EP 16: Communication & Tough Conversations

In Episode 16 of the NP Launchpad Podcast, Christopher, Jason, and Vanessa tackle one of the most challenging aspects of clinical practice: communication and tough conversations. Learn practical strategies for de-escalating tense situations, setting professional boundaries, delivering difficult news with empathy, and protecting both patient relationships and your license. The team explores proven communication frameworks, including SPIKES and Ask-Tell-Ask, while sharing real-world tips for documenting difficult encounters and avoiding common pitfalls. 

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Transcript

Voiceover 0:01

Welcome to NP Launchpad, presented by Fitzgerald Health Education Associates, the podcast created for newly graduated nurse practitioners navigating the transition from school to clinical practice. Hosts Jason Gleason, Christopher Gleason, and Vanessa Pomarico-Denino deliver real talk, real experiences, and practical guidance to help you succeed from day one. So if you're ready, let's jump right in.

Christopher Gleason 0:35

Hello, everyone, and welcome back to NP Launchpad. I am here with my friends and co-hosts, Dr. Jason Gleason and Dr. Vanessa Pomarico-Denino. So this week we're going to talk about those hard conversations. And um I think we've all had patients that, you know, kind of test the waters with us, and we found we've had to have not only hard conversations with them, but kind of set boundaries with them as well. So mail drop. If you want to get a hold of us at nplaunchpad @FHEA.com, that is nplaunchpad @FHEA.com. You can email us your questions, your comments, uh, and we may answer them on on air, actually. So, and one quick disclaimer this is for education only. We're here's your friends and your colleagues. This is not legal, it is not clinical advice. So if you need either either one of those, please seek out the uh the professional. All right, so topic one, the escalation basics, tone pacing, and words that lower the temperature. So kind of touched on that, you know, at the beginning. We all have those patients, and I know we actually we touched on it in previous uh podcasts that you know they really start escalating, they start ramping up. And these are the tips and the tricks that you know hopefully will help de-escalate the situation. V, you know, we talked about that at one point uh with you in that patient that you had. Uh, what are your thoughts on that?

Vanessa Pomarico 1:49

So, you know, again, that uh that was a real heavy session that we did.

Jason Gleason 1:54

Yeah, well, I know, but it is You're triggering me. You're triggering me.

Vanessa Pomarico 1:58

I'm sorry. Um, and I know, and I do want to just you know make a little disclaimer here that I know that this discussion might be activating to some of you who are out there. Um, I know a number of nurses who were assaulted by patients, and it doesn't need necessarily need to be physical assault, but it can be verbal assault as well. So, you know, the thing that we always have to think about is what do the therapists do when they have a patient who's escalating? And um, you know, I'm I am certainly no expert, but my husband is a therapist and I've gleaned a couple of things along the way. Um, and one of the things that he always said to me was lower your tone and speak really slowly. Right. And keeping keeping your body, so instead of doing this with the patient, I'm leaning in, but yeah, I'm speaking so slowly that to me, I almost think I'm I'm I'm talking too slowly. But you have to remember when when you have a patient who is very, very agitated, their mind is racing. And so we're speaking slowly, but they're like 15 steps ahead of us. So it's really important that you just kind of really slow it down, lower your tone. Almost like if you were talking to a young child, or you know, if you have a pet that wasn't doing the right thing, you know, certain tones that you take with them. And that's really the best thing that you can do to help de-escalate or at least start the de-escalation.

Christopher Gleason 3:24

Absolutely. And I definitely think one thing to keep in mind too is when when our patients get to that state where they're highly escalated, their personal bubble is shrunk like almost completely. So anybody outside of that, they're not gonna, they're not gonna respond really well to. So, you know, lowering your tone, uh, talking really slowly, that can really kind of help bring them back. And what are your thoughts on it, Jason?

Jason Gleason 3:45

You know, I I find it so interesting. I one case comes to mind is that when we had a very disruptive patient and he was out of control, and he had a lot of mental health stuff going on, a lot of stressors, and I I felt horrible for this guy, but he was out of control to the point where he took it out to the waiting room. And and so what happened was that we did good things and not so many good things at this case. I think number one, because it was so disruptive, many of our of our clinic staff went out to the the waiting room area to kind of see what's going on and to protect our colleagues, right, from this. But I think that just heightened the situation even more because more people are showing up and you know, it just heightens the situation. And I'll never forget this. His therapist actually responded as well a little bit later, a few minutes later. And I was so impressed with her because all she said to him was, Hey, so-and-so, come here right now to my office. And it's like it was a break. And he listened to that. And why did that work? Because they had that relationship, right? You would never I if I told him that, he'd probably escalate even more and want to punch me or hurt somebody, right? But I I was I was just blown away by wow, that is some skill for her to know when you have to go Dr. Phil on people and like let's have a reality check here, and then you have to know, like you said, Vanessa When you have to tone things down and bring it down to a different level just to calm everybody down. But there are moments where you have to have that blunt conversation, like, what are you doing? You know, I'm your friend, you gotta snap out of this, right? And she was so skilled at doing that. And it but you have to be so careful because if you do that to just somebody you don't have a relationship with and build that rapport with and that they trust, then it's just gonna escalate. But in that case, I was so blown away because they had that trust between them. And he he totally settled down. He went back to her office like a little puppy dog, and he was able to get help, the help that he needed. So I was so impressed with that. So patients respond to different things, right?

