?

    Physician: No no, it was another patient, who heard something going on. I’m wanting to check this out with you because I’ve got to find out what actually happened.

    Nurse: Have you met Mr. Jones by any chance?

    Physician: Yes I actually have met Mr. Jones, yeah. Mhmm.

    Nurse: So which patient was this, that complained?

    Physician: Do you know what, I’m not going to worry about telling you that. I just need to check out what happened this morning. Can you tell me in your own words what happened?

    Nurse: Yeah, I was getting Mr. Jones ready for you guys to come around, for grand rounds.

    Physician: Right yeah okay.

    Nurse: So if you had met Mr. Jones, you probably have an idea of what I was up to.

    Physician: Yeah, well I know.

    Nurse: Have you seen him?

    Physician: Yeah Mr. Jones is difficult I will give you that, but what happened?

    Nurse: Yes he is.

    Physician: What went down?

    Nurse: Like I said, all I was trying to do is clean him of all the, you know, urine that was covering him up.

    Physician: Yeah. Right.

    Nurse: His barf, everything else that was going on.

    Physician: Yeah.

    Nurse: And that’s about it, I don’t know the problem is here so.

    Physician: Well what I’ve been told is the person heard some verbal abuse and heard what he thought was a slap and. But but but, is that the truth, is that what happened? Did you actually do something to this patient?

    Nurse: So I’m sorry, you’re coming in here accusing me of abusing somebody, you haven’t even … you’re taking the …

    Physician: I’ve been told this by another patient, and you know all these patients on this ward are my responsibility, I have to check this out and I really want to find out what’s going on. I thought I’d do you a favour and talk to you first before I talk to your supervisor. But that’s what I’ll have to do if you’re not going to tell me what happened.

    Nurse: Well thank you very much, I appreciate that.

    Physician: Okay.

    Nurse: But I’m afraid that, you know, all I was doing was getting him prepared. I don’t, like I said, I don’t think you recognize who this man is.

    Physician: Look …

    Nurse: He’s a …

    Physician: Look I know he’s a difficult patient and I …

    Nurse: Excuse me do you mind if I finish.

    Physician: I can’t …

    Actually, you know what, I need to find out in your words, did you slap this patient? Were you abusive to him? Verbally? Did you swear at him? Is that what happened? Huh?

    Nurse: Can I talk now?

    Physician: Well, you know I would really like to hear what you have to say, yeah.

    Nurse: Okay. So, basically, what happened is that I was trying to get him cleaned up, he was full of vomit.

    Physician: Yeah.

    Nurse: Um, he defecated over himself, I mean have you seen this? Of course you haven’t seen this.

    Physician: Well I’ve seen patients who are difficult and were not expecting …

    Nurse: No, no, no, wait a second.

    Physician: … these people to be perfect when we come in.

    Nurse: I thought.

    Physician: What happened? Do I need to report this? Or what’s happening here? Because if that patient is in danger from the care of one of the personnel here, that’s my responsibility and I need to report that. So I got to find that out.

    Nurse: Yeah well I’m actually trying to tell you what happened, so obviously you’re not interested in hearing my side of the story, are you?

    Physician: Look I’m interested, and I think you should just calm down because I need to get the facts before I make a report about this and I just you know, like I, you know, you’re obviously not in a great space, so like let’s find out what really happened.

Commentary on: Interprofessional conflict, introduction, version 2

The physician again initiates the conversation. It sounds similar to version 1, where she says “I need to talk to you.” Here she says “I wonder if you have a minute.”

  • Is there a difference in tone between “need” and “wonder”?
  • Is asking permission an indication of respect?
  • What do these statements say about the physician’s attitude toward nurses?
  • What is the response this time?

Having set the tone and asked her opening question, the physician receives an unexpected emotional response from the nurse.

  • Is this related to the physician’s inquiry or to the situation with the patient?
  • Is the content relevant to the physician’s concerns?
  • Is the emotional nature relevant to the physician’s concerns?

The physician does three things to defuse the charged situation:

  • She apologizes
  • She changes to a less confrontational physical position (sits down)
  • She says: “Let’s start again,” giving the nurse an opportunity to regain self-control

Interprofessional conflict: Information gathering

  • Physician: Alright, let’s just start this from scratch okay? I’m going to be honest with you and tell you exactly what I heard, and then I would love to hear your story, if that’s, is that okay?

    Nurse: Mhmm.

    Physician: Alright. So this patient came up to me a couple of minutes ago and said that he had heard, when you were giving Mr. Jones his morning care this morning, before rounds, he had heard some abusive language, and he thought he heard a slap. And he just thought he should report it to me because he was afraid for this patient. Now it’s my responsibility to check into these things, so …

    Nurse: Afraid for Mr. Jones, the man lives on the street, you don’t understand what I have to put up with. This is not the first time he’s been in here. He comes in here about once a week, abuses all of us, verbally abuses everybody, and then I have to sit there and clean him up. Do you know what he’s like? The guy hasn’t seen a shower from the last time he was in here. That’s what I have to put up with. And this, this is the guy that you’re now coming to me and saying that I was abusive to him? Do you know what he calls us? Do you have any idea? Do you know what he looks …

    Physician: Does he swear at you?

    Nurse: Yes he swears at us, and he, and he, and he … knocks things out of your hands, he knocks things away …

    Physician: Mhmm.

    Nurse: I mean I’m supposed to get him cleaned, so that you guys don’t have to see him like that …

    Physician: Right.

    Nurse: You know, you don’t get to see him all, with his, I mean, he’s defecated all over himself, he’s urinated.

    Physician: Yeah.

    Nurse: And I have to make sure that he’s clean so that you guys don’t have to deal with it. And what I am dealing with, is he’s … he’s trying to hit things out of my hand, you know, I mean I have about eight other patients I have to look after, right?

    Physician: Mhmm. You sound really, really frustrated.

    Nurse: Yeah, I am really frustrated, I really don’t appreciate, on my coffee break, being cornered about this kind of a person, after 25 years. You know why don’t you go and ask the rest of the patients on my ward and see how, if they think I’m being tough on them. Of course I’m not, because they’re respectable human beings, they’re sick. This guy isn’t sick, he’s just a drunk.

