Shakaib Rehman, MD, FACP 1

Ralph H. Johnson VA. Medical Center/Medical University of South Carolina, Charleston

Expanding Our Skills for Dealing With

Difficult Patient Encounter
Workshop WD04

SGIM
Annual Meeting, Loss Angeles
April 28, 2006

Shakaib U. Rehman, MD, FACP

Physician Manager, Assistant Professor
Ralph H. Johnson V.A. Medical Center
Medical University of South Carolina
Charleston, SC

Dennis W. Cope, MD, FACP

Professor and Chairman, Dept of Medicine
UCLA-Olive View Program
Sylmar, CA

Richard M. Frankel, PhD, FACP

Professor of Medicine
Indiana University School of Medicine
Senior Scientist
The Regenstrief Institute for Health Care
Richard Roudebush V.A. Medical Center

Soma Wali, M.D, FACP

Associate Professor and Program Director
UCLA-Olive View Program
Sylmar, CA
Shakaib Rehman, MD, FACP 2
Ralph H. Johnson VA. Medical Center/Medical University of South Carolina, Charleston

Objectives:
1. How to be more effective therapeutically and time efficient in dealing with
difficult patient situations?
2. How to increase clinical effectiveness when patient’s symptoms are not
explained by biomedical possibilities?
3. To enhance participants' skills in addressing the behavioral and
psychological aspects of medical encounters.
4. Participants will learn techniques to improve the patient satisfaction level
and reduce their stresses in every day practice.
5. To enhance participants’ repertoire of strategies for coping with patients
who are “difficult” to deal with.

What Your Patients Think of

You—and Vice Versa

From nationwide telephone polls taken for

Hippocrates by Roper Starch Worldwide
Inc. of 750 patients and 200 physicians in
August 1995. Answers do not include
“don’t know” responses.
Hippocrates, November/December 1995, pp. 40-41.
Shakaib Rehman, MD, FACP 3
Ralph H. Johnson VA. Medical Center/Medical University of South Carolina, Charleston

What behavior in your doctors do you

find most difficult to deal with?

E They’re too rushed 30%

E They’re hard to get hold of 19
E They speak too technically 11
E They don’t give enough guidance 5
E They’re too arrogant 5
E None 24

Who do you find most difficult to deal

with? The patient who:

E is hostile or angry 49%

E doesn’t follow instructions 19
E is too demanding or needy 19
E doesn’t know how to describe
his symptoms 11
E asks too many questions 2
Shakaib Rehman, MD, FACP 4
Ralph H. Johnson VA. Medical Center/Medical University of South Carolina, Charleston

Medical school does not train doctors

adequately to deal with the emotional needs
of patients. How strongly do you agree?

E Agree strongly 31%

E Agree somewhat 37
E Disagree somewhat 18
E Disagree strongly 12

Model of Clinical Care

Biomedical Model

• Find it
• Fix it

Communication model (The Four Habits of Highly Effective Clinicians)

• Invest in the Beginning

• Elicit the Patient’s Perspective
• Demonstrate Empathy
• Invest in the End
Shakaib Rehman, MD, FACP 5
Ralph H. Johnson VA. Medical Center/Medical University of South Carolina, Charleston

Model of Complete Clinical Care

Opening

Communication Biomedical Task

Tasks

Engage Find it
Empathy Fix it
Educate
Enlist

Closing
Shakaib Rehman, MD, FACP 6
Ralph H. Johnson VA. Medical Center/Medical University of South Carolina, Charleston

Outcomes of successful communication

Agreement on diagnosis

Informed consent

Adherence to treatment

Positive health outcomes

Mutual satisfaction

Decrease in malpractice risk

Communication matters
Improvement in health outcomes
– Diagnostic accuracy Beckman & Frankel, 1984
Safran et al, 1998;Roter,
– Adherence 1999; Haynes 2002
– Biological and psychological
measure Roter, 2000; Stewart 1999

