Modules

Communicating with adolescents

Part 5

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

  • Anne Gregory, a pediatrician specializing in adolescent eating disorders
  • Phil Hofmeyer, a pediatric psychiatrist
  • Gary Collins, a social worker
  • Mary Welbourne, a dietician
  • Ben Taylor, a pediatric resident doing a rotation in adolescent medicine
  • Jennifer Bryant, a nurse practitioner
  • Jennifer: All right, our next patient is Kelsey Cournoyer a referral from Dr. Burnside in Humphreys Harbor, seen last week. Ben, you did the initial history do you want to give us a background? Speaker

    Ben: Sure. She’s a 15-year-old girl presented to her family doctor six months ago. At the time, she weighed 45 kilograms and her BMI was calculated at 17. She was having regular periods which started at 13 years old but then they stopped two months ago. She was in denial and seems to have features of weight phobia presentation. She was sent to a dietitian then she was sent to a family therapist but without really much response. She continued to slowly lose weight, has admitted to episode of bulimic behavior as well. I would say her risk factors are pretty much typical. She did well in school. She’s a high achiever. She restricts her diet. Her mother also diets. Family conflict with the recent divorce proceeding. She also was kicked off the skiing team for not maintaining her weight.

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

    Ben: She seems to fit the criteria. She’s got also a subtype of bulimia.

    Anne: And no features of depression or any other major psychiatric disorder?

    Ben: Not so far.

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

    Ben: No.

    Anne: Okay sounds good, Ben.

    Jennifer: Does anyone have any questions about the diagnosis? All right, who’s next?

    Gary: Well, I can certainly agree with Ben on the family conflict piece. The parents are getting a divorce but I think the problem started before that and had an impact on Kelsey’s behavior. She doesn’t get along well with her father and her mother, unfortunately, doesn’t seem to be very strong emotionally. There’s a lot of work to be done I believe with Kelsey about her family.

    Phil: Kelsey’s eating disorder behavior really started with typical teen rebellion and a vulnerable personality. There’s been some mild features of obsessive compulsive behavior but it’s really about anxiety. She’s angry. I mean, she’s angry at everybody but there are no signs here of depression in Kelsey and there’s no sign of suicidal ideations. So, I don’t think at this point that we should be treating with medication.

    Gary: Yes, I agree. She might respond to counseling and behavioral therapy a lot better.

    Phil: Yes.

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

    Mary: I’ve been thinking about her diets. Now, she’s limited herself to a couple of vegetables at the moment but I think we can work around this to improve her caloric intake. My main concern is inpatient or outpatient. The family situation is so complicated at the moment, I think it might be worth it to have her admitted for a while. I don’t see the appropriate resources at home.

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

    Gary: Yes but how can we consider that knowing she lives 200 kilometers away and her mother has two other children. She can’t possibly make it to daily treatments. Mind you, if she’s inpatient now we’re taking her away from her friends and school which may be her only means of support at the time.

    Mary: They’ve had no luck with the dietician at home.

    Ben: So there’s no actual medical reasons for admission but then there’s no local resources; so what do we do in this situation?

    Anne: Well, any ideas?

    Jennifer: She has already seen on a local social worker who does family therapy and the family doctor does seem invested in her care; so maybe they can work together to manage it especially since the family dynamics are so important in this case. Phil, what do you think?

    Phil: I’ll be happy to talk to the family physician. I think that I could get something organized over there.

    Anne: Okay, let’s look into that.

    Jennifer: All right., so our next patient…

Commentary

Inter-professional relationships and conflict resolution

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

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

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

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

How well teams function depends on several factors:

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

 

Conflict resolution

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

 

Sources of conflict

Differences in:

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

 

Ways of thinking about conflict

Naming
Learn to recognize the signs and symptoms of conflict.

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

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

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

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

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

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

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

 

Read the following articles:

Reflective exercise 6

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

Commentary

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

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

Physicians often expect to be, and are, the leaders of teams. Here it would seem to be the nurse-practitioner, an indication of the current more egalitarian view of health-care teams (Question 2). However, while the nurse-practitioner is certainly the administrative leader, how are decisions made? You might have chosen “B” rather than “A” in that case.

For Question 3, you might wonder why the decision about in-patient/out-patient treatment was a conflict, whereas the other choices were not. Clearly, all were in agreement with the diagnosis. The social worker and psychiatrist both felt comments on depression were within their area of expertise and in this case, they agreed, a decision accepted by the others. There was no discussion of severity; everyone deferring to the pediatrician’s expertise. The treatment issue brought up a difference in viewpoint that most members felt comfortable addressing. The problem of patient placement, admission and discharge is one that occurs frequently between physicians and other health-care professionals (Question 4). One reason for that is addressed in the next question. The pediatrician dismisses the dietician’s concerns, saying other patients are “sicker.” What does “sicker” mean to each of the team members? The pediatrician indicates her meaning earlier, in the interrogation of the resident: “metabolic, cardiac abnormalities?” The dietician says that the family situation is “so complicated.” This demonstrates different ways of looking at a problem and, if this is not recognized, a simple disagreement may escalate into conflict.

The social worker tries to frame the problem by elevating the discussion to non-personal issues and presenting all sides of the issue — he is collaborating (Questions 5 and 7). If the dietician felt as though her expertise had been attacked (watch her non-verbal response to the pediatrician), this may have added tension. The resident summarizes by stating both sides of the issue (Question 6). Note how a decision is reached. No-one challenges the pediatrician’s decision not to admit the patient. This is not a team in which decisions are made by vote. She does however ask everyone to problem-solve: “any ideas?” The nurse-practitioner, who may have the best overall view of the issues, suggests a compromise (Question 8), proposing collaboration between the local physician and the social worker.


 

Next: Conclusion

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