Christopher Gleason 5:38

And one thing to remember too is you know, if you're in that situation where you have a patient that's escalating, it is very, very easy for you to escalate. Yeah. Because you're gonna you're gonna get amped up as as they're getting amped up. So it, you know, to Vanessa's point, that's when you really need to slow everything down and you need to slow yourself down as well.

Jason Gleason 5:55

Yeah.

Vanessa Pomarico 5:56

Right.

Jason Gleason 5:56

Yeah, it's very interesting.

Vanessa Pomarico 5:58

One of the things that I always say is that you know, you need to validate the person's feelings, whatever it is that they're going. I see that you're upset, but it's not negotiation time. No, so I'm validating their feelings, but I'm not negotiating with them to, you know, snow blow me and and try to, you know, strong arm me into giving them something that they're not, they should not be getting.

Jason Gleason 6:20

And they'll want that, and they will. They it's manipulative behavior, not from evil or bad people, it's just what they they do. It's their survival mode, right? I have one patient. Oh, there's it is, it is, it's all connected to that. And I had one patient that I recall that the nicest woman on the planet, and she was in her 60s or 70s, she was a little older, and she would come to the emergency department almost clockwork, like every few days for a shot of morphine for her migraine headaches. And she had gotten that for years, so as an expectation. Her providers unfortunately started her down that road at some point, right? And it was an expectation that she would come to the ED, get her shot, she'd feel better and go home. And so finally, one day I talked to her and I said, you know what? We really need, we can't be doing this every week. It's not good for you to get this morphine on this regular of a basis for your headaches, plus it's gonna make your headache worse because it does in some patients, right? And so I told her, I thought it was brilliant. I told her, you know what? I want you to go to your neurologist because she saw a neurologist. I said, ask your neurologist if it's okay for you to come here to get a shot of morphine on a regular basis like this. And if it's okay with your neurologist, please have him write us a letter and we'll think about it. We'll consider that then. What does she do? She goes to her neurologist. I could have freaked out on the neurologist. He gave her a letter that said, You can have you can have one shot of morphine every week for your migraine headaches, just once a week, though. So, what would she do? Clockwork to the day she'd show up for her shot of morphine. And so I finally got to the point where you have to be and again, build that rapport, be a friend to somebody, see them as a human being, right? Because so much of the time we demonize our patients. It's like, oh, them again, I can't believe they're on the schedule and they're gonna ask for this and manipulate us and all this stuff. But if you tear it down, and what I usually like to do to get beyond all that in myself, because as a human being, that's what we do. We tend to demonize other people or or you know, just dread seeing them uh when they come in. But what I tend to do to get over that is I see them as what they were like as a child before their before their lifetime trauma, before all the issues that they had that brought them to the place that they are now. I think, how are they as a kid? And I approach that in that degree, like i it it brings some innocence to the situation, right? So in that case, to really be somebody's friend. But like you said, Vanessa, have boundaries, don't give in, it's not time for negotiation. So in this woman's case, I finally got to the point where I had that kind of doctor fill moment with her, and I said, Yeah, and I and I and I was going out on the limb here because I really could have insulted her, but I said, You really don't have migraine headaches, do you? I was blown away. She said, I don't. And she started crying. It's making me emotional now. But she started crying, and I was so blown away by this. She said, I don't. I never have had migraine headaches, but I'm addicted to morphine, and I I'm sorry. She said, I don't know what to do. I'm scared, right? I'm scared. And this is after years, and yeah, she must have been on morphine on a regular basis for like over five years. Jeez. And so it was such a remarkable moment. I'll never forget. And so, what did we do? We got her the help she needed. We got her plugged in to chemical use disorder clinics, and she went into inpatient treatment. And then she came back to see me and she said, I'm not here for morphine. I'm I'm here to thank you for seeing beyond my addiction and seeing me as a human being. And I'll never ever forget that. So don't give up on those people that drive you bananas that we tend to demonize, set your boundaries and don't negotiate. But sometimes it's good to be real with our patients and call them on their stuff, but do that in such a way as you're approaching them as your as their friend and as their provider that really cares about them and not somebody that's demonizing them and judging them. And you'll see the magic happen. You really will. So absolutely. Now I need to go to the show.