Improvement in social outcomes

– Patient satisfaction Pathman et al, 2002
– Clinician satisfaction
– Informed consent Braddock 1997; 1999; Levinson, 1999
– Malpractice risk Beckman, 1994, Entman, 1994,
Levinson 1999
Shakaib Rehman, MD, FACP 7
Ralph H. Johnson VA. Medical Center/Medical University of South Carolina, Charleston

Different situations call for

S
E S
tailored responses
D U R E
U R “COMFORT ““CHALLENGE”
CHALLENGE”
”
Engage Acknowledge problems
E D

“HELP”
Empathize Discover
C E

meaning Extend the

Educate System
O C

Opportunities
R O

for compassion
Enlist
PR

Boundaries
P

The label “difficult”

is subjective
SE S
ES

„ Interpersonal in nature
M II S

„ Based upon discomfort with:

EM

‰ what has happened

RE

‰ what might happen

PR
P
Shakaib Rehman, MD, FACP 8
Ralph H. Johnson VA. Medical Center/Medical University of South Carolina, Charleston

“Difficult” is different for

individual clinicians
SE
M II S S
ES „ A patient labeled “difficult” by one
clinician may not be seen as quite so
difficult by another
EM

Differences in expertise and experience

RE

„
account for differences in perception
PR
P

“Difficult” is a function
of the relationship
SE
M II S S
ES

„ Two people
„ How they
EM

interact
PR
P RE
Shakaib Rehman, MD, FACP 9
Ralph H. Johnson VA. Medical Center/Medical University of South Carolina, Charleston

Clinicians can have fewer

“difficult” relationships by:
SE
M II S S
ES „ Discovering what factors contribute to the
label “difficult”
EM

„ Exploring techniques that can lead to more

satisfactory relationships
PRRE

„ Experimenting with new skills

P

Relationship difficulties
develop when….
E LL

• Success
DE

is frustrated
Cl
OD

ini
nt

“D” • Expectations
cia
ti e
MO

Pa

are
A M

misaligned
A

Illness
• Flexibility
Systems is insufficient
Shakaib Rehman, MD, FACP 10
Ralph H. Johnson VA. Medical Center/Medical University of South Carolina, Charleston

Instructions
In the spaces below, indicate which situation you believe would be (1) most difficult for you to
work with, (2) next most difficult, and (3) least difficult.

Then, in the space provided, jot down your reasons for selecting the situation you did as “most
difficult”.

SET ONE Situation A Situation B Situation C

Home to Prescription for Fill my disability
Puerto Rico Percocet form

-------------------- --------------------- ---------------------

Reasons for selecting the situation you did as “most difficult” for you

SET TWO Situation A Situation B Situation C

You don’t care Fat genes Heart beats
fast

-------------------- ----------------- -----------------

Reasons for selecting the situation you did as “most difficult” for you

SET THREE Situation A Situation B Situation C

Wants results You call my Sees a
now daughter naturopath

-------------------- ----------------- -----------------

Reasons for selecting the situation you did as “most difficult” for you
Shakaib Rehman, MD, FACP 11
Ralph H. Johnson VA. Medical Center/Medical University of South Carolina, Charleston

Review your selection above paying attention to the reasons for the selection.
Then complete the following statement.

“I tend to experience a situation as “difficult” when….”

Use adjectives or phrases to describe what you need in the clinician-patient relationship.