    Physician: Okay so it sounds to me like this guy feels, like, different than the rest of your patients.

    Nurse: Well yeah he is …

    Physician: And you feel. Did you treat him differently this morning? Than you treated the rest of your patients?

    Nurse: No the rest of my patients don’t try to hit me.

    Physician: Mhmm.

    Nurse: The rest of my patients, when I’m trying to wash them are respectful. I mean this guy’s … so yeah, you have to be a little bit more forceful, okay, yes.

    Physician: So did you, did you actually hit Mr. Jones?

    Nurse: I didn’t, you know, you just have to be strong with these guys. I mean he’s, I had to, I had to for … I had to make sure that he wasn’t going to do it again, okay? I mean, jesus, 25 years, this guy …

    Physician: I know you told me that you’ve been here for 25 years …

    Nurse: … comes in here, he’s drunk, he misuses, and look at me, this is great.

    Physician: Okay Molly, I’m going to ask a few things. I need to know, if you actually did, use forcible behaviour on him. Did you actually slap him or push him down?

    Nurse: I probably, was a bit stronger than I should have been, yes.

    Physician: Okay and thank you for being honest with me. It sounds like he was being extremely difficult to deal with and physical himself. So, yeah, okay and something else I’m going to ask you. You’ve met him before, you’ve dealt with him before, what was different about today? What got to you more than usual? Or has this happened before?

    Nurse: No. It’s just, I’m just fed up with our waste of money and time, when there’s not enough to go around in the system for people who are really sick. And people like this abuse the system, you know. And, I don’t know, I was up late, my son didn’t come home last night, so I guess maybe that was a bit of a trouble too, I don’t know. You know I’m just tired of people abusing their bodies and then expecting other people to take care of them, you know, and then being …

    Physician: But do you feel like your behaviour this morning was different than you usually exhibit towards with your patients?

    Nurse: Yeah. I wouldn’t be doing this for 25 years. I’m a good nurse, I’m a very good nurse. And I love my job and love my patients.

    Physician: I absolutely appreciate that fact, and I respect you’re being honest with me. Sounds like this is an unusual thing that hasn’t happened before, and it is my responsibility, and yours too, to report any kind of behaviour that’s, you know, against the safety of a patient.

Commentary on: Interprofessional conflict, information gathering

Note the quality and quantity of information gathered this time. The physician is non-judgmental and the nurse is less defensive.

Please refer to the Observation Guide for the following sections:

Among the techniques, find where the physician appropriately uses:

  • Explaining
  • Facilitating
  • Legitimizing
  • Summarizing

Among the styles, find where the physician appropriately uses:

  • Silence
  • Checking-in
  • Open-ended questions
  • Body language
  • Gathering the equivalent of biomedical (the incident) and psychosocial (personal) information
  • Integration of information

Among the attitudes, find where the physician appropriately uses:

  • Encouraging discussion and feedback
  • Being non-judgmental
  • Respecting the other’s viewpoint
  • Being empathic

Interprofessional conflict: Management

  • Physician: Okay Molly so I’d just like to throw back at you what I’ve heard, and let me know if I’ve got the facts straight here. Sounds to me like you’ve had a pretty difficult morning with an extremely difficult patient. On top of the fact that you haven’t had a lot of sleep and you’ve had some upset with your son, so you’re in a bit of a space, and perhaps you behaved in a way that was somewhat inappropriate to Mr. Jones. Is that accurate?

    Nurse: Yeah I guess so.

    Physician: Okay, alright, and again I thank you for, you know, being honest with me about it all. And I’m just, I’m wondering what you think, what would you like to do next, we do have to deal with this. What’s your thoughts on that?

    Nurse: Um … you know, it’s been, I’ve been a nurse for 25 years.

    Physician: Mhmm.

    Nurse: I’m very good at it.

    Physician: Yeah.

    Nurse: Well you came in here, I’m sure you have an idea of what you want to do.

    Physician: Yeah okay well, I mean, the reality is we do have to adhere to hospital policy, so this incident does have to be documented, that’s for sure. I, you know, we have a couple of options there. We have to write it down, we also have to report it to your nursing supervisor. Now we could go together and do that, or you have the option of talking to her on your own. And I could just go down after and, you know, follow up with my side of the story, and write it down on paper too. What would your choice be in terms of talking to your supervisor?

    Nurse: No, I’ll talk to her myself.

    Physician: Mhmm.

    Nurse: I mean I’ll just go down.

    Physician: Okay. Yeah that’s great. And I can just follow up later and if you want to talk any more about this, please seek me out and I’d be happy to talk some more. We’ll see where we go from here.

    Nurse: Okay.

    Physician: Okay. Thanks Molly.

Commentary on: Interprofessional conflict, management

Here we see the techniques of negotiating and summarizing used to good effect in finding common ground. Asking the nurse for her input to the process shows respect, and the physician is honest about her responsibilities to other stakeholders, e.g., hospital policy. The problem and not the personalities are dealt with, and both parties retain self-respect.

The boundary crosser

MCC role objectives

Professional

  • Maintain the highest personal, professional and legal standards at all times (3.3)
  • Abide by the profession’s rules, regulations and ethical codes (4.1)
  • Report a colleague’s actions or behaviours as required or appropriate, using the applicable reporting mechanism (4.4)
  • Observe appropriate and/or legal boundaries in relationships with patients and health professionals (6.3)
  • Be sensitive to, and do not abuse, the power relationships within the health-care system (6.4)

Entrustable professional activities

  • Assess, diagnose and manage patients with acute, common and complex diseases across outpatient settings (2)

 

Critical competencies

  • Develops rapport, trust and ethical therapeutic relationships with patients and families (8)
  • Develops a common understanding on issues, problems and plans with patients, families and other professionals to develop a shared plan of care (12)
  • Demonstrates knowledge of and applies the professional, legal and ethical codes for physicians(21)

Introduction

How much self-disclosure is acceptable in a physician-patient relationship? Patients, who genuinely like and respect their physicians, often want to know a little about them. If you are an international medical graduate, they may be interested in your background. How much should you tell them? Will it be rude, or damage the therapeutic relationship, to refuse?