Vanessa Pomarico 10:14

What a great story, Jason.

Jason Gleason 10:16

I am a sap.

Christopher Gleason 10:19

Um in one of those, one other point to the setting boundaries is you can always offer offer choices. You know, give them two safe options. Yeah, it'll definitely be one impossible to brand, right?

Vanessa Pomarico 10:30

Yep.

Jason Gleason 10:31

Absolutely.

Christopher Gleason 10:32

And you know what? If safety concerns rise up, bring help early. And you know, V you talked touched on this before. We know who we know those patients that have the potential to become, you know, agitated during our visits and things like that. And if you know they're there, um they have that potential, bring somebody with you. Have a chaperone, have somebody stand outside the door. You know, something that um have something in place that's gonna keep you safe, and that's key.

Jason Gleason 10:55

Yeah, yeah, definitely.

Christopher Gleason 10:57

So moving on to topic two, breaking bad news and structure and empathy. So, what are some key points to consider with this? V, what are your thoughts on this?

Jason Gleason 11:08

Bad news for a patient. How do you handle that?

Vanessa Pomarico 11:11

Uh it's really, you know, I think it's a case-by-case basis. Um, you know, you have to think about, you have to, especially for our new providers out there, it's not easy to deliver bad news. And and if you're not, if you haven't gotten any of that content in your program, there are other continuing ed programs that you can take online. And I'm sure there's something in our Fitzgerald library that talks about those difficult conversations. But, you know, frame it in a way that you're comfortable with. And until you get used to delivering that news, make sure that you kind of follow the same approach every time you have to do it. Fortunately, we don't have, at least in my job, we don't have to give a lot of bad news.

Jason Gleason 11:50

Right.

Vanessa Pomarico 11:51

Um, but there was a time, and I might have mentioned this in a previous podcast. So forgive me if I did, but there was a time when we had paper charts and we would have patients, we would call them up and say, come on into the office so you can I can go over the results. And patients automatically know it's got to be bad news because if it wasn't, she would just tell me, no, your mammogram is fine. So one of the things that I do is if I'm really concerned about something, and I just recently had to do this, I had an 81-year-old who found a breast mess when she was in the shower. Um, and I immediately sent her for um, you know, a mammogram and an ultrasound. And I said to her, schedule an appointment with me in the next few days so we can go over the results. And I always say, good, bad, or indifferent, I want you in front of me. Because the last thing I wanted to do was have an 81-year-old drive to my office to nervous wreck because she knew that I was going to give her some bad news.

Jason Gleason 12:41

Wow. Right. What a great approach.

Christopher Gleason 12:43

Yeah, definitely. So what are your thoughts on it, Jason?

Jason Gleason 12:46

Yeah, it it's such a hard thing. And I'll I'll tell our listeners out there as new nurse practitioners, you'll never forget your first time you have to do this. Yeah. And what I would recommend that you do, and and I would hope a lot of NP programs out there would have a at least a class on this, maybe a few hours. They should. I know mine didn't. I wish it would have, because you will be faced with this, is to even do a practice session with like the nurse that works with you, right? Say, okay, I got to go in there and I got to tell them this, but can I practice on you first? Would you mind and then give me some feedback? It takes five minutes, right? Just so you can practice it out in your brain, you know what you're gonna say. But beyond that, I would say be real, be genuine. But here's the deal. I think that when patients are told bad news, like let's say they have cancer, and I know this because I've had family members with cancer, right? And and most of us have somebody with some chronic illness that's been quite s severe or serious. But I think when a patient is given bad news, the first thing that they're desperately wanting is information. Okay, I got this bad news now. How bad is it? And what am I gonna do about it? And what's the next step? And I think it's horrible practice to tell the patient their bad news, you have cancer. And oh, by the way, we're gonna work on scheduling you with oncology in the next few weeks. I I think that's terrible. I think that the thing that you need to have in place before you mention the bad news is have a very good plan in place. And so what I tend to do, and it takes some time, you have to invest the time into this, before I call the patient, and it all has to be done usually on the same day. You don't want to wait, you know, weeks out before you share the news because they will find out through the EHR review or other means. But what I usually do is I'll get on the phone with oncology, I'll get a plan in place. Okay, here's all your appointments are set up. So when you share that news, Barbara, I'm so sorry we found a breast mass, but here's what we're gonna do for you because your peace of mind is paramount to me. We're gonna get you into these specialists, and here's the appointments I made for you. If you can't keep these, that's fine. You can reschedule. But I got these as soon as we can get you in. And and so here's your plan. This is what you need to do next. And your peace of mind is so important. Let's get you the answers you need right now. Because would I think both of you would agree that sense of I need to know, right? I knowledge is power in these instances, and to empower your patients is so vital. So that that's my approach, not only to break the news and to be very sensitive about that, but also what are you gonna do about it now? What what plan is in place and really have good steps in place?