“Based upon this analysis, I see myself wanting clinician-patient relationship in which…”
Shakaib Rehman, MD, FACP 12
Ralph H. Johnson VA. Medical Center/Medical University of South Carolina, Charleston

Procedures to improve
relationships
„ ACKNOWLEDGE PROBLEMS

„ Discover Meaning

„ Opportunities for Compassion

„ Boundaries - Adjust

„ Extend the System

Difficult Patient encounter- Differing Role Expectations

When the doctor and the patient have a different expectation, difficulties may arise that lead to
impaired interactions during the medical interview. Some common examples may include:
• The patient expects you to prescribe medications that he or she requests – you expect
to perform a history, exam and understand the problem to confirm the medication is
safe and appropriate.
• The patient expects you to fill out disability papers – you expect to participate in a
discussion of whether the problem merits labeling as a disabling condition.
• The patient expects you to address 10 different problems in a 15-minute interview –
you expect to address one or two problems with appropriate level of attention.
Suggested Approach to Dealing with Differing Role Expectations:

1. Recognize there is a problem – often feeling discomfort in the interaction is a clue that
some boundary has threatened.
2. Begin a discussion of the issue.
3. Avoid blame and name-calling
4. Avoid thinking of yourself as a victim of patient
5. Set limits if rules of communication are dramatically broken
6. Negotiation:
a. Opening up the disagreement for conversation begins the process of negotiation.
b. Openness to what your patient is saying, whether you agree or not with his/her
theory, is an act of respect. Try to learn how the patient has come to his/her
opinion and what is motivating it.
c. Try to understand the patient and try to let the patient know that you understand.
Shakaib Rehman, MD, FACP 13
Ralph H. Johnson VA. Medical Center/Medical University of South Carolina, Charleston

d. If negotiation fails, you might end gracefully and peacefully despite disagreement.
7. Avoid:
a. Getting offended and settling into an intransigent position
b. Repeating yourself, more loudly each time.
c. Failing to understand your patient’s ideas and values.
d. Missing an opportunity for empathic communication.
8. Pearls: Ask what leads your patient to think what he or she thinks (patient belief system)
a. Etiology: ‘What do you think is wrong?” “What do you consider unlikely, but is
your most worrisome concern about what is wrong?”
b. Pathogenesis: “What do you think has contributed to your illness?”
c. Diagnosis: “What thought have you had about possible treatment needed for your
problems?”
d. Prognosis: “What thoughts have you had about possible outcomes of your
illness?”

Angry Patient
Anger in patients is usually obvious, but sometimes anger is expressed in more subtle ways such
as discordant message between the verbal expressions and the nonverbal communication.

Physicians frequently avoid addressing anger, most commonly by ignoring it or by changing

topic. The two most common reasons given for failure to address anger are for fear of unleashing
more anger, or fear of time involvement. This practice may escalate the anger. Responding to
patient anger with anger may further escalate the tension, prolong the encounter and visit may be
non productive.

Patients’ anger is usually a defense mechanism for dealing with a fear of their own:
- fear of loss of control
- fear of dependence
- fear of rejection
- fear of meaning of illness
- fear of inadequacy
- fear of dying

Following are some of physicians’ responses:

- fear
- Vulnerability
- Confusion
- Reduced empathy
- Resentment
- Sense of being manipulated
- Exhaustion
- Impatience
- Frustration
- Desire to punish
Shakaib Rehman, MD, FACP 14
Ralph H. Johnson VA. Medical Center/Medical University of South Carolina, Charleston

- Anger

Strategies:
1. Active Listening – Paralanguage skills, position, posture, eye contact, facilitative
responses, silence
*Try talking as little as possible during this time. Listen and paraphrase what you’ve heard.
2. Framing – “Sounds like what you are telling me…”
“Let’s see if I have this right…”
3. Reflecting Content – Factual as well as nature and intensity
4. Identifying and Calibrating the Anger – Sometimes content is evident, but nature of
anger is unclear
“That situation really got to you, didn’t it?”
“I can imagine how angry I’d feel if that happened to me”
5. Requesting and Accepting the Correction – “Did I get that right...?”
6. Empathy – Three implications
Cognitive – enter patients’ perspective but don’t loose your own
Affective – put yourself in patient’s place
Action – verify emotion so patient can correct and/or feel listened to.
*If you’d like to show empathy without saying “I’m sorry” which might imply responsibility for
the situation, consider using a statement with the words” I wish”, for example, “I wish you didn’t
have to wait as long as you did.”

