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Managing Conflict & Negotiation Skills

Drs. Ramesh Mehay & Nick Price Programme Directors (Bradford VTS)

1. the causal factors leading to conflict 2. systems and strategies that may prevent it 3. skills in managing conflict positively

John is a 54 y old man you have been seeing for low back pain and has been getting repeat sick notes from you. One day, on a home visit to someone else, you see him working in his garden. Youve asked him to come in. Call him in.

What's all the Fuss?

"An exhausting consultation between a doctor and a patient which often triggers off some powerful emotions either in the doctor dealing with them, in the patient or both!

And it can affect the next consultation


You might carry those feelings back home stress, fear, anger, low morale, helplessness The patient might feel and take them home too
and thats not fair nor good for either of you

Can you relate to any of this

Are you hooked?

So, What are we after?

A (patient) lose lose (doctor) aproach ?
A (patient) win lose (doctor) aproach ? A (patient) lose win (doctor) aproach ? A (patient) win win (doctor) aproach ?

The Session Plan from here

1. 2. 3. 4. Causation Strategies & Skills to Prevent It Strategies & Skills to Halt Escalation Recovery strategies when things go really belly up

Individually: take the next 5 minutes to reflect on a emotionally dysfunctional consultation and the factors you think led to it In trios, pool together your thoughts and discuss new items (flip chart) Team up with another trio and pool together your thoughts and discuss new items (flipchart)

Buckets of Shit: Causation

Unidirectional Consultations

Failing to ICE illness vs disease Missing cues empathise Personalities Language Egotism


doctor Before the consultation: accessibility conflict with others (other patients, reception) Doctor running late


Patient behaviour that annoys the doctor Christie & Hofmaster (1986)
Pull Yourself Together report (2000), Mental Health Foundation) Certain Medical Illnessses - Christie & Hofmaster (1986

Doesnt all this remind you of JoHaris Window?

Things the patient knows

Things the patient dont know

Blind spot

Things I know about the patient Things I dont know about the patient




In trios, think about.

1. Things you can do to prevent consultations from going bad
2. How you can recognise things are going bad 3. What can you now do to try and stop things getting worse (15 minutes)


The Calgary Cambridge model

You cant go wrong!

Read the patients notes Acknowledge and apologise
for running late etc you told me to come in Any others?

Establish Rapport and attend to patients comfort (physical, emotional) Figure out their agenda Neutralise YOUR feelings Be aware of your own negative verbal/non verbal cues

1. 2. 3. 4. Explore ICE properly Figure out the ILLNESS vs disease Really show EMPATHY Figure out the patients agenda, Identify your agenda, and BLEND the two.(SHARED AGENDA SETTING)


AVOID PREMATURE REASSURANCE PITCHING explanation SHARED planning WITH the patient CHECK understanding and acceptability (seeking agreement before moving on)

Paying attention to your language

Prefacing your remarks
Sounds like", "So,", "In other Words", "Youre saying"

Avoiding absolute words such as "always" and "never" Replacing "loaded" words with neutral words.
"wastes time" "takes time to"

Using words/phrases that have positive connotations

"She always wastes time" "You want to work more efficiently.

Reflecting the emotional tone of the message as well as the words

eg sound like you feel xxx because of yyyy

Responding to Cues
Verbal/Non-verbal Suchman 1997: patients seldom verbalise their emotions directly and spontaneously, but tend to offer cues instead Skills to Consider: Encouragement, Silence, Repetition (echoing), Paraphrasing

Following the helical model

ie what I say influences what you say in a spiral fashion (ie what you then say influences whay I say next) reiteration and repetition coming back around the spiral of communication at a little different level each time are essential


Read the patient continuously

Verbal (HEAR) tone, pitch, rate, content I sense that you're not quite happy with the explanations you've been given in the past. Is that right?' Non-Verbal (SEE) facial expressions, posture, agitation 'Am I right in thinking you're quite upset about your daughter's illness? Check how you are feeling


Take a deep breath, stay calm. Neutralise YOUR feelings Be aware of you own negative verbal/non verbal cues Dont fight anger with anger, Dont be defensive Look for the reason for the reaction, remember, its often not personal Recognise and accept the feelings as natural and reasonable Remember that the irrational component of anger may have it origins from previous experiences and you may need to explore this (with care)

Specific Communication Skills

Get down physically to the patients level Feedback what you see or hear Go back and revisit the patients framework + other contributory reasons for the anger (INFO GATHERING) Listen to the patients distress Express empathy, concern and support Apologise that they feel upset (and mean it!) Reformulate the main problems for the patient (INFO GATHERING) Move on with the patient re: possible solutions, ways forward (JOINTLY) = PLANNING Offer realistic and achievable help (PLANNING)

Try it again
John is a 54 y old man you have been seeing for low back pain and has been getting repeat sick notes from you. One day, on a home visit to someone else, you see him working in his garden. Youve asked him to come in. Call him in.

Confrontation with a little C

Sometimes, a little bit of confrontation can be good eg challenging an attitude, belief or behaviour, to bring something to someones attention, an uncomfortable truth Your aims in this case would be to Allow the pt to hear and acknowledge you without destroying to Dr-Pt relationship To address behaviour whilst affirming the patients worth as a person BUT: our own anxiety gets in the way: our past experiences of confrontation (personal and professional) and the present situation lead us to either to sledgehammer or pussyfoot or avoid

How DO You Do IT Then?

Be honest, be supportive Feedback what you have seen or heard directly from the patient its hard to argue with the evidence BUT Do this sympathetically. Heron shows you how..

Heron (1975) says

Signpost your intent State what the problem is & the effect it has
effect on U and patient, use I statements

State what you would like to happen

and why (eg the benefits for both of you)

Make a valueing statement about the person

separate the pts behaviour from them as a person

Overtly demonstrate your care/empathy Then give plenty of time, ask about feelings, explain difficulty fo u too, negotiate how to move on (planning)


Why recover? Let it go???

It is cost saving Avoids polarization of parties It is educative thru understanding Probes wider issues It promotes fairness Gives disputants more control over the dispute process

You may need a cooling off period before engaging Both parties (Dr and Pt) must be willing to participate Establish ground rules Ensure both you and patient understand win =win aim; own volition into engaging, not enforced No interrruptions whilst other is talking

How to Do IT
An agreement to talk about a set agenda One party speaks without other interrupting healthy venting of emotions, what the problem is for them Other party paraphrases what they heard First party corrects any miscommunication Process repeats the other way round What does each party need or want to light of whats been said
Boulle, L (2005) Mediation: Principles Processes Practice, Australia, LexisNexis Butterworths

Key Message
if you resolve conflict positively you can really build upon a foundation of loyalty and trust in the relationship