Clinical Courage OR Harmony and Dissonance

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Clinical CourageORHarmony and Dissonance

• CDR Mark J. Flynn
• Naval Hospital, Camp Pendleton

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Objectives

• Address the concept of courage in the face of
  conflict within the examination room.
• Discuss dissonance and concordance as key
  components of harmony.
• Raise the issue is all conflict bad?
• Utilize clinical scenarios to understand the
  issues.

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What Is Courage?

• A quality of spirit that enables you to face
  danger or pain without showing fear

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So What Is Clinical Courage?

• Having strength in your personal convictions
• Seeking a true therapeutic partnership with your
  patients, yet not being afraid to contradict
  their wishes when warranted
• Asking yourself at the end of the day if you
  provided the best medical care you could, and
  finding the answer to be yes

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What Does That Mean In the Exam Room?
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Case Scenario

• It has been a long day. Youre tired, you are
  running late, and you still have all those charts
  to do before you can go home and see your family.
  The last patient is a child with ear pain.
  You recognize the name and know the mom often
  insists on antibiotics to treat minor illnesses.

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Case Scenario

• You also are aware that she has written letters
  of complaint to the commanding officer when she
  felt the care they received was substandard.

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Case Scenario

• Your exam is unremarkable except for findings
  consistent with a mild cold. Throughout the
  visit the mom makes comments about how her child
  gets better so quickly when antibiotics are
  used.

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Options

• You know what she wants. She knows what she
  wants. You decide to
• A. Give the antibiotics. Today, that is the
  easiest thing to do. Besides, he might have a
  really early ear infection.
• B. Pretend the labor deck is calling and flee
  from the room.
• C. Take time with your patient to explain the
  diagnosis and proper treatment.

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Options

• You know what she wants. She knows what she
  wants. You decide to
• A. Give the antibiotics. Today, that is the
  easiest thing to do. Besides, he might have a
  really early ear infection.
• B. Pretend the labor deck is calling and flee
  from the room.
• C. Take time with your patient to explain the
  diagnosis and proper treatment.

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Options

• You know what she wants. She knows what she
  wants. You decide to
• A. Give the antibiotics. Today, that is the
  easiest thing to do. Besides, he might have a
  really early ear infection.
• B. Pretend the labor deck is calling and flee
  from the room.
• C. Take time with your patient to explain the
  diagnosis and proper treatment.

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Options

• You know what she wants. She knows what she
  wants. You decide to
• A. Give the antibiotics. Today, that is the
  easiest thing to do. Besides, he might have a
  really early ear infection.
• B. Pretend the labor deck is calling and flee
  from the room.
• C. Take time with your patient to explain the
  diagnosis and proper treatment.

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Harmony
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Harmony

• Compatibility in opinion and action
• Agreement of opinions
• An agreeable sound property

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Clinical Harmony

• It is
• Having our patients agree with our suggestions
  and recommendations
• Finding little need for stress
• Getting excellent results every time
• highly elusive.

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Harmony

• Two opposite yet important components
• Consonance
• Dissonance

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Consonance
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Consonance

• Harmony that brings about a concordant or
  agreeable combination of notes is termed
  consonant.

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So Why Do We Like Consonance?

• Easier to hear
• Makes sense to our ears
• Allows us to feel good
• Felt to be more productive
• Positive

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Dissonance
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Dissonance

• When chords do not fit into an accepted pattern
  of harmony, they are said to be dissonant or
  unstable.
• Dissonance is often used to create moments of
  suspense that later resolve into more pleasing
  tones of consonance.

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Dissonance

• Dissonance is the simultaneous sounding of two or
  more notes to produce a jarring, harsh, or
  disagreeable result, an effect of clashing or
  unease.
• It is from the Latin words for sounding and
  apart, and its opposite is consonance , a
  pleasing sound, a sounding together.

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Why DONT We Like Dissonance?

• Jarring
• Harsh
• Disagreeable
• Clashing
• Fingernails on a chalkboard
• Unpleasant

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Consonance
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Dissonance
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• Mozarts Dissonance Quartet begins with an
  introduction that some contemporaries of Wolfgang
  found objectionable.
• Their attempts to improve it failed.

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Conflict

• What is so bad about conflict?
• Is it always destructive?
• Can it be constructive?