* Empathy is not the same as agreeing with patient. Empathizing is expressing understanding of
how the patient feels.

7. Sorry - I you made a mistake that lead to anger, admit it and apologize.
Do not try to excuse, explain or discuss specifics at first… the patient will need to have his or her
feelings validated first before they are willing to listen if they are angry. Trying to excuse the
problem may lead him or her to feel as if their feeling is not valid and lead to more anger.

8. Consider Motivation – Secondary gain? Hidden agenda

9. Recognizing Physician Limitations.

Dealing with Patient Emotions

Dealing with a patients’ anger or any such strong emotion could be a challenging task during the
medical consultation/interviewing. The strong emotion could affect the interview process in
many ways including the ability for the physician to obtain necessary information during the
interview, to negotiate a plan of care with patient and to have a long-term relationship for
continued partnership in care.

It is important to address and diffuse the emotions otherwise it will create barrier to effective and
efficient communication during the encounter.
Shakaib Rehman, MD, FACP 15
Ralph H. Johnson VA. Medical Center/Medical University of South Carolina, Charleston

Following is a suggested algorithm providing strategies for dealing with difficult emotions.
(Mnemonic: NURS the emotion)

1. Name – name the emotion

a. I can see that you are frustrated…”
b. If you’re not sure of the emotion or you “guess” wrong… the
patient will correct you….”I’m not frustrated, I’m angry”
c. Move forward and name the correct emotion, “I can see that
you are angry…”

2. Understand – show the understanding of the reason for the emotion

a. “I can understand how you would be angry if you had to wait as
long as you did…”
B. Or ask the patient the reason for his emotion

3. Respect – Provide recognition for the helpful behaviors the patient is

exhibiting
a. “I appreciate the fact that you choose to wait to see me even if you
were upset about…..”
b. Respect their reason with out judgmental comments.

4. Support – Provide a statement of ongoing support and partnership

a. “I’d like to know that I am going to do my best to help you with
the time we have today..”

Motivational Interviewing Skills

Developing Discrepancy by Eliciting Change Talk:

1) Evocative Questions for all 4 types of change talk

- Disadvantage of status quo -- What worries you about your condition?
-- What difficulties have you experienced?
- Advantage of change -- If your condition magically went away,
how might your life be better?
-- What would be good about quitting?
Shakaib Rehman, MD, FACP 16
Ralph H. Johnson VA. Medical Center/Medical University of South Carolina, Charleston

- Optimism about change -- When have you changed in the past?

-- Who might support you in this change?
- Intent to change -- What do you think you might do?
-- What do you want to happen?
2) Importance Ruler – “On a scale of 0 to 10, how important is change right now?
follow up w/ “What would it take for you to go from (answer) to (higher #)
and “Why are you not at 0?”

3) Exploring both sides of the decisional balance – don’t just focus on the
negatives of behavior and the positives of change, help the pt to explore both sides of
the ambivalence, keeps you from arguing against pt

4) Elaboration – once a pt starts change talk, keep them talking about it by asking
- “In what way? How much? When?”
- for an example
- “What else?”

5) Query extremes – “What is the worst thing that could happen to you if things
stay the same?”
“If the best came of your change, what would that be like?”

6) Exploring values – Find out what is important to patient. Is this affected by

condition?

Rolling with resistance:

1) Simple reflection – acknowledge pt’s concern, without being defensive

“It’s hard to imagine how I could understand”

2) Amplified reflection – take pt’s statement farther than intended “My wife is
always exaggerating. I haven’t ever been that bad.” Response “It seems to you that
she has no reason for concern.”

3) Double sided reflection – “You are experiencing a lot of pain and at the same time
you think that exercise will help in the long run.