Christopher Gleason 15:07

Yeah. And that makes absolute sense. I mean, you're gonna want to um ask what they understand, tell them in small chunks, you know, ask them if they have any questions, pause during that conversation because that's gonna give them the time to process the information and perhaps develop any questions that they may have for you. Yeah.

Vanessa Pomarico 15:22

One of the other things too is to always say to the patient, you know, I know that I've just hit you with an awful lot of information. Please feel free to call me or message me. I know that when you hang up the phone, you know, you're gonna start processing this. You may have other questions, or your family members might have questions. So feel free to call me back. I'm happy to answer any questions. The biggest thing the patients say, especially if it's something like cancer, is you know, some of them will say, Well, how long do I have to live? You know, or how bad is this? Yeah. And I always try to give them as much information as I can. And sometimes I say to them, I don't have all the information. I could tell you that you have a very small mass in your breast. You know, you're I already put you scheduled to see the breast surgeon. They're going to do a few more scans to see if it's spread anywhere, but we've got all of this in place for you. And and that that's kind of like what they need to know. They need that reassurance, like you're not going to just pass me off and then nobody's gonna know me, but you know me. So now we've already made those connections. Like you said, Jason, we've already got everything in place for you. And then what I do is I usually keep the consult note in my inbox. And then I usually call the patient after I get like their um, they've had their visit. I usually call them like a day or two later and just say, oh, you know, I uh I see that you met with the oncologist. You know, do you want to tell me how that went? And it just gives them a little bit of of information to know that I I haven't forgotten them as their primary. I may not be treating them for this, but they they know that I I at least care. And and I have to tell you, it comes back to me all the time. Patients say, you know, I know people in their primary never even reached out to them after they found out that they had cancer, or, you know, but you called me and and they it, you know, that two-minute phone call goes a long way.

Christopher Gleason 17:09

It sure does. Absolutely sure does. Rapport is is key, definitely. And some things to remember too when you're breaking uh bad news to patients is avoid medical jargon. You know, don't give them, don't give them a false sense of hope. You want to be, you want to approach it with, you know, like you and you and V were talking about, with that rapport, with that kindness, with that empathy. But don't don't give them false hope. And also document what you say. Anything that happens in the visit visit, please, please document. Because as we said before, you know, if if you don't document it, it doesn't happen.

Jason Gleason 17:39

Right. Mm-hmm. You know, I think one of the travesties of our healthcare system is that we don't have a healthcare system where let's say you're diagnosed with a mass or some serious health issue and you really need it worked up further, you know, to get that plan in place to treat it. Sometimes that's months out, sometimes it's weeks out. You know, I think it's horrendous that that we as a society and we we have a healthcare system, and it's much bigger than this podcast or any any one of us can provide the solution for. But we have a healthcare system like you break the news to a patient and then it's three weeks before they can get the next step in their care. That's horrific. I I think we should have a system where if you're diagnosed on a Monday, you should be seeing all the specialists you need to see within that week, you know, and get your answers. Because what is our patient doing in the meantime? They're doctor Googling like crazy, they're asking family, they they think the worst that they're gonna be dead, you know, and it's just horrific, you know, the the toll that it takes on their mental health. So I think as many steps as we can get in place, the better. One thing I want to mention is when you're getting those steps in place, like you're referring the patient, let's say, to oncology, call the oncologist's office yourself or ask the nurse that works with you to call them and don't speak with the scheduler because the scheduler is gonna look well, and the schedulers are wonderful people and they're very compassionate and they know the urgency here too. But talk to the specialist nurse at least that works with the specialist and say, hey, here's the situation. I got this patient, it's a new diagnosis. Can you please work them in somewhere? Because oncologist practices, as you know, are over maxed. I mean, they're so busy, it might be a month out or two months out before they can even be seen. But if you call, sometimes they'll get them right in, especially if you have a patient with maybe some mental health issues or they're not going to take the news very well. Go above and beyond, and your patient will certainly appreciate that. You'll have better outcomes. Definitely.

