Walk Toward The Fire

It’s your last patient of rounds, and you’re seeing them last because there are usually many questions from their family. This is the patient’s fifth day in the hospital, and he hasn’t improved much. You’re concerned that he’s aspirating and don’t think he’ll do well at home. You take a deep breath and walk into the patient’s room. Immediately, you notice that the family member seated at the bedside looks angry, with arms crossed and a cold expression.  

Encounters like this are common in medicine and dreaded by many healthcare professionals. While clinicians are extensively trained in specialty skills, few are specifically taught how to navigate challenging conversations. Healthcare professionals speak to several patients and families daily, and these discussions are sometimes filled with emotionally charged topics. Entering such conversations without feeling confident in one’s skills can feel exhausting and stressful.  

Some of us would ignore the crossed arms and cool expression. We would give a succinct clinical update and leave the room as quickly as possible, moving on to see another patient. While this is a tempting path,  it usually leads to more distress later. 

Conflict is inherent to caring for others. In medicine, conflict has been described as “a dispute, disagreement or difference of opinion related to the management of a patient involving more than one individual and requiring some decision or action.” 

Conflict can feel like fire. Imagine walking in a pristine forest and seeing a smoldering campfire nearby. If you recognize and acknowledge the hot coals, douse them in water or dirt, it stops there. Conversely, if you turn and walk away, not addressing it, there could be a destructive forest fire. 

Just like the campfire, ignoring early signs of conflict can lead to escalation. Rather than walk away, walk toward the fire. Addressing conflict is critical and there are tools we can use. These, as well as other communication tools, are described at VitalTalk.org, Here are a few to keep in mind: 

1. Recognize the signs of conflict.

This can be body language or feeling as though someone else isn’t hearing you (chances are they aren’t feeling heard either.) Take note of sighs, eye rolls, or other signs of increasing irritation for the patient or family. Check your own emotions and recognize if you feel frustration.  

2. Find a nonjudgmental starting point.

Pause. Take a deep breath. Ask to discuss the issue without defensiveness or aggression. Try something like, “Sometimes this conversation can feel difficult,” or, “You and your family have been through a lot. Can we talk about this?” 

3. Listen first.

It’s critical to understand the other’s perspective. Really listen. Everyone knows the data that physicians interrupt patients after only 11 seconds. Often, we aren’t really listening but are instead preparing how we’re going to defend ourselves. To paraphrase Stephen Covey in “The 7 Habits of Highly Effective People,” listen with the intent to understand rather than the intent to reply.   

4. Identify what the conflict is about and articulate it as a shared interest.

There’s almost always a shared interest. A statement like, “We both want to see your loved feel better,” can help get everyone aligned.  

5. Brainstorm options.

Are options that meet both your medical recommendations and the family’s goals?  

6. Look for options that recognize the interests of everyone.

7. Remember that some conflicts can’t be resolved.

There will be times when you can’t find a middle ground, and you may feel that what the family is asking for is unreasonable. It’s ok to agree to disagree, and you can do this while preserving the patient-doctor relationship. Try a phrase like, “I understand that you feel like ____ might be helpful. I worry that that might cause more suffering and I can’t recommend it. What other things do you think could help?” Use the patient’s desired quality of life as the true north. 

In situation in the introduction to this piece, you use your skills to recognize that the family is upset. You sit and ask to talk. You learn that they feel like their loved one’s medical care has been fragmented and that no one really cares about their family member. This is a start to putting out the fire.  

This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.