4) Shifting focus – “Ok, the judge said I have to be here, tell me what I have to do.”
Response “I don’t know you well enough for us to even start talking about what
makes sense for you to do, instead, let’s…”

5) Reframing – offer new meaning to pt’s observations (after validating) ex. Pt is

disappointed at multiple failed attempts to change, reframe to emphasize
perseverance and learning from set backs

6) Agreeing with a twist “Nobody can tell me how to raise my kids. You don’t live there
or know how it is.” Response “The truth is that it really is up to you how your kids
Shakaib Rehman, MD, FACP 17
Ralph H. Johnson VA. Medical Center/Medical University of South Carolina, Charleston

are raised. You’re in the best position to know which ideas are likely to work or not.
It really is important that you are a full partner in this.”

7) Emphasize personal choice and freedom – helps to diminish “No one tells me what to
do” response. e.g. “I can give you information, but the choice is up to you.”

8) Paradox - “It may just be worth it to you to keep on drinking as you have, even
though it causes some problems. It’s worth the cost.” “It’s possible that after giving it
another try, you still won’t be any better off, so it might be better not to try at all.
What do you think?”

9) Active paradox – set up a role play where you argue against change and the pt has to
try to convince you otherwise

Bibliography of Difficult Patient Interactions

1. Walling A, Montello M, Moser SE, Menikoff JA, Brink M. Which patients are most
challenging for second-year medical students? Fam Med. 2004;36(10):710-4.
2. Eggly S, Tzelepis A. Relational control in difficult physician-patient encounters:
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Dec;3(6):532-7.
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6. Daberkow D 2nd. Preventing and managing difficult patient-physician relationships. J La
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8. Simon JR, Dwyer J, Goldfrank LR. The difficult patient. Emerg Med Clin North Am.
1999; 17(2):353-70
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10. Hahn SR, Thompson KS, Wills TA, Stern V, Budner NS. The difficult doctor-patient
relationship: somatization, personality and psychopathology. J Clin Epidemiol. 1994
Jun;47(6):647-57.
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14. Crutcher JE, Bass MJ. The difficult patient and the troubled physician. J Fam Pract. 1980
Nov;11(6):933-8.
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(1978). 298(16): 883-887.
Shakaib Rehman, MD, FACP 18
Ralph H. Johnson VA. Medical Center/Medical University of South Carolina, Charleston

16. Steinmetz D, Tabenkin H. The 'difficult patient' as perceived by family physicians. Fam
Pract. 2001;18:495-500.
17. Beckman, H. B., K. M. Markakis, et al. "The doctor-patient relationship and malpractice.
Lessons from plaintiff depositions." Archives of Internal Medicine. (1994).154(12):
1365-1370.
18. Levinson, W. "Frustrating patients: using our feelings as diagnostic clues [editorial;
comment]." Journal of General Internal Medicine. (1991). 6(3): 259-260.
19. Fisher, R., W. Ury, et al. Getting to Yes: Negotiating Agreement Without Giving In.
Boston, Houghton Mifflin. (1991).
20. Novack, D. H. "Therapeutic aspects of the clinical encounter." Journal of General
Internal Medicine. (1987). 2(September/October): 346-354.
21. Novack, D. H., A. L. Suchman, et al.. "Calibrating the physician: Personal awareness and
effective patient care." JAMA (1997) 278(6): 502-509.
22. Lipkin, J., M., S. M. Putnam, et al. The Medical Interview. (1995).NY, Springer-Verlag.
23. Tavris, C. (1982). Anger: The Misunderstood Emotion. New York, Simon and Schuster.
24. Platt, F. W. (1995). Conversation Repair: Case studies in doctor-patient communication.
Boston, Little, Brown and Company.
25. Platt, F. and G. Gordon (1999). Field Guide to the Difficult Patient Interview.
Philadelphia, Williams and Wilkins.
26. Suchman, A. L., K. Markakis, et al. (1997). "A model of empathic communication in the
medical interview." Jama 277(8): 678-682.
27. Hahn SR. Physical symptoms and physician-experienced difficulty in the physician-
patient relationship. Ann Intern Med. 2001 May 1;134(9 Pt 2):897-904.
28. Eggly S, Tzelepis A.Relational control in difficult physician-patient encounters:
negotiating treatment for pain. J Health Commun. 2001 Oct-Dec;6(4):323-33.