Vanessa Pomarico 19:24

You're so so true. Jason and and and Chris, if you don't mind, I want to just share share a little bit of a personal experience that I had to that end. Um, so my husband was having some symptoms, and it literally, you know, took four months to get in with a neurologist. It took two months to get a CAT scan. And then the neurologist said, um, I want him to see on oncology. And uh, you know, of course, then I started to unravel a little bit because having been an oncology nurse, but and they were giving us an appointment four months from from when the when the referral went in. And, you know, not that I expect any preferential treatment, but that is not appropriate. And, you know, David, my husband has a um a very strong family history of very aggressive blood cancers. So you could tell that this was weighing very heavily on my mind. Oh, yeah. So I I emailed the one of the uh oncologists who doesn't deal with um with hematology. He's really more for GI and stuff, but he and I have known each other our entire careers. And I messaged him and I just said to him, I just need your advice. And I just wrote in a just a message because I was afraid if I I called him on the phone, you know, I didn't want it to seem presumptuous, but I just messaged him and said, this is what's going on. And they're giving us an appointment four months from now. As you know me, you know that this isn't sitting well with me. I put it all back on me. And within 20 minutes, he answered me back and he CC'd the scheduler and said, please put Vanessa's husband on the schedule, you know, Tuesday. And I think this was like a Thursday. Yeah. So, you know, you're right, Jason, in saying, you know, that that pick up the phone and call somebody. The schedulers can do just so much. Right. And when you call the provider directly, they're usually going to be much better about getting them in. And we were able to get, you know, David, and it was a positive ending to all of it, but still it was a very stressful time during that time. So just pick up the phone and call them or message them. And they usually will get them in. I had a patient, my the one I was just telling about with the breast mass, and I messaged the um the uh the breast surgeon directly. And I messaged I sent my note, and that's how I was able to route it. I sent my note and I had all of the the um the um results in the note as well. And she got the patient in within two days.

Christopher Gleason 21:42

That amazes me.

Vanessa Pomarico 21:43

But they didn't have to wait. Yeah, they don't have to wait four months. But again, if you if you don't pick up the phone to call and don't be afraid to call.

Jason Gleason 21:50

Yeah, right.

Vanessa Pomarico 21:51

You know, because you're really there to advocate for your patients.

Jason Gleason 21:54

That's our job. Absolutely. Yeah, yeah, good points. And I'm so sorry, I'm thinking glad things ended up. Well, with your husband, thank you. Thank you. Yeah. Four months waiting. Can you imagine if you had to wait four months? I go out of my mind.

Vanessa Pomarico 22:06

Listen, it took us a year to even figure out what was going on. And then they wanted another four months. And I remember one of the schedulers said, Well, and I said, it's been a year. She goes, Well, what would another four months be?

Christopher Gleason 22:19

Oh, you've got to be kidding me.

Vanessa Pomarico 22:21

You don't know who I am. Like my head's going to explode right now. Yeah.

Jason Gleason 22:25

Yeah. Wow. That is something. That is very something. Yeah. Oh, wow.

Christopher Gleason 22:30

All right. So moving on to our next topic. How do you say no without setting off fireworks? V, what's your approach to this?

Vanessa Pomarico 22:39

Um, so you know, I think you guys know me well enough to know that I don't have any problem saying no. Um it all depends on on what it is. You know, if the patient is asking me for narcotics or antibiotics, you know, I always give them the rationale behind it. And I say, you know, I'll always say, like, your migraine story was a perfect story. So, you know, we've had patients that were so used to getting narcotics to break their migraines. And again, though those providers were not following standards of care. And we all know, or we should know, that if the usual medications aren't working, you know, then we can give them prednisone for status migrainous. And and the first time I said that to the patient, she said, Well, you're not gonna give me my codeine. And I said, you know, codeine actually can make your migraines worse. And that fell out of favor a long time ago. So here's what we're gonna do I'm gonna give you some prednisone to take to break this migraine. I'm gonna give you two codine tablets. So if I'm wrong and the prednisone doesn't work, you got your codeine there. And I only gave her two tablets because I thought one was being cheap. I'll give her two. But I knew the prednisone was gonna work. And after being on an opioid for her migraines for umpteen years, yeah, she actually called me and she said, I did not leave your office happy with you. She said, I actually thought about finding another primary care provider, but I really do like you and I respect the fact that you gave me the codeine in case the prednisone didn't work. I'm calling you to tell you you were right the prednisone worked.

Christopher Gleason 24:10

Wow.

Vanessa Pomarico 24:10

So it's it's all a matter of giving them that rationale and you know, acknowledging their feelings, but again, that is not standards of care. And that's what I say to them. I keep up with the standards of practice, and that has fallen out of favor that we don't use that anymore because there's better options available. And once you appeal to that intelligent side of them, you very rarely will get pushback.

Jason Gleason 24:34

I love it. I love it. And you helped her, right? Yeah, her migraines are better.

Vanessa Pomarico 24:38

Yeah, migraines are much better.

Christopher Gleason 24:41

So, Jason, how do you say no without setting off fireworks?