There is the potential for inadvertent or deliberate boundary crossing in every physician-patient interaction. The degree of risk depends on the context: patient and physician age and sex, the clinical situation and the local environment. As professionals, physicians are totally responsible for the ethical conduct of the physician-patient interaction. Physicians must not exploit the power of their position relative to patients, and must manage situations in which patients initiate the incident.

What happens in the scenarios here is quite clear: the patient is crossing the physician-patient boundary and the physician must deal with it. Everyone knows that one does not enter into an intimate relationship with a current or previous patient. There are, however, many less obvious situations which are considered possible boundary issues in Canadian practice. What do you think about:

  • Looking forward to a patient’s visit, either because you like them, or they praise your professional skills.
  • Making special arrangements to see a patient. This may be a compassionate and reasonable professional action, or it may not. Is this only once or a frequent occurrence? If it is a frequent occurrence, your actions must be justified by the patient’s needs. What is your motivation?
  • It might be difficult to maintain appropriate professional boundaries in a small community; however your code of ethics must nonetheless be respected. Are you or the patient attending the same events because you belong to the same sports club or do you attend as an excuse to meet? You might be put in a situation where you encounter your patients outside of the medical environment. You should therefore have a strategy in mind to help you maintain proper professional boundaries. Think of a situation where this may happen. What would be your response?
  • How comfortable are you with the cultural norms for personal space and touching, particularly in the physical examination? How do you assess the patient’s cultural expectations?
  • Do you know when you should or must report a disclosure of sexual abuse of a patient? Who do you contact? If you do not report and the issue becomes public, what happens? Please refer to the regulations of the medical regulatory authority in the province or territory in which you would like to practice.

The boundary crosser: Part 1

  • Physician: Okay Coleen. So, you’ve said that you are feeling anxious. Can you tell me more about that?

    Patient: Yeah. I get sort of panicky inside, with like, my heart starts to race.

    Physician: Okay.

    Patient: And, my hands get all sweaty and I get tongue-tied, and I feel like I’m going to say something stupid. But I uh … yeah.

    Physician: Okay, do you feel like a tightness in your throat?

    Patient: Sure, yeah.

    Physician: You have difficulty breathing?

    Patient: Yeah. No.

    Physician: No.

    Patient: No.

    Physician: You don’t get short of breath?

    Patient: No.

    Physician: Okay.

    Patient: No.

    Physician: And when this happens, what … what do you do?

    Patient: Umm. I usually feel like leaving the situation.

    Physician: Okay.

    Patient: Like, this is really interesting because I normally feel like leaving the situation but I don’t feel like that right now.

    Physician: Right now. Okay, so when you talk about situations, what sort of situations are you talking about?

    Patient: Um. This usually happens around men, but I’m not really feeling that uncomfortable right now, so … And that I think it’s probably because you are so nice.

    Physician: I’m a doctor.

    Patient: I can tell.

    Physician: That’s probably why.

    Patient: Except you don’t wear a tie, or anything like that.

    Physician: Well sometimes.

    Patient: It’s nice actually.

    Physician: Good. Well let me get back to uh … are there any other symptoms? So you get tightness in your throat. Do you feel like you’re flushed, your skin is flushed, you’re warm? Anything like that?

    Patient: A little.

    Physician: A little.

    Patient: Yeah, yeah.

    Physician: And what about … do you perspire?

    Patient: A little bit.

    Physician: A little bit.

    Patient: Yeah. I like …

    Physician: So, not a lot?

    Patient: No.

    Physician: Anywhere in particular: chest, forehead?

    Patient: No.

    Physician: No.

    Patient: But, you know, I was just going to say, like, I know it’s really in style now for guys to shave their heads. I think it is so attractive.

    Physician: Oh good.

    Patient: Yeah. Really, I really do.

    Physician: Okay.

    Patient: It’s very nice.

    Physician: So uh, alright. Now this situation that you’re in, you’re telling me about, what sort of situations precisely, I mean how often do you run into them?

    Patient: Usually …

    Physician: When does it happen?

    Patient: Uh. Usually around men.

    Physician: Right, but … I mean, what do you do for a living?

    Patient: I’m a teacher.

    Physician: Okay, and are there men in where you teach?

    Patient: Uh, yeah. There is a couple. Well …

    Physician: You have problems …

    Patient: Usually parent-teacher meetings, that kind of thing, I’m okay with moms, not so okay with the dads.

    Physician: Okay.

    Patient: I have a question for you.

    Physician: Alright.

    Patient: I have tickets to go see the premiere of an Oliver Stone movie and I was wondering if you might like to join me.

    Physician: Well, you know, we can talk about that later, but right now, I still need some more information. Okay? That’s okay?

    Patient: Sure.

    Physician: Okay. So uh, so how … this started how long ago?

    Patient: Uhh, six months maybe …

    Physician: Six months. Okay. So did it happen like all at once? Was it a gradual thing?

    Patient: Are you left handed?

    Physician: I’m left-handed, yeah.

    Patient: That is so sexy.

    Physician: Okay. Uhh, alright so started six months ago … I really need to ask you these questions Coleen, and you have to help me, okay?

    Patient: Okay.

    Physician: I need you to focus, alright? Thank you. So it started six months ago. Did anything happen six months ago? Any change in your life?

    Patient: (shakes head)

    Physician: No.

    Patient: Not that I … well … well, it’s not really a change, we’ve been separated for a bit, but uh just …

    Physician: So are you uh … who was separated?

    Patient: Uhh my husband and I.

    Physician: So you were married.

    Patient: Yeah.

    Physician: Okay, and you’re …

    Patient: You’re not married.

    Physician: Not married now. No I’m not.

    Patient: That’s nice.

    Physician: So what happened …

Commentary on: The boundary crosser, part 1

It might seem contradictory to talk about physician control in a patient-centred interview. How does the physician respond to the patient in this version? Does he seem comfortable, in control of himself and the situation?

The physician uses a number of styles and techniques in this interview:

  • His questioning style uses both open- and closed-ended questions. However, note the change in the type of question as the interview proceeds. Why do you think this happens?
  • He repeats or reiterates a lot. Why do you think he does this? Is it to clarify or because he is uncomfortable?
  • What is the physician’s response to the patient’s personal questions and observations?
  • Note the non-verbal language of both speakers.
  • He indicates his attempts to control the situation twice: “We can talk about that later,” and “I need you to focus.” What is the result of those attempts?