Bibliography for How to Break Bad News

1. Buckman R. How to break bad news: A guide for health care professionals.
Baltimore,Maryland, Johns Hopkins University Press, 1992.
2. Cassileth BR, Zupkis RB, Sutton-Smith K, March V. Information and participation
preferences among cancer patients. Annals of Internal Medicine, 92:832-836, 1980.
3. Christensen, J. F., W. Levinson, et al., The heart of darkness: the impact of perceived
mistakes on physicians, Journal of General Internal Medicine 7(4), 1992, p. 424-431.
4.Frankel, R. M. (2000). Challenges and opportunities in delivering bad news. Physicians
Quarterly. 25: 1-6.
5. Gawande A. Whose body is it anyway: What doctors should do when patients make bad
decisions. The New Yorker, Oct. 4, 1999, pp. 84-91.
6.Girgis, A., Sanson-Fisher, R.W., Breaking bad news: Consensus guidelines for medical
practitioners. Journal of Clinical Oncology 13(9), 1995, p. 2449-2456.
7.Ley, P., Memory for medical information, British Journal of Social and Clinical Psychology,
18, 1979, p. 245-255.
8. Lo, B., Quill, T., Tulsky, J., Discussing palliative care with patients, Annals of Internal
Medicine 130(9), 1999, p. 744-749.
9. Maynard, D. W., On clinicians co-implicating recipients' perspective in the delivery of
diagnostic news, Talk and Social Structure: Studies in Ethnomethodology and
Shakaib Rehman, MD, FACP 19
Ralph H. Johnson VA. Medical Center/Medical University of South Carolina, Charleston

Conversation Analysis, D. B. and. D. H. Zimmerman, Cambridge, Polity Press, 1991, p.

331-358.
10. Ptacek, J. T., Eberhardt, T.L., Breaking bad news: A review of the literature, Journal of the
American Medical Association, 276, 1996, p. 296-302.
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151:463-68, 1991.
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Internal Medicine, 92:837-842, 1980.
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26:81-101, 1985.
14. Fallowfield, L., M. Lipkin, et al. (1998). "Teaching senior oncologists communication
skills: results from phase I of a comprehensive longitudinal program in the United
Kingdom." Journal of Clinical Oncology 16(5): 1961-1968.

References for Patients Refusing Medical Treatment:

1. Arthur Kleinman, MD "Eight questions" (p. 260) in the book: The Spirit Catches You
and You Fall Down by Anne Fadiman.
2. Roth LH, Meisel A, Lidz C. Tests of competency to consent to treatment. Am J
Psychiatry. 1977; 134(3):279-284.
3. Culver C, Gert B The Inadequacy of incompetence. The Milbank Quarterly. 1990;
68(4):619-643.
4. Mebane A, Rauch H. When do physicians request competency evaluations?
Psychosomatics. 1990; 72:211.
5. Frankel, R. M., T. Stein, et al. (2003). The Four Habits Approach to Effective Clinical
Communication, Kaiser Permanente: 1-18.
Questions

QUESTION # 1
The Four Habits of Highly Effective Clinicians include all of the followings except.