Jason Gleason 24:44

Well, the first thing is to know when to say no, right? Because saying no is sometimes the most therapeutic thing that you can say to a patient and do that kindly and respectfully, but you have to set limits, especially for our new NPs out there, because I'll tell you what, the people out there, they're not using medications as they should, but they usually have a use disorder and they're, you know, they're hooked on a medication dependent on it, and the they have all these manipulative behaviors to get their meds, and it's their survival mode and there's rationale for it, and they're not bad people, right? Like I mentioned in the past, but they have some serious issues with use disorder. They will manipulate the system and they will find out who you are as a new provider in the community, and they'll approach you. And then if you say yes that one time, if you don't set those, take two, if you don't set those boundaries and know when to say no, word's gonna get out. These people, I swear they have a beeper system, like beepers flash off, like, oh, you need to go see this person because they'll give you whatever you want. Word will get out, and that's what your practice will will become very quickly, is you'll be just seeing those patients every single day. So you do you need to know when to say no, like you said, Vanessa, and offer alternatives that are appropriate or within the standard of care and that are so much more helpful than saying yes. Because sometimes we should not be saying yes uh to our patients' requests. So so I'd say no when to say no, and then to do that compassionately. And another key thing that I'd recommend is if you have that patient where you think, uh, I don't know where this is really gonna go, bring a chaperone in the room with you. Bring a chaperone in the room with you. Not me necessarily for your physical protection at that point, that's always important, but just so you have a witness as to the discussion and what was said, right? Because they could they could file a complaint against the board against you that you know you think they're drug seeking and you're, you know, you're discriminating against them and all these things that then you have to defend yourself on. Make sure you bring a witness into the room with you when you have those difficult conversations when you're gonna say no to somebody, and then just document it well and offer them the appropriate alternatives, like you mentioned, Vanessa.

Christopher Gleason 26:39

That's what I think. Right. Okay, perfect. Great tips. And that actually leads us into our next hot topic. So, our next hot topic, documentation. When you're document documenting those harder conversations, what are some things you should really make sure that you do? So, first up, what was requested? Document the facts. What was requested? What did you offer and why was that decision made? Vanessa, when you're having conversations, those difficult conversations with patients, and then you're going to document. Do you have any tips or tricks as far as documenting?

Vanessa Pomarico 27:10

So I always exam uh put in there again, you know, that the patient came in requesting X, Y, and Z. Um, I offered X, Y, and Z, and then my rationale. And I would put in there, you know, antibiotics are not warranted at this time. Or if it's somebody who has chronic pain, um, then I will give them again alternatives. You know, I'll I'll send them for imaging, I'll put them on a short course of steroids, you know, I'll send them off to either ortho or neurology, depending on what their issue is or physical therapy first, and then send them off. Um, but everything would be documented. And then again, putting in the note, um discuss with patient that opioids are not part of this treatment plan. So that everything is there again in full transparency. Our patients are gonna read their notes. And so everything that I need is going to be in there. And I just make sure that again, you know, repetition is how you're gonna really drive home how you document things. Yeah. So don't reinvent the wheel, just keep doing it the same way all the time and it'll it'll stay in your head.

Jason Gleason 28:12

It will, it will, and document everything, even quotes from the patient. I usually put that in the record too. And they said, even if it's inappropriate, put it in there, document it well. So if you need it in the future, it's well documented. Because if you paint a rosy picture in your chart thinking, well, I'm afraid the patient might read this and don't go there. Make it very factual based, but document everything that they may have said because sometimes they do not say nice things to us, right? In response to no. And uh you want that well documented in case you need it in the future.

Vanessa Pomarico 28:40

One of the other things about documenting, too, is that you've got, like, like you said, Jason, you need to keep it factual because if you're gonna dismiss the patient, you know, eventually, all of that information is in there. And and, you know, as I said in a previous podcast, we have a committee of people that review any of our requests to dismiss a patient. And if you sugarcoat things and make your note look more rosy, that's not gonna help your case. But if you put things down, what's relevant, the patient, you know, was threatening or using strong language, you know, the, you know, that the patient uh refused to accept what I was giving them, whatever it was, you document it in there. I had a patient that actually had um gotten, he never came in for his appointments, he would never answer his cell phone. Um, I would send him letters, he wouldn't open them up. And I finally said to him, How can I get a hold of you? He said, Text messaging. I said, Well, I can't text you from my phone, but we had an app. There's a little app, it's called Docsimity. I don't know if you guys have Docsimity or not. So Doximity is a great app and um it's free and you can actually set it up. So when I call from my cell phone, it looks like I'm calling from my office. Nice and um, I was able to text the patient through there. The patient still didn't answer. And then after a while, I was like, you know, you haven't been here at a year and a half. He's on all these medications. So I said, I'm done. I sent it to the committee. I had everything documented. And then the patient called up and said, What do you mean you're kicking me out of your practice? I said, You never come in, you don't answer anything. He's screaming at me on the phone, dropping F bombs with me. And that is like automatic, automatic dismissal in our practice. You drop, you, you speak to us in that derogatory manner, you're gonna be out. And I said, Um, did you you told me, and I have it here, dated on such and such a date. You told me to text you. I texted you and I had screenshots of the text messages. And he's looking at his phone and he went, Yeah, all right. So I got the text messages and I didn't answer. Okay, again, how am I supposed to get in touch with you? But had I not documented everything about trying to get in touch with him, about him using abusive language with me, I would not have been able to have dismissed him. So again, make sure that you don't sugarcoat it. It's the only way that's going to protect you as a provider if you do need to dismiss the patient.

