Part of practicing medicine is telling patients NO. It’s never fun to do so and it can be a draining daily task. It doesn’t have to be that way! In this episode, we break down pitfalls and pearls in these situations as well as specific scripting to help the medicine go down.
Mentioned in this episode: Scott Weingart and I are putting on the Flameproof: Shift KickAssery workshop on May 29, 2023, at the Cosmopolitan Hotel, Las Vegas. 9a-1p. Limited space (intentionally). This is a PreCon for Essentials of Emergency Medicine. Register Here.
The Spock Retreat: falling back on logic to solve an emotional situation.
The scenario: a patient pushes for something that they think will help but will actually harm
- Asking/demanding antibiotics for a viral upper respiratory infection or sinusitis that began 2 days ago because that treatment is what has worked for them in the past
- What do you tell them? Probably something like, “You have a cold, antibiotics won’t make it better, in fact, all they’ll do is harm.”
- You lay out the… Logic.
- What did they just hear? Their ears picked up the noises you were making, but oftentimes, all they just heard was NO.
- How do we usually respond to being told no? It isn’t a discerning analysis of why we’re told no. It’s either feeling affronted, angry, or invalidated. Reason has just crashed against the wall of emotion. Logic has just met the limbic brain. How does that usually go? Not well.
A common response when we get pushback on our logic
- When logic does not work, we often double down and respond with more logic.
- One problem with this is illustrated by Nicholas Taleb in Black Swan “When you develop your opinions on the basis of weak evidence, you will have difficulty interpreting subsequent information that contradicts these opinions, even if this new information is obviously more accurate.”
You can’t please all the people all of the time
- There is a consistent minority who are just going to be pissed off regardless of what you say or if you don’t give them what they want (or what they think they want.)
- In healthcare, we are natural pleasers.
- When we are in a situation where a patient is displeased, it just doesn’t feel good.
When embracing our inner Spock is the right move
- Much of the time, Spock works really well in decision-making such as in critical situations, in the resuscitation bay, or even sitting in front of your computer interpreting data or generating a differential diagnosis.
When embracing our inner Spock could be the wrong move
- When we are giving the answer “no.”
- Sometimes this will be met with a reasoned reply, but often it’s met by an inner tantrum (if even only an echo of one).
Introducing Bones McCoy
- Dr. Leonard McCoy, AKA Bones is the ship’s doctor on the Starship Enterprise. Where Spock is pure logic, Bones understands emotion.
- It is our inner Bones McCoy who understands the needs of the patient in a compassionate and heartfelt way
Why scripting is important
- If you lament that you have to have a laborious and draining conversation 10 times a day, this is not the place to have a bespoke discussion that is built anew with every encounter.
- Just like you have a standard approach to medical issues, it’s ideal to have a standard approach to this one. Try experimenting to find the version of this conversation that works best for you (and your patients!).
How to approach a situation that is frustrating and illogical.
- Step 1. Notice if you are in the Spock retreat. Not that using logic is a bad thing, but we can use it as a defensive posture. The Spock retreat can be like an inner version of a Spartan battle phalanx ready for action! Hooah!
- But here you are engaging with a human being who’s approaching this from what likely they think is logical but is actually emotional.
- Step 2, take a beat, and then speak as your inner Bones Mccoy sprinkled with Spock.
- The only way to effectively meet emotion is with empathy and compassion.
- Step 3. Stay focused on your goals to prevent becoming overly emotional. What are the goals here?
- To make an accurate diagnosis and rule out life threats. To convey that and the treatment plan to the patient
- Understand and evaluate their concerns.
- To not get a patient complaint, although that is not fully in your control, deserves mention.
- To not prescribe an antibiotic.
- Key move. Do not dismiss or invalidate
What do you want to avoid?
How to say “no” in a positive way: The Yes, No, Yes framework, compliments of the Harvard Program on Negotiation
- First, understand why you’re saying no – what really matters to you? This is what you’re saying YES to. In this case, to avoid harm and also satisfy yourself that you’re doing the right thing. Or maybe, “I am saying “yes” to embracing the Hippocratic Oath and practicing medicine in accordance with those values.” This sets the foundation of your purpose.
- Validate their concern and history of what’s happened. The best way is to actually listen to them.