A. Invest in the Beginning

B. Elicit the Patient’s Perspective
C. Finding and fixing the problem
D. Demonstrate Empathy
E. Invest in the End

QUESTION # 2
Outcomes of successful communication will include all of the following except.
A. Agreement on diagnosis
B. Better adherence
C. Mutual satisfaction
D. Positive health outcomes
E. Increase in malpractice
Shakaib Rehman, MD, FACP 20
Ralph H. Johnson VA. Medical Center/Medical University of South Carolina, Charleston

QUESTION # 3
Last year you found that your patient, an active 56yo carpenter who also serves in city
government, had diabetes. He dieted and walked more and lost 15 pounds, reducing his Hgb
A1C from 8.5 to 6.0. This year, his weight slowly increased and his A1C is 8.5. His wife reveals
his liking for Girl Scout cookies. Patient complains of worsening hip pain, which you previously
successfully treated with NSAIDS. After discussion, you advise him to lose 15 pounds again,
and he says, "Oh doctor, with my hips, I just can't walk enough!" His wife again interrupted and
complained about his sweet tooth.

Which of these POSSIBLE RESPONSES do you prefer?

A. Perhaps stopping cookies will get the weight off.

B. I think I can ease your hip pain.
C. You lost weight before; can you do it again?
D. You may have to start a diabetes medication.
E. You want to manage the diabetes, but are concerned you can't lose weight because of
your hip pain and your wife is worried about your eating habits.

QUESTION # 4
You are doing an initial complete history & physical examination on a new patient who is a 42-
year-old construction worker. Two days prior to the visit his spouse called you and made you
aware of the fact that she is very worried about his heavy drinking and that she wanted you to be
sure to address it in the context of the visit, but not to divulge the fact that she called.
During the history taking the patient reveals that he has 3-4 beers "on the way home with the
boys" then usually another three or four each evening. He made it clear that he sees this as a
modest intake as it is "only beer." He denied having his drinking ever interfere with his
interactions at home, his work situation or his driving, although he reveals he had one "close
call" for a DWI.

Which one of these POSSIBLE COMMENTS regarding this patient's drinking do your prefer?

A. Your alcohol intake is clearly excessive and will likely get you into medical trouble down
the line.
B. I understand from your wife that your drinking has been a problem at home.
C. You are drinking the equivalent of six or eight shots of liquor each evening.
D. I am concerned about your drinking.
E. It is only a matter of time until you get caught for a DWI.

QUESTION # 5
Shakaib Rehman, MD, FACP 21
Ralph H. Johnson VA. Medical Center/Medical University of South Carolina, Charleston

About 25-305 patients in practice are considered “difficult to deal with”. ADOBE model is a
good mnemonic for strategies to deal with these patients. All of the following are part of the
ADOBE model except.

A. Acknowledge the problem

B. Discover meaning
C. Opportunities for compassion
D. Adjust boundaries
E. Educate the patient

Answers:
Question # 1: C
Explanation: Finding and fixing should be part of complete care model but it is not the part of
communication model.

Question # 2: E
Explanation: Research has shown that clinicians could reduce the malpractice risks by using
communication model.

Question # 3: E
Explanation: Research shows that engagement and commitment are enhanced when doctors
paraphrase patient's thoughts, particularly when the patient's initial response is qualified or
negative. This strategy is called "reflective listening". It demonstrates your attention and gives
the patient freedom to suggest a plan, to ask a question, or to name additional concerns. Letting
him have the lead ((as well as his wife)) will boost your efficiency at finding successful
solutions.
Giving orders (C) or simple fixes (A, B) to complex lifestyle problems often fails. People will
succeed only when they make a considered decision.
Shakaib Rehman, MD, FACP 22
Ralph H. Johnson VA. Medical Center/Medical University of South Carolina, Charleston

Threats (D) leave him hanging and stifle dialog, as would emphasis on his admitted transgression
(A).

Question # 4: D
Explanation: Personal ("I") statements reflecting sincere concern on the part of an empathic
physician are very powerful tools in building a relationship and gaining trust. In a patient who is
still in denial, accusatory statements such as A or E often only result in further alienation from
the clinician. An educational statement such as C, to help with the reality check can be helpful,
but perhaps not as an initial offering. Certainly statement B, which betrays trust in three
directions will only serve to make the patient suspicious and likely not return.

Question # 5: E
Explanation: The correct answer is Extending the system

Notes