Jason Gleason 31:00

And you know, I would add to that too, because sometimes in our mind, you know, if it's an older adult, let's say they're in their 70s, what do we think? Oh, they're harmless. Yeah, they're threatening. They drop F-bombs. It's kind of cute because they're so old when they drop the F-bomb and they're harmless. They would never really hurt me, right? No, document everything regardless of their age, because you know, I'm here to tell you all it takes is the pull of a finger on a trigger to end your life. And you may have a patient that's severely disabled or 95 years old, they can still shoot you. And you think I'm, you know, being extra cautious here. I'm not, you know, I I remember one case where um a disruptive behavior board person on that board who reviews these cases actually said, Oh, they're harmless. Come on. They're an older adult. They would never do that, they never hurt anybody, right? They're just acting out. No, it's disruptive. Make sure it's documented in a factual way and always cover yourself by doing that because you don't know when you're gonna need it.

Christopher Gleason 31:52

And I actually have an example of that. I had a I had a patient that was, you know, their older gentleman, he was in his 70s to 80s, um, would come in on uh one of those scooters and he also had uh cane with him. Oh wow, yeah. He could run you over. He could run you over, and he could also hit you with his cane. And that was and that's actually what happened during the visit. He ran you over? No. Oh my gosh, Vanessa he got run over.

Jason Gleason 32:15

I'm sorry, go ahead. I'm just gonna hit him with a cane. I'm being disruptive. Yes, you are, and then report you to the committee. I can't believe he got run over. You never told me this. All right, go ahead. Good forward.

Christopher Gleason 32:27

But anyways, with this patient, he did have a cane and he did threaten to use it, and he would he uh waved it at the nurse during this instance. He was very he was very vulgar, he was very loud. Um and you know, obviously, he had the he had the means to physically hurt somebody, yeah, even in you know, his what 70s or 80s. So it's that's really important, really important to remember. Yeah, absolutely. All right, so next up, let's look at some resources to share on air. And just remember, you can always find these in your show uh in our show notes. So Vital Talk, uh communication skills training. I'm not gonna go through the uh web address again, those are in your um that's a cool one though, Vital Talk.

Jason Gleason 33:08

That sounds really good.

Christopher Gleason 33:09

I'll have to check that out. And it's VitalTalk.org, right? That'll be in their show notes. Yes, it'll be in the show notes. Another great resource is spikes, setting for reception, invent invitation, knowledge, empathy, strategy, and summary uh summary. It's a protocol overview. Um, it's breaking bad news. Again, uh, you'll have that um web address on your show notes or in your show notes. And next up is our favorite uh time of the show. It's fact or fiction. So let's look at our first question. Naming emotion. I can hear you're frustrated, can lower intensity fast. Facts or fiction, V.

Vanessa Pomarico 33:44

Uh that's fact. Remember, um, validate but not negotiate.

Christopher Gleason 33:49

Absolutely.

Jason Gleason 33:49

Validate, don't negotiate. I love that. I love that.

Christopher Gleason 33:53

All right, Jason, you're up next. Saying no always damages the therapeutic relationship. Fact or fiction?

Jason Gleason 33:59

Fiction, know when to say no. It can be therapeutic, but do it in the right way.

Christopher Gleason 34:03

Absolutely. So uh, Vanessa, structured approaches like spikes can help with bad news conversations.

Vanessa Pomarico 34:11

Fact. And everybody should take a look at that web address. It's really helpful, especially for those of you that did not learn how to deliver bad news.

Jason Gleason 34:19

Which many of us haven't. Most of us haven't, right? I love that resource. Uh, spikes.

Christopher Gleason 34:23

Make sure you check it out. All right. Jason, documentation of a tough conversation should focus on facts and next steps. As we reviewed, absolutely. Yes, that's a fact. Absolutely. All right. So next up, we're going to look at our mail drop. Again, if you want to email us, uh, please email us at nplaunchpad @Fhea.com. That is nplaunchpad @Fhea.com. Um, and we may answer your questions on air. So, what questions do we have this week? What tough conversations are you dreading right now? Opioids, no antibiotics, life change, or diagnosis.