What is the quality and quantity of information gathered by the physician? How successful is he in following his interview plan with this patient?

The boundary crosser: Part 2

  • Physician: Alright Colleen I need to be honest with you right now. I’m feeling very uncomfortable, okay. And I think we need to set some ground rules in order for me to help you. Because I want to help you, but I can’t help you if you keep making this a personal relationship or trying to, as opposed to a professional one, okay? So this is a doctor’s office and I’m the doctor, and in order for me to help you, you can’t be, you know, crossing that line, right? So do you understand that?

    Patient: Yeah I’m sorry. I feel like I just said something terrible.

    Physician: I know, I know. And that’s fine, and that’s something we need to explore because I think that’s part of the problem right now. Okay. But if you find you can’t, you know, stop yourself from crossing that line, between the patient and the doctor, then there’s a couple things we can do. Number one, I can bring the nurse in, okay, we can have her in the room. I can have you see another doctor, maybe a female doctor. Or I can leave the room and just give you five minutes, and you can, you know, have a bit of a think and then I can come back in and we can try again. Now, how does that sound to you?

    Patient: Well, I’d rather you see me, I don’t want to be seen by anybody else.

    Physician: Okay. So I would be happy to talk to you, as long as we’re on the same page here, alright?

    Patient: Okay.

    Physician: So do you understand what I’m saying?

    Patient: Yeah I’m sorry.

    Physician: Do you understand what I’m asking?

    Patient: Yeah I’m sorry, I’m really sorry.

    Physician: You know, you don’t have to …

    Patient: I feel like yeah I’ve done it again, you know.

    Physician: Okay so this is something that you’ve done before?

    Patient: Mmhm.

    Physician: Okay so this is the kind of behaviour we may want to discuss, alright, in order for me to help you. Is that okay?

    Patient: Mhmm.

    Physician: Okay.

Commentary on: The boundary crosser, part 2

Here is one way of dealing with such a situation. The physician attempts to regain control of the interview:

  • The physician stops the usual physician-patient conversation.
  • He is honest about his own feelings, indicating self-awareness.
  • He is specific, indicating that she keeps trying to make this a personal situation.
  • He notes that in order to help her, the relationship must be entirely professional.
  • He then describes the professional dialogue, and checks for understanding.
  • He is respectful of the patient and presents several courses of action for her to consider.

Note that in his body language he draws an imaginary line, which represents a boundary neither should cross.

He then asks for feedback about her understanding in order to find common ground.

Ethical dilemmas

MCC role objectives

Communicator

  • Gather information about the patient’s concerns, beliefs, expectations, and illness experience (2.3)
  • Respect patients’ rights to be given complete and truthful information (3.1)
  • Identify the personal and cultural context of the patient, and the manner in which it may influence patient’s choices (3.2)
  • Establish a common understanding and negotiate agreement concerning diagnosis, management, and follow-up (4.1)

 

Professional

  • Know, and appropriately implement, current ethical and legal aspects of the consent and capacity process. (2.4) These include:
    • determination of capacity for differing contexts of consent (2.4.3)
    • principles of the “reasonable person” standard (2.4.4)
    • principles of full disclosure (2.4.5)

Entrustable professional activites

  • Assess, diagnose and manage patients with acute, common and complex diseases across outpatient settings (2)
  • Manage transitions of care (7)
  • Collaborate with patients, families and members of the interdisciplinary team (9)

 

Critical competencies

  • Develops rapport, trust and ethical therapeutic relationships with patients and families (8)
  • Develops a common understanding on issues, problems and plans with patients, families and other professionals to develop a shared plan of care (12)
  • Demonstrates a commitment to their patients, profession and society through ethical practice (19)

Introduction

There are frequent ethical implications in the decisions physicians make every day. Although not everything is an ethical dilemma, physicians must remain aware of potential issues and be prepared to deal with them.

Consent, which is viewed as being integral to human rights, is the most frequent ethical issue that physicians deal with in Canada. Consent is enshrined in laws and legal statutes which all practicing physicians must understand. Each case in the previous section illustrates some aspect of consent.

This section illustrates communication issues that arise from dealing with an ethical dilemma about consent. Again there are two versions, one more physician-centred and one more patient-centred.

Ethical dilemma: Version 1

  • Physician: Okay Kim. Let me just make sure I’ve got all the facts right, that you told me about your illness. You wanted just to come in and talk to someone who had a fresh point of view, who didn’t know you, about your dialysis and thinking that you might want to stop it. You’ve had kidney troubles since you’ve got glomerulonephritis at age 10. You had all kinds of problems when you were growing up with drugs and things, and finally they took your kidneys out and put you on dialysis when you were … 23, I think you said.

    Patient: Twenty-three, yeah.

    Physician: Okay, but then you got a transplant at 25 and you were okay for a while. But that failed four years later; so, now another spell of dialysis and we’re now four years into that.

    Patient: Yes.

    Physician: Have I got those timelines right?

    Patient: Yes.

    Physician: And you are thinking that you don’t want to wait for another transplant, continue with this …

    Patient: No.

    Physician: Well, you know, the consequence of that, because you have no kidney function of your own, is pretty obvious, and pretty final.

    Patient: I’ll die, yeah.

    Physician: Yeah. And that is not something, obviously as physicians, we like to see because there is so much we can do for this and, you know, chances are very good with all the trouble you’ve had that, I mean depression could very well be an issue.

    Patient: (shakes head)

    Physician: I know you’ve told me you’ve seen someone.

    Patient: Yes.

    Physician: And they’ve said you weren’t depressed, then, but this is now.

    Patient: Well, I’ve seen two and the other one told me that I was acting out on my frustrations, which maybe, you know, that’s not so far off, because I’m definitely frustrated.

    Physician: Sure.

    Patient: But really, I’ve seen so many doctors, and finally, one of them told me I have a choice. So now, I want to make that choice.

    Physician: Well, I think the problem with that is that a choice to choose to die or to kill yourself is something that, that we would view very very … uh … with great difficulty because of the possibility that you’re not being quite rational about it. And you know, there is an awful lot we can do. We’ve got, you’re not alone in this. I mean all kinds of people with kidney problems come to us …

    Patient: I just want to choose to let nature take its course here.

