The Difficult Conversation and How to Stay Aware

In my role as a psychiatric consultant in the general hospital, I’m having difficult conversations daily. The term “difficult conversations” comes from the book of the same name, “Difficult Conversations: How to Discuss What Matters Most”. I try to recommend this book and what I think is its close companion, “Getting to Yes: Negotiating Agreement without Giving In” to medical students and residents rotating on the service whenever I can[1, 2].

Not a day goes by when I don’t try to remember the basic principles espoused by the authors of both these non-medical and non-psychiatric books which never stop inspiring me to remember to stop and listen to whoever I’m talking with about the usual and unusual issues that arise in a busy hospital inpatient setting. These are among the very few books I re-read for inspiration and guidance about how to be “hard on the issues and soft on the people”.

These books are not written by psychiatrists and they’re not required reading as far as I know in any medical school or residency curriculum—but they ought to be. Whenever I find myself in a tough negotiating situation in which I think there has to be a winner and a loser, I try to channel the authors of Difficult Conversations.

One of the better examples of a difficult conversation is the one about transferring patients from the medical wards to inpatient psychiatry units. Well, sometimes that’s in a patient’s best interest…and sometimes it isn’t. And the conversation gets a little more intense when there are no beds open on any of our psychiatric wards. This is not an uncommon occurrence these days. I can remember when I was a resident psychiatrist taking overnight call and being without a bed to admit someone to when it was really necessary for his or her safety. It was a rarity.

Occasionally there are no beds available on psychiatric inpatient units anywhere in the state. Try explaining that to a busy general medicine hospitalist who is fielding calls from physicians at outside hospitals, emergency rooms (especially emergency rooms these days!), outpatient medicine clinics and intensive care units all clamoring to admit patients to non-ICU beds. They have a tough job.

I’m a hospitalist too, a psychiatric hospitalist. The conversation about where and why to transfer patients between medical and psychiatric inpatient units can get to be pretty focused on positional bargaining—something the authors of “Getting to Yes” advise us to try to avoid. In these situations, trying to take the high road can be challenging when we’re all so accustomed to finessing the finer points of positional bargaining. I can’t always avoid it. And I always appreciate it when my colleagues work with me.

I try to help steer the conversation to focusing on our common goals on behalf of patients. And when I’m tired, my colleagues stand by me. It’s not easy when we’re both up against the wall and say so. It’s hard to reply to a verbal jab like, “I’ve got 3 traumas who need an ICU bed now and your psychiatric patient doesn’t need an ICU bed!!” It’s hard not to feel just the tiniest bit of relish when I can return with the verbal uppercut, “I’m so sorry, but there are no beds–in the state.”

That’s the kind of language we sometimes fall into when we’re in the trenches day in and day out in any hospital, large or small. I was never a big fan of the old M.A.S.H. TV series, but for reasons that are probably linked to my own professional experience, I frequently recall Colonel Potter’s stern and paternal remark in the operating room, “This is meatball surgery, son!”  This was probably in response to the lament that not more could be done for soldiers losing limbs and lives from the battle raging not far from the medical tents.

We can choose another way to have difficult conversations, and not in Red Green’s Man’s Prayer way, “I’m a man… but I can change…if I have to…I guess”. We can work together by remembering patient care is not about winning or losing, it’s about caring for the patient.

This approach to difficult conversations can work for colleagues, couples, corporations…and countries.

1.            Fisher, R., B. Patton, and W. Ury, Getting to yes : negotiating agreement without giving in. 2nd ed. 1991, New York, N.Y.: Penguin Books. xix, 200 p.

2.            Stone, D., B. Patton, and S. Heen, Difficult conversations : how to discuss what matters most. 1999, New York, N.Y.: Viking. xxi, 250 p.