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Scripting tough talks
A group takes a practice-makes-perfect approach to difficult conversations

Keywords: Hospitalists write and practice scripts to improve their communication with patients


by Phyllis Maguire



Published in the July 2012 issue of Today's Hospitalist

CHANCES ARE THAT your hospital is filled not only with sick patients, but with communication minefields about to explode. Think angry patients, ED doctors who insist on an admission or a boss who's sure you've got time to head up one more committee.

"We are the first people outside the ED who patients meet in the hospital, and often they're not happy, which catches us by surprise," says Margarita Ibanez, MD, the assistant medical director of the hospitalist group at Baptist Hospital in Miami." We're the ones who have to set the
"We are the first people outside the ED who patients meet in the hospital, and often they're not happy."

Margarita Ibanez, MD
Baptist Hospital

tone."

To help the hospitalists in her group with difficult conversations, Dr. Ibanez and her colleagues decided to take a practice-makes-perfect approach. They identified nine critical conversations that hospitalists struggle with. Then they wrote scripts to illustrate the worst and best ways to handle each of those. Group members then used role play and individual training sessions to practice using each script.

The sessions, which went from October of last year to May of this year, have been a big help. "I no longer feel like I'm being attacked if a patient is angry," says Dr. Ibanez. She's instead able to stay calmer during tough talks. "It's taken a big weight off my shoulders," she adds, "which makes me a better doctor."

What made the list?
Dealing with angry or frightened patients was the subject of one of the tough-talk workshops, which 10 of the group's 16 hospitalists attended every other week. (The other six physicians were placed in an informal control group to gauge the impact of the training.)

Other critical conversations focused on meeting the patient for the first time; facilitating admission and discharge, which addressed communicating with nurses and other staff; delivering bad news; obtaining consent; transferring care to another physician; dealing with competency comments, which crop up when a patient insists on seeing a specialist; and asking for help and getting to "no."

Group meetings consisted of workshops in which physician volunteers wrote and acted out three scripts for a worst, better and best scenario on that specific topic. Individual physicians then each had five sessions over the eight-month period in which they practiced the "best" scripts and delivery.

Group and individual sessions lasted about two hours. The hospitalists worked with the Center for Executive Leadership, a Boulder, Colo.-based company that helps organizations foster better leadership skills. The consultants assisted in both the group and individual sessions and helped guide script development.

Taking "the second position"
Dr. Ibanez says that during the sessions, she learned how variable physicians can be in approaching the same situation.

"Many times, doctors didn't realize the important points to cover," she says. "They don't mention certain things, or they use language that gives a very different effect."

Probably the biggest mistake the physicians made in each type of encounter was taking things personally and getting defensive. And many physicians confronting an angry or frightened patient automatically make the mistake of trying to come up with an immediate solution.

"We learned that listening to patients was more important to clarify what was really making them upset," says Dr. Ibanez. As part of that clarification, physicians practiced paraphrasing what patients were saying about their fear or anger.

Dr. Ibanez also lists several pointers that the physicians practiced, regardless of the specific encounter: Maintain good eye contact, sit down when talking and be aware of your body posture. Don't cross your arms, for instance, because it makes you appear more defensive.

The communication consultants "also taught us a lot about 'being in the second position,'" she explains. "That basically means seeing things from the perspective of the patient or the staff, and being better listeners."

Pocket cards and apps
To gauge the impact of the scripts, the hospitalists devised surveys to assess patients' experience with the doctors who went through the training and those who didn't.

Preliminary results show that the physicians practicing the scripts have a slight edge in terms of patients perceiving respect and compassion and feeling they received understandable, timely care.

Eventually, Dr. Ibanez says, all the hospitalists will take part in the training sessions and learn the scripts. The group may try to expand the process to other specialties using the hospital's simulation center.
In the meantime, each script is being printed on a card that the hospitalists can carry to refresh their training. The group is also turning the scripts into a smartphone app.

"We definitely need constant reminders," says Dr. Ibanez. "This isn't a one-time thing."

Phyllis Maguire is Executive Editor of Today's Hospitalist.


A script for delivering bad news

WHAT'S THE TOUGHEST CONVERSATION that hospitalists struggle with? According to Margarita Ibanez, MD, the assistant medical director of the hospitalist program at Baptist Hospital in Miami who spearheaded a program of scripted sessions to help doctors communicate more effectively, the No. 1 communication challenge is dealing with angry or frightened patients.

But a close No. 2 is delivering bad news. Working with a consultant company, Dr. Ibanez says that she and her colleagues learned to follow a script in that situation that uses the SPIKES acronym:

S: Set up the interview. When delivering bad news, Dr. Ibanez says, "make sure that patients have with them any family they want present and plan a time when you're not busy and not getting phone calls."

P: Perception.

I: Invitation. Steps 2 and 3 both relate to how doctors need to determine what patients already know and "how much they want to know and how much they don't want to know," she says. "We think that everyone needs to know everything, and that's not necessarily so."

K: Knowledge. "When you're delivering information, make sure you're talking in patients' own vocabulary and using words they can understand," says Dr. Ibanez. "Instead of 'metastasize' in cancer, say 'spread.'"

E: Be more empathetic. Pay attention to patients' emotional reactions. Doctors should be comforting and should pace the discussion with patients' reactions in mind.

S: strategies. "Outline your next several steps of what we can do next," says Dr. Ibanez.

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