    Physician: That’s sort of equivalent to committing suicide and you know, when we hear that, we say: are you really thinking straight. You know, we’ve got counsellors, we can get your family in to talk to them, they have lots of experience, a new kidney may come up in the near future and suddenly your life turns around and you might regret having made this decision when it’s too late. So, I really feel that probably you are making the wrong decision.

    Patient: You just want me to see more doctors, more psychiatrists and I just don’t see the point.

    Physician: Well, there is a lot we can do to help you.

Commentary on: Ethical dilemma, version 1

The physician begins by stating why the patient has come, that is, to talk to someone new about her problem. The physician then summarizes. What information is included in the summary?

  • Medical
  • Psychosocial
  • Illness experience
  • Patient’s values and worldview
  • Integration of information

She checks in that her summary is correct, but the focus tells us where the physician’s interests lie. She makes this explicit by stating: “As physicians we don’t like to see …”

As physicians we are trained to help people and to cure them if possible. Dialysis and transplantation are two of many technological breakthroughs which have saved lives and which we are obliged to use as professionals. This would appear to be the physician’s worldview: “There is an awful lot we can do …”

  • Is there a clash of values between the physician and the patient?
  • Does the physician show empathy (understanding of the patient’s worldview)? Empathy can be expressed both verbally and non-verbally.
  • What is the physician’s non-verbal style?
  • Does the physician show evidence of self-awareness?
  • Does the physician do anything to validate the patient’s feelings or views?

When the patient clearly becomes irritated and tries to interrupt to make a point, the physician rides right over her points and ignores the patient’s non-verbal message. In fact, the physician rarely looks at the patient and appears caught up in her plans to fix things.

The physician openly doubts the patient’s rationality about depression and minimizes her past experience. Common ground is not achieved: “I really think you are making the wrong decision.” The physician does not respect the patient’s point of view and will therefore be unable to help her, despite genuinely wanting to do so, but on medical terms only.

Ethical dilemma: Version 2

  • Physician: Okay Kim. Did I get the timeline of this long illness and your dialysis right?

    Patient: Yeah.

    Physician: Yeah. I can see you’ve been through a lot and …

    Patient: I really just don’t see the point of it anymore.

    Physician: Uh-hm. You said that you were thinking of stopping your dialysis.

    Patient: Uh-hm.

    Physician: And you understand the consequences of that?

    Patient: Yes. I mean, I will die.

    Physician: You appreciate that that’s an irrevocable decision?

    Patient: Yeah.

    Physician: Okay. A lot of times when people make decisions like that, they are depressed. You’ve seen a couple of psychiatrists.

    Patient: Uh-hm.

    Physician: They said you weren’t.

    Patient: That’s right.

    Physician: And from what, I mean from what I see of you, I think you are … you know … understandably low, but again I don’t think you are depressed to the extent that you are unable to make decisions for yourself. So, I would agree with that, but still it’s something that needs to be thought about very seriously. Yeah.

    Patient: And I have been for at least six months.

    Physician: Uh-hm.

    Patient: Yeah.

    Physician: Have you talked to your other doctors about this?

    Patient: Yes. I mean I have seen so many, and, finally, I did see one who mentioned that it is my choice.

    Physician: Uh-hm.

    Patient: That I could choose not to continue the treatment.

    Physician: That is true, and it may give you a sense of control over your life, which would be important to you probably. Uh, you can refuse treatment, of course you can, assuming that, and I think this is true, that you are in your right mind and that sort of thing. But, and you do seem to understand the consequences.

    Patient: Yeah.

    Physician: But, because it is something that you can’t go back from, it would really be good if we all made sure that, that it was the right decision for you.

    Patient: Uh-hm, this is why I’m here essentially.

    Physician: Yeah. I’m glad you came because I do think a fresh look sometimes may … may help.

    Patient: Uh-hm.

    Physician: I would like to talk with you more, and hear more about your life, what this has done to your life, what you would have thought of doing in the future if you had been able, or perhaps could even now. I would also like to find out, perhaps from your doctors, a little bit more about … you know … how they are treating you, are there things that perhaps could be done to make it easier. I don’t know that yet.

    Patient: Uh-hm.

    Physician: And they’re probably busy a lot of the time and …

    Patient: Yes.

    Physician: So, if I could speak to them, and then maybe you and I can talk again, if you were willing. You’ve got lots of time to make this decision.

    Patient: Yeah, I suppose that’s true.

    Physician: I won’t try to talk you out of it, but I would like to talk with you about it, if that would be agreeable to you.

    Patient: Yes. That actually I appreciate because I get most people talking me out of it.

    Physician: Okay. I won’t do that. But let’s talk again soon. Would that be okay?

    Patient: Yeah.

    Physician: Alright, we’ll fix it up for next week.

    Patient: Okay.

    Physician: Good.

Commentary on: Ethical dilemma, version 2

After a summary similar to that in version 1, the physician checks in again then acknowledges the illness experience with a simple empathic statement: “You’ve obviously been through a lot.” No more needs to be said. The statement is sincere and the patient knows that she has been heard and understood.

The physician then explores in some detail the ethical issue of capacity:

  • She summarizes previous psychiatric consultations.
  • She is honest about her opinion (she agrees the patient is not depressed).
  • By doing so she validates and respects the patient’s point of view.
  • She acknowledges ethical rules concerning refusal of treatment, but:
  • She also makes it clear that in life and death decisions, the level of capacity the patient requires might be higher than in less critical situations.
  • She does this by clarifying and contextualizing the consequences of such a decision.
  • Does the patient both understand and appreciate the consequences of such a decision?

The physician validates the patient’s point of view (“Of course you have the right to refuse …”) and then bridges to a management mode with “But …”

  • Recognizing the patient’s ambivalence about the decision, she states her position as a professional: “We all need to make sure it is the right decision for you.”
  • She indicates her need for more information in order to fully understand the patient.
  • She attempts to find common ground: “I would like to talk more with you.”
  • The patient responds that she has been heard and understood: “I appreciate that. Most others try to talk me out of it …”

What is the major difference between the first and second interview? It is the physician’s attitude.