- When you speak, come from a place of respect. “Nope, not gonna happen,” vs, “I’m glad you shared that with me. This is a common experience for many patients, feeling better after starting antibiotics when they have a cold or recent sinusitis. Here’s what I see happen with that. Those who do and don’t take the antibiotics end up having the same duration of illness and those who get antibiotics get a lot more diarrhea. That may not have happened to you yet, but it’s the real deal. “
- You are saying no to the issue, not the person. This is a mindset shift from judgment to discernment. It’s much easier to say no to the question rather than the person.
- Avoid “You” statements” in favor of “The” statements. For example, “You are incorrect in thinking that an antibiotic will fix you,” vs, “The idea that antibiotics effectively treat this kind of infection is common and to the best of our knowledge, it’s just not the case.”
- Set the boundary. What you are and aren’t willing to do? This is important in life and medicine because, as Harvard Negotiankon’s William Ury says so eloquently, “What you say no to is part of what defines who you are.”
- Propose a viable alternative. Even though you’ve got this beautifully reframed as a yes, they’re still going to hear it as a no, so there needs to be another option. This can’t be a sleight-of-hand option where you’re trying to fake them out. This other option is your plan B and can’t be a compromise you’ll be uncomfortable with – this is a real plan.
- Expect resistance! Stay firm with your boundaries, but guide the patient to the acceptance of the situation with kindness and compassion.
What does Yes, No, Yes sound like in real-time?
- The internal Yes, I want to embody do no harm and practice evidence-based medicine.
- The external yes, “Good news, it doesn’t look like a bacterial infection or anything serious right now. “
- “You’ve told me that you’ve gotten better in the past when you’ve taken a z-pack (validation). This is a common experience for many patients (social proof), feeling better after starting antibiotics when they have a cold or recent sinusitis. In my experience, here’s what I see happen with that” those who do and don’t take the antibiotics end up having the same duration of illness and those who get antibiotics get a whole lot more diarrhea.
- It’s no fun having a cold, I know I hate it (compassion) what I’ve found works well for this situation is X plan”
A script for pushback.
- Frustrated patient, “So you aren’t going to write me for antibiotics?”
- You in a compassionate tone, “I hear you! And I know it can be frustrating (empathy and compassion). It’s a common question I get every day (social proof) and to the best of our knowledge, antibiotics do more harm than good with what you’ve got going on.”
Lon Setnik, MD FACEP, MHPE says
Hey Rob, thanks for the great session on negotiating with patients. I have a slightly different take that I’d like to share with you.
The mindset shift is from I have special knowledge to tell the patient (that viruses don’t need antibiotics) to THEY have special knowledge I need to really understand. The special knowledge in this case is what brought them to the ED. It’s what’s behind why they want antibiotics.
How do I know when I understand their special knowledge? When they say, “That’s exactly right.” I try to get there BEFORE the physical exam, so they have to whole time to see how I’m looking to address their underlying concern.
Here’s how it goes:
Me “So you’ve got chills, congestion, cough, and have had 2 negative COVID swabs in the last 3 days. What’s on your mind?”
Them “I can’t be sick, I think I need an antibiotic.”
Me “Tell me more”
Them “My husband has Parkinson’s and we are going to Tanzania in 2 weeks, I can’t miss this trip! It’s a life goal of ours and we will never be able to do it again.”
Me “So you’re worried if you don’t get the antibiotics now, you’ll miss the trip?”
Them “Well, I’m not missing it no matter what, but I can’t be sick for it, I’ll be with a ton of people, many who are older, I can’t be contagious. I need to be better.”
Me “So you’re thinking if you get an antibiotic now it’ll make sure you aren’t contagious for the trip?
Them “That’s exactly right.”
Me “Alright, let’s check you out!”
This is usually ONE MORE sentence than I had previously used. I have found this works 99% of the time. They feel heard, and I can address their ACTUAL fear, anxiety, reason for coming. In this case, “You won’t be contagious in 2 weeks, you might still be coughing, but an antibiotic won’t change that, and you could get something like C. Diff from it that would throw everything out of whack.”
If they feel, and this is a feeling that is earned by our action not our degree, that we can be open to them being reasonable, they will be open to us being reasonable. We have to lower the power differential, and believe in our souls that they have (in their mind) a good reason for the cost and time of an ED or UC visit, and our job is to find that reason, and be open to it, we will then avoid most of the arguments that might arise.
I hope after reading this, you say, “That’s exactly right” and I’m open to the idea that you could make this better 🙂
This concept is from the book “Never Split the Difference” by former FBI negotiator Chris Voss. It’s a great book that changed my thinking about negotiating.