Committing to treatment

In this scenario, a healthcare provider speaks with a patient about committing to his hemophilia treatment regimen. The healthcare provider is concerned about the risks to the patient, who hasn’t been following his treatment plan. We’ll explore this scenario using the “directive” and “constructive” approaches to see which approach leads the patient to reflect and reconsider his responsibility for treatment. Each approach is followed by commentary to provide background on why one approach may have been more effective than the other.

TRANSCRIPT

Transcript

  • Physician:

    “So, Perry, I see you’re 13 years-old now, and uh, shot up quite a bit since the last time you were in.”
  • Perry:

    “Yeah”
  • Physician:

    “I also found out that you’re not doing your infusions the way you’re supposed to be doing them.”
  • Perry:

    “Well, it’s not really fair that I have to do them and nobody else my age has to do them.”
  • Physician:

    “Well, son, you’re going to learn that life’s not fair. And other people your age don’t have hemophilia, and they don’t have the risks that you have. So you really need to do your infusions.”
  • Perry:

    “But, I’m careful and I feel fine.”
  • Physician:

    “It’s not a matter of you being careful, other people around you sometimes aren’t careful. And you can’t feel when your blood’s clotting or not clotting the way it’s supposed to. Those are the risks you have. You need to do your infusions”
  • Perry:

    “Whatever. I’ll do it”
  • Physician:

    “So, my understanding is I can tell your parents at this point that you’ve agreed to do your infusions like you’re supposed to.”
  • Perry:

    “Sure”
  • Physician:

    “Okay.”
  • Dr. Bruce Berger:

    “What happened here? The healthcare provider dismissed the patient’s frustration as being irrelevant. In fact, the healthcare provider was often condescending. He didn’t seem really interested in understanding anything from the patient’s perspective and really showed no empathy. He scolded the patient and directed the patient as if he was a parent or an expert in his role. He acted as if simply telling the child what to do was now sufficient. What do you think the probability of change taking place will be? While the patient said he would do the infusion, was he really committed to doing so? Let’s now take a look at this interaction using more appropriate communication.”
  • Physician:

    “So, Perry, I see that you’re, uh, 13 years-old now, and that you’ve really shot up a lot since the last time you were in my office.”
  • Perry:

    (chuckling) “Yeah”
  • Physician:

    “Um, I also noticed that, uh, from my record, that it doesn’t seem that you’re doing your infusions regularly. What’s going on there?”
  • Perry:

    “Well it’s just not fair that I have to do them, and no other kids my age have to even worry about it at all.”
  • Physician:

    “You know, it, it really isn’t fair. You know, it just doesn’t seem right that you have to do these things especially when other kids don’t have to do these things. Plus you sure didn’t ask for hemophilia.”
  • Perry:

    “No...”
  • Physician:

    “Um, you know, it really isn’t fair and I wish you didn’t have to go through this but given that you do have hemophilia, what I want to know is, you know, how important is it for you to be as healthy as you can be?”
  • Perry:

    “Well, I really don’t want to have a bleed cause that’s very bad for me.”
  • Physician:

    “Yeah, you’re right. So…given that it’s important to you not to have a bleed, what steps are you willing to take to reduce the chance?”
  • Perry:

    “Well, doing my infusions I guess...even though my parents bug me about it all the time.”
  • Physician:

    “Okay, So I’m really glad to hear that you’re committing to doing your infusions. Um, Sounds like your parents bugging you is a source of some frustration in the house. Can I share with you some, some of what I think may be going on with your parents bugging you?”
  • Perry:

    (shaking head yes) “Yeah, sure.”
  • Physician:

    “I think you’re parents because they love you, get worried. And they imagine you leaving the house when you haven’t been doing your infusions, and they get these pictures in their head of you being injured and bleeding. And it scares them. And rather than just telling you how scared they are because they love you, it comes across as the infusion police.”
  • Perry:

    “...Yeah”
  • Physician:

    “What’re your thoughts about that?”
  • Perry:

    “Well. I really don’t want them to be scared, but I don’t like it when they bug me either.
  • Physician:

    “Okay, so if I can kind of summarize where I think we are, it sounds like um, on the one hand even though it’s not fair that you have to deal with this, you are willing to do your infusions to reduce your risk of a bleed. I suspect if you do that, your parents will bug you less. And maybe if they bug you some you can imagine that they are doing it because they’re just scared. Um, I’m really glad to hear that you’re committing yourself to doing this. I would hate to see you have a bleed, when you can take steps to reduce the risk. And, fact of the matter is, the only person that can really do this is, you. So, can we at this point tell your parents that you are committing yourself to doing your infusions?”
  • Perry:

    (shaking head) “Yes.”
  • Physician:

    “Okay, I’m glad to hear that. Um, I want you to be as safe as you can be.”
  • Perry:

    “Me too.”
  • Physician:

    “Okay.”
  • Dr. Bruce Berger:

    “So, why did this work? The healthcare provider really listened to and showed concern for the patient’s frustration. He explored the patient’s thoughts and feelings given the reality that he does have hemophilia. He asked the patient how important is it to him to not have a bleed or serious complications. The healthcare provider supported the patient’s decision to continue to do his infusions, and he does not dismiss the patient’s complaint about his parents bugging him. Instead he offers an explanation for their behavior and asks what he thinks. In the end, he summarizes and creates a verbal contract regarding what they have discussed. And more than anything, he treats the patient with dignity and respect throughout the interaction.”

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