In the second interview, the physician gives control to the patient and accepts that the patient has the right to control her life: “Knowing you can stop dialysis may give you a sense of control.” She does not attempt to use her expertise in a paternalistic way to “fix” the problem. Rather, she enters into a professional dialogue with the patient.

Cross-cultural interviewing

MCC role objectives

Communicator

  • Initiate an interview with the patient by greeting with respect, attending to comfort and to the need for an interpreter if applicable, orienting to the interview, and consulting with the patient to establish the reason for the visit (1.1)
  • Use appropriate non-verbal communication (positioning, posture, facial expression) (1.2)
  • When appropriate, facilitate collaboration among families and patients, while maintaining patient wishes as the priority (1.5)
  • Gather information about the patient’s concerns, beliefs, expectations, and illness experience (2.3)
  • Indentify the personal and cultural context of the patient, and the manner in which it may influence the patient’s choices (3.2)
  • Provide information using clear language appropriate to the patient’s understanding, checking for understanding, and clarifying if necessary (3.3)

Entrustable professional activities

  • Assess,diagnose and manage patients with acute, common and complex diseases across outpatient settings (2)
  • Collaborate with patients, families and members of the interdisciplinary team (9)

 

Critical competencies

  • Develops rapport, trust and ethical therapeutic relationships with patients and families (8)
  • Develops a common understanding on issues, problems and plans with patients, families and other professionals to develop a shared plan of care (12)

Introduction

Some feel that competent cross-cultural communication requires a detailed knowledge of every culture, something that is clearly not possible. The position taken here is that, with basic knowledge of the techniques of patient-centred interviewing, relatively little additional knowledge and skills are required to perform a cross-cultural interview. This is because of the considerable overlap of the two models: in both, physician self-awareness, willingness to relinquish power and find common ground with the patient, and appreciation of the distinction between disease and illness are central to the physician-patient interaction. (Hanson et al., 1996)

Barriers to cross-cultural communication

  • Belief that one must know the details of each patient’s cultural values and beliefs.
  • Belief that it takes too much time, especially if one must work with an interpreter.
  • Belief that the medical model is the only valid model of health care.
  • Beliefs about others that are based on our own cultural experiences. We may not be aware that these beliefs can be a barrier to effective communication.

The physician’s explanatory model

The physician has two cultures:

  • His/her own social/ethnic background (e.g., born Canadian, Chinese, South African)
  • The medical culture learned in medical school and subsequent practice

Often we do not think about either of the physician’s two cultures as contributing to a cross-cultural encounter. We think of the medical knowledge and skills we learned as being “without culture” and therefore neutral and objective. But in fact, western medicine is grounded in social values and beliefs, as are all human activities. The western model of medicine is therefore a culture. The second explanatory model of the physician is his or her personal history. This is part of us all, but especially evident in international medical graduates. We all try to live in the seemingly culture-neutral medical world, but our personal background influences all that we do and say. If we are not aware of this in working with patients, misunderstandings are certain to occur.

Since the patient is seeking the physician’s help, and the physician is the one with professional expertise, it is the responsibility of the physician, not the patient, to recognize the differences in points of view and to not make assumptions.

The patient’s explanatory model

While the physician’s model is disease-oriented, the patient’s model is illness-oriented. A patient does not know that their gall bladder is inflamed and full of stones; they just know that they have a pain in the belly. Perceptions of illness are culturally determined and different for each person. They provide the meaning of what is going on: how we decide we are ill, why we think we are ill, how we cope with illness, and when we decide we are no longer ill. These beliefs may differ in the same individual over time. For instance, a patient may have a relatively western approach to an illness until the stress of end-of-life issues result in a reversion to original values and traditions. Think about the patient in Module 2 with this in mind.

Determining a patient’s explanatory model of illness

  • What do you call this illness? What do you think caused it?
  • Why did it happen at this time?
  • How does the illness affect you?
  • How bad is it? How long do you think it will last?
  • What kind of treatment do you think you should have?
  • Have you tried any treatments already?

As you can see, this is a variation on the patient-centred method. It is important also to realize that the physician answers the same questions about the patient’s problem, but from his or her own biomedical and cultural perspective. You may “know” that the causation of the belly pain is gallstones while the patient “knows” it is due to something else. Failure to openly acknowledge any differences between the patient’s and your model will make it difficult to negotiate common ground.

Psychosocial and acculturation issues

This additional information may be particularly important in working with patients who are from a non-Canadian background. Again, most of this should be part of any good patient-centred interview.

  • Family structure (here and in home country)
  • Decision-making process (individual and/or family)
  • Size of community here (confidentiality may be an issue in small ethnic communities)
  • Education and current functional status in Canada
  • Type of primary culture (avoid stereotyping)
  • Age at immigration/length of time in Canada
  • Degree of interaction and integration into Canadian social structure
  • Understanding of the Canadian health care system
  • Language fluency

Using the Observation Guide, note the techniques and styles used by the physician in both interviews. How does the interviewer need to change his approach when working with interpreters?

Cross-cultural interviewing

  • Version 1

  • Physician: Hi, I’m Dr. Welsh.

    Interpreter: Hi, I’m Yanna Novak.

    Physician: Hi.

    Interpreter: Oh, this is Pavel Novak, my cousin.

    Physician: Hi.

    Patient: Hello.

    Physician: So what brings you in today?

    Interpreter: Well I came in because my cousin, Pavel, has diabetes and I don’t think he’s looking after himself very well. And he doesn’t speak English.

    Physician: Okay. So will you be able to interpret for us?

    Interpreter: Yes.

    Physician: Alright. So you say he has diabetes.

    Interpreter: Yes.

    Physician: How long has he had it?

    Interpreter: I think he’s had it for about eight months.

    Physician: Okay. And you said he’s not doing very well?

    Interpreter: Well he has pills but he’s not taking them every day, or he’s not taking the prescription like he should.

    Physician: Alright, and why isn’t he taking his prescription?

    Interpreter: I think sometimes he thinks he feels well.

    (patient and interpreter speak to each other in Czech and Slovak)

    Physician: Sorry, excuse me …

    Interpreter: Sorry.

    Physician: I’m sorry, what …

    Interpreter: I was just saying that he doesn’t take his pills and that he needs to take his pills and look after himself, a little better.

    Physician: Right.

    Interpreter: Mhmm.