Jason Gleason 34:57

Jason, that's a heavy topic, right? I would say for me, I I don't know. It just I find it, I know when to say no, but I find it so exhausting, the opiate issue when opioids come up, and if there's a manipulative piece to it, because you invest so much time into documenting, and you know, it's a patient that's usually disruptive, that keeps coming back, that keeps asking, and it's so manipulative and just getting down to the roots, right? It's like it's like peeling the layers off an onion. You know, you got to get down to well, why are you asking for this all the time? What is going on inside you that makes you want to manipulate the system to get the opiates in the first place? Have that tough conversation with them. Is this really a migraine headache, or are you using the morphine for other purposes, like I mentioned, right? And those are not always easy, but they I find them exhausting though in in many ways. Yeah. And just the threat to you personally, like I shared that story about the the surgeon that had his house burned down and his wife nearly killed, you know, it's horrific. So yeah. People, people with opiate use disorder and other use disorders, their brains are just not processing things correctly, right? And they're not bad people, but it's such a big challenge. So I'd say that that's the one that I just I don't like the most.

Christopher Gleason 36:08

And I think it's important to remember, and we touched on this earlier in the show, set those boundaries for the for these patients that you have. Um, I used to work in interventional pain management, and I would prescribe opiates for patients uh for their pain management. And I had one patient that came in. The um they were coming to me as a new patient. They had driven, I think, two, about two hours to actually get to the get to my office. And they I talked to them, I had a plan of care in place. My plan of care did not include opiates because I never, I would never start with opiates. I'd always start with things like muscle relaxers, you know, NSAIDs, things like that. And as soon as I mentioned this patient that there was no opiates, they exploded at me. And they informed me that they knew that as a provider I had to write for these medications and things like that. And I and that I had to have that hard conversation and set those boundaries and say, well, in fact, I don't have to um prescribe these medications for you if I don't find them to be safe.

Jason Gleason 37:05

Yeah.

Christopher Gleason 37:05

And or if I don't choose to in general. So uh definitely set those boundaries and and have those conversations if you need to. So uh what phrase has helped you just de-escalate and upset patient when things get heated? Vanessa, what do you think?

Vanessa Pomarico 37:21

So usually when things are starting to escalate, I usually will start off by saying, again, validating, I see you're upset, I understand you're upset, but I can't help you if you're yelling at me.

Jason Gleason 37:34

I love that.

Vanessa Pomarico 37:35

I keep it very quiet, very calm. My adrenaline is running, but I usually and I just keep repeating it. And then usually once I I just say to the patient, you know, once we can get them to calm down, then I'll just say, I need you to help me help you. And then once I kind of put it on them, and of course, you know, you might get the answer back. Okay, help me by giving me a prescription for opioids. Right. That's not gonna happen. No, so let's talk about some of the alternatives. We're gonna try A, B, and C first, and then we'll go from there. And usually if you give them something, yeah, it usually will help them. But again, not a narcotic.

Jason Gleason 38:14

I like that approach. Stay firm. Yeah. What are your thoughts on the Jesus? Stay firm. I'd agree with Vanessa 100%.

Christopher Gleason 38:19

All right, absolutely. All right. So next up, this is very, very important. We appreciate all of our listeners and we'd like to share some special savings with you. If you visit FHEA.com, that's Fhea.com, and use our code launchpad20, that is launchpad 20, all uh one word, you will get 20% off all CE and memberships. And that's just our way of saying thanks for supporting the show. So to wrap up, here's our landing checklist. What are the what are our three take-home tips for the week? Practice one empathy line and one boundary line until they're automatic, which is just huge. I love it.

Jason Gleason 38:53

And you can use those on your kids by learning how to say no.

Vanessa Pomarico 38:56

Okay. That's right.

Christopher Gleason 38:58

Um, use structured frameworks. Spikes is huge. You know, we we've given you the that resource. You have the web address in there, please use it. So, what's your homework for the week? Practice one tough conversation, script it out. Um do uh do rehearsals with it. You know, we talked about that earlier. If you're gonna have that difficult conversation, work with your nurse, work, work with your MA, have that have that script in in hand or in mind before you go into the uh patient rooms. All right. So, in closing, what I'd love for you guys to do is drop us five stars. It really helps the um the podcast ratings, it helps to bump us up, it helps us uh stay visible. Hit follow, tap subscribe, but most importantly, share this podcast, share it with your NP colleagues, MP friends, np students that you know, anyone that could potentially utilize this information, please, please uh share that information with them. And again, stay in touch with us, nplaunchpad @fhea.com. Uh that's a good great way to get us uh your comments, your questions, your concerns, anything like that. Hopefully not concerns, but if you do, send them out anyways. So that is our show for the week. Thank you again for uh joining us. And Jason and V, thank you again for us and joining this week. So don't get run over this week. I'm gonna hit you with a cane this week. Yes, don't get run over. Hit me with a cane. See you all have a great week. Thanks for everything. Bye everyone. Thank you.

Voiceover 40:26

You've been listening to NP Launchpad, presented by Fitzgerald Health Education Associates. Like, subscribe, and share. And for more tools to power your NP career, visit FHEA.com.