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Ethical Dilemma

• BMC Medical Ethics study
• Top 10 List of Health-Related Ethics Challenges
• Disagreements between patients/families and
  health care professionals about treatment
  decisions

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• Disagreements between patients/families and
  health care professionals can occur in any health
  care context. Medical disagreements can be as
  serious as an end-of-life conflict, or as mundane
  as a family physician refusing to give in to a
  patients request for antibiotics.

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Constructive Confrontation

• Model based on theory that confrontation is
  inevitable
• Cyclical no established beginning point, usually
  no end
• Very flexible and adaptable to the problem at
  hand
• Treatments undertaken, results monitored,
  strategies adjusted if not effective

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Challenging Patients

• Estimated that 15 of patients are considered
  frustrating or difficult.
• In a day of 20 encounters, a family physician
  will have about 3-4 challenging visits per day.

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Obesity Management

• Adult
• Pediatric

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Abusive Relationships

• Domestic
• Child
• Sexual
• Elders
• Past or present

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Saying Im Sorry
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Emotional Issues

• Depression
• Stress

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Chronic Pain and Narcotic Use
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Longitudinal Patient Example

• Mr. W, a 42 year old medically-retired Air Force
  E5
• Failed Back Syndrome
• Fell about 30 feet, landed on feet resulting in
  numerous vertebral fractures, disc abnormalities,
  and leg injuries
• Subsequent spinal surgeries
• Chronic narcotic use

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Longitudinal Patient Example

• Managed on
• Percocet
• Amitriptyline/Elavil
• Cyclobenzaprine/Flexeril
• Starting around July 1999 attempts started to
  convert to long-acting narcotics.
• These attempts were not successful.

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Longitudinal Patient Example

• PCM introduced idea of a pain contract, referred
  him to the command pain clinic.
• Each visit stressed concept of avoiding
  short-acting narcotics for chronic use to control
  pain.

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Longitudinal Patient Example

• Over several months, he was seen by several
  different providers/clinics until able to see
  PCM.
• From 29 October 1999 to 24 January 2000, he was
  given 1,024 Percocet.
• Averaged out to over 11 tablets per day.

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Longitudinal Patient Example

• From July 2001 to March 2002, Mr. W was given
  2,152 Percocet.
• Averaged out to around 9 tablets per day.
• Then

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Longitudinal Patient Example

• PCM convinced Mr. W to stop using Percocet.
• A reluctant Mr. W agreed to try.
• Plan utilized
• MS Contin
• Elavil
• Surfak, Fleets enemas, Dulcolax

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Longitudinal Patient Example

• For the next 9 months, Mr. W had reasonable pain
  control.
• Problems that developed
• Weight loss 20 pounds total
• Nausea required addition of antiemetics
• Falls at least two instances, one resulting in
  a nose fracture, the other in a severe ankle
  sprain and knee contusion

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Longitudinal Patient Example

• First visit with new PCM in September 2002.
• Mr. W stated his desire to go back on Percocet.
• PCM reinforced need to stay on long-acting
  narcotics and avoid a high acetaminophen load.

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Longitudinal Patient Example

• Through early 2002, Mr. W continued to have
  problems tolerating long-acting narcotics due to
  side effects and injuries.
• Both PCM and pain clinic manipulated
  formulations, dosing, intervals, use of
  additional non-narcotic agents.

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Longitudinal Patient Example

• After many months and many combinations of
  medications, it became apparent that this plan,
  while medically sound, was not working.
• Mr. W was restarted on daily Percocet, although
  with strict limits.
• He continued to use Elavil and muscle relaxers.
• The nausea, weight loss and instability resolved.
• Patient and provider were happy again.

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Conclusion

• What is courage? Ultimately, it is defined by
  the individual.
• Everyone has times when taking the easy way is
  best for the situation.
• Seeking harmony is not always the optimal
  approach to take in patient encounters.
  Sometimes conflict, or dissonance, is necessary
  to foster real harmony.

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Final Scenario

• You are seeing an older, retired male. He has
  arthritis in one knee, but is able to ambulate
  well without use of assistive devices.
• He is asking for your signature on the DMV forms
  he has brought in seeking a permanent disability
  placard for his car.

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Final Scenario

• He states that his knee hurts, and besides, he
  has been shot at for his country. He deserves
  this.
• On the other hand he can, quite literally, tap
  dance in your exam room.
• The forms are all filled out, and missing only
  your signature.

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What Would YOU Do?
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Questions?