    Physician: Okay. And, sorry, what was he saying?

    Interpreter: Just that he, you know, he says feels fine so he doesn’t think he needs to take it, and he doesn’t like to take the pills and …

    Physician: Okay. Well I mean, that question can easily be answered if we take him in for some blood tests that’ll establish right off the bat whether or not he has …

    (patient and interpreter speak to each other in Czech and Slovak)

  • Version 2

  • Physician: Hi I’m Dr. Welsh.

    Interpreter: Hi I’m Yanna Novak.

    Physician: Hi.

    Patient: Hello.

    Interpreter: This is my cousin, Pavel Novak.

    Physician: Okay. And what brings the two of you in today?

    Interpreter: Well I brought Pavel in today because he has diabetes and I’m wondering if you could talk to him about that. And he doesn’t speak English.

    Physician: Oh I see. Will you be able to act as an interpreter for us?

    Interpreter: Mhmm.

    Physician: Oh that would be great. Okay now, if you don’t mind, just if could we set down a few ground rules just so we’re all comfortable with how we do this.

    Interpreter: Mhmm.

    Physician: Alright, now I’d prefer if I can just speak directly to Pavel, and I don’t want you to feel like I’m ignoring you but just so that I can just, you know, establish a connection between us. And if you can interpret as exactly as possible the words that I say, so that he gets a good sense of it. And then the same for him, when he speaks if you can interpret as exactly what he saying as possible for me. It will just make everything a lot easier.

    Interpreter: Sure.

    (patient and interpreter speak to each other in Czech and Slovak)

    Physician: Is that alright with you?

    Patient (through interpreter): Yes.

    Physician: So your diabetes, how long have you had diabetes?

    Patient (through interpreter): Eight months.

    Physician: Eight months, okay. And are taking any medication for it?

    Patient (through interpreter): That he takes the Diabeta.

    Physician: Okay. Now, did you bring any of that in with you today?

    Patient (through interpreter): No he doesn’t.

    Interpreter: Now I’m afraid that he doesn’t take his medication, not every day. And I just don’t think he’s looking after himself the way he should be.

    (patient and interpreter speak to each other in Czech and Slovak)

    Physician: Excuse me, I’m sorry, excuse me.

    (patient and interpreter speak to each other in Czech and Slovak)

    Physician: Excuse me please.

    Interpreter: Sorry.

    Physician: Can you please tell me what was going on?

    Interpreter: Just that he’s not taking his medication every day and he only takes it when he’s feeling bad and …

    Physician: Okay. And what were you saying?

    Interpreter: Just that he needs to take it every day, he needs to look after himself.

    Physician: Alright now I’m sorry, I’m going to have to get a bit back on track, I’m sorry. Now if you can, just ask him this and just ask the question that I’m asking, please?

    Interpreter: Mhmm.

    Physician: Okay. So why don’t you want to take your medication all the time?

Breaking bad news

MCC role objectives

Communicator

  • Respect patients’ rights to be given complete and truthful information (3.1)
  • Effectively communicate in challenging situations (delivering bad news, addressing anger, confusion, medical error, misunderstanding and media interviews) (3.5)
  • Establish a common understanding and negotiate agreement concerning diagnosis, management, and follow-up (4.1)
  • Disclose patient information only when legally permitted (6.1)
  • Adhere to provincial or territorial requirements for obligatory disclosure of patient information (child abuse or abandonment, reportable communicable diseases, duty to warn threatened individuals) (6.2)
  • Transmit information to third parties (insurance companies, government agencies) truthfully and in a timely manner (6.3)

 

Professional

  • Know and communicate to patients the limits of professional confidentiality (reportable conditions, duty to warn) (2.3.2)
  • Maintain the highest personal, professional, and legal standards at all times (3.3)

Entrustable professional activities

  • Assess, diagnose and manage patients with acute, common and complex diseases across inpatient settings( 1)
  • Manage transitions of care (7)
  • Collaborate with patients, families and members of the interdisciplinary team (9)

 

Critical competencies

  • Seeks appropriate consultation from other health professionals, recognizing the limits of one’s own expertise (5)
  • Conveys relevant information and explanations accurately to patients and families, colleagues and other professionals (10)
  • Develops a common understanding on issues, problems and plans with patients, families and other professionals to develop a shared plan of care (12)

Introduction

Breaking bad news is among the most difficult tasks a physician faces. We might be concerned about the emotional response of the patient — and ourselves. We might feel that we have failed the patient in some way and therefore feel guilty or helpless. We might be unsure of what the patient knows already and how much they want to hear. Concerned family members might make requests or demands that are difficult to fulfill. We might have had little or no training in how to break bad news, have had to do it infrequently or never before. Lacking a logical approach and appropriate words, we might appear clumsy, uncomfortable or insensitive. Failure to deal with these issues might result in a conversation with a patient at a critical moment in their life that is less effective than it could be.

Here are two articles that provide structured approaches to breaking bad news. They describe acronyms one can use to remember all of the things one should do. However, it is important not to apply these rules in a rigid manner. It is particularly important when breaking bad news to tailor your words and behaviour to the patient’s needs. Perhaps the one constant rule should be: plan ahead, if possible. Think about the situation, the patient and what you might, or might not, say and do.

You can read the articles before or after watching the interviews:

  • Challenge 1

  • Physician: Come on in Henry, have a seat.

    Patient: Hi doc, how are you?

    Physician: I’m alright, how are you?

    Patient: Oh not bad I guess.

    Physician: And how’s your wife?

    Patient: Oh, she’s okay, she went to see her specialist last week and he said that she’s stable.

    Physician: Well that’s good.

    Patient: Yeah.

    Physician: And, did you take her in?

    Patient: Oh yeah, I drive her, I always do, you know.

    Physician: Alright. That’s actually one of the things I wanted to talk to you about today.

    Patient: Yeah, I was afraid of that. You know that that test really wasn’t fair.

    Physician: Henry, please, I know what you’re going to say. I have the results of your driving assessment, and I know how important this is to you and that’s why I wanted you to go to this independent, professional company for the test. But, all it did was confirm my fears about your driving. They say that unless there are changes with your Parkinson’s, you really shouldn’t drive …

    Patient: But …

    Physician: And I know this is the last thing you want to hear, but I agree with them.

    Patient: Yeah, but I’m a careful driver, doc. Honestly. I mean, I drive slowly, and we only have to go out to the drugstore, or the grocery or the doctor’s or you know, I can’t get her to the buses, it’s a half mile away. And I just got to drive her so that I can look after her properly.

    Physician: Well I know you’re careful Henry, but it’s your reaction to another driver or something unexpected that worries me. And you have to admit your vision’s not as good as it was. And you don’t want to be hurt, you don’t want Shirley to be hurt, or anyone else in an accident.

    Patient: No, no of course I don’t. But, but I mean they say down at the driving school or that older drivers are safer than these young yahoos driving around you. It’s, I mean, can’t we get another medication, or give me a larger dose or something …

    Physician: Henry. I do understand. But unfortunately, this is one of those situations that I will have to report it to the ministry and they’ll probably take your license.

    Patient: But you can’t tell other people about my … my Parkinson’s, can you?

    Physician: I’m afraid this is one of those situations that I’m forced to break patient confidentiality. And you know, I wish it could have turned out better. But as it stands I have some ideas on how to keep you moving without you being the driver.

    Patient: I can’t afford taxis, you know that. I mean you know where we live.

    Physician: Yes, but there are a number of seniors groups that are able to help, and there’s some in your area.

  • Challenge 2

  • Physician: Hello, Helen Sebastian?

    Patient: Yes, that’s me.

    Physician: Hi I’m Dr. Alvarez. We haven’t met before, I’m one of the residents here. We just actually changed our rotation yesterday so I’ll be looking after you now.

    Patient: Oh, okay, nice to meet you.

    Physician: You too. Do you mind if I have a seat?

    Patient: Oh no, please, do. You know there’s so many doctors in and out I’m not really sure who my doctor is, but …

    Physician: Right.

    Patient: I was hoping to go home soon and I think they’ve finished all the tests.

    Physician: Yes the tests are all in actually, that’s actually what I wanted to talk to you about. Now I see from your chart you’ve actually had some bloating and some other bowel problems over the last six months or so, is that right?

    Patient: Yeah, yeah. You know I didn’t really think much about it but I checked in with my doctor about it and he thought, given my history, I should …

    Physician: Yes, I see you have, two … two years ago you have had an operation. What did they tell you about that?

    Patient: Well, they said I had ovarian cancer and they were able to get it all and I’ve been feeling quite good actually.

    Physician: Right. So you’ve had two good years, or let’s say I guess, one and a half or so?

    Patient: Mhmm yeah.

    Physician: Right. Um Helen, do you mind if I call you Helen?

    Patient: No, please do.

    Physician: Um, forgive me, if you don’t mind my asking, is there anyone at home with you?

    Patient: Uh … uh, no, I’m divorced, and my children live out of town. Why … why are you asking?

    Physician: I see. Um, the results are in, and basically, we can go over them now. There’s no real easy way for me to explain this to you but the news isn’t very good I’m afraid. The CT scan and the ultrasound, um … they didn’t exactly give a definite reason for your bowel problems. But the laparoscopy did, and I’m afraid it looks like the cancer has in fact returned. Had you been worried about that possibility?

    Patient: Uh, yeah, you know, I had wondered, and sometimes I felt scared but, I don’t understand, I mean they said that they got it all, did they, did they lie to me? I feel good.

    Physician: No, I don’t think they lied, they honestly thought that they got it all but just try to understand that this is the nature of ovarian cancer, it often acts like this.

    Patient: Well I mean, how bad is it, is there treatment, like chemo or something?

    Physician: There are drugs that are used, sometimes …

    Patient: Yeah.

    Physician: … but I’ll be perfectly honest with you … Um, we don’t actually have a cure, for this. And the drugs that are used are very toxic, so it’s something that we would have to sit down and discuss.

    Patient: Uh, are you saying that, I mean what about an operation, you know they said that they could get everything last time, what about that?

    Physician: Helen I’m really sorry to have to … to have to explain this to you, but the cancer has spread throughout your abdomen and we just don’t have the ability to operate or a cure for it, we just don’t … we just don’t have it. Now, is there someone you would like to have by your side, a friend, a clergyman? We do have support staff here, on-site.

    Patient: Um, I think I just need to be alone for a few minutes. You know, maybe a little bit later I could talk to somebody.

    Physician: I understand. Is there anything I can do for you right now?

    Patient: No I just need a minute.

    Physician: Okay. I’m going to leave now, but when I return I’m going to come back with a social worker. If that’s okay, just because we feel it’s important to have someone here for you to talk to. That’s alright with you?

    Patient: Yeah.

    Physician: Okay. Alright.

Commentary on: Breaking bad news, challenges 1 and 2

The first interview illustrates the more common kind of breaking bad news situation. The news is not life threatening nor life-ending, although it is definitely unwelcome and disturbing to both physician and patient. The tone of this conversation shows two people who clearly have an ongoing physician-patient relationship. While the situation is not life-threatening, it represents a loss of freedom and independence. It may result in a profound emotional response from the patient, and perhaps a sense of guilt or helplessness in the physician.

Mandatory reporting 

There are a number of situations (e.g. suspicion of child abuse, and communicable diseases, etc.) in which a physician is legally required to report the patient condition to a third party. When a patient has a medical condition that makes them unfit to drive, a physician must be prepared to discuss this with the patient and may have a duty to report. Provincial and territorial reporting obligations vary, physicians must know how to have these conversations and where to find the appropriate resources. We recommend reviewing the following resources:

In cases of mandatory reporting, only the relevant information can be disclosed. The patient should be informed of the disclosure, and with the patient’s permission, a discussion with family is encouraged. You must clearly document the details of the discussion.

Those interested in finding out more about evaluating fitness to drive can read Determining Medical Fitness to Operate Motor Vehicles and consult DriveABLE.

The second interview is the classic kind described in the literature: a terminal illness in a patient unfamiliar to the physician. Also, the physician is a relatively inexperienced resident and is clearly uncomfortable. Compared to the first interview, he uses many more of the behaviours and techniques suggested in the literature. While his approach lacks finesse, his honesty and compassion are evident. What other behaviours suggested in the literature does he use? How successful are they? Which behaviours would help the physician communicate more effectively?


 

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