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Defusing Difficult Situations

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Defusing Difficult Situations

Defusing Difficult Situations

Date: 02/01/2017

How a provider communicates can make a patient feel listened to and cared for — or talked down to and dismissed. Not only is the patient’s experience of care affected by providers’ communication skills, but the safety of that care is, too. Thirty-seven percent of all high-severity patient injury cases nationwide involve a communication failure, according to a recent report by CRICO Strategies, part of Harvard Medical Institutions.

Because communication is so important to delivering safe, patient-centered care, Suburban Hospital has initiated a provider communication skills course called PEARLS. The acronym encapsulates the goals of the course, which is to communicate with patients with:

  • Partnership
  • Empathy
  • Apology
  • Respect
  • Legitimization
  • Support

“There is good, hard evidence that patient outcomes are improved when physician communication is better,” says Diane Colgan, Suburban Hospital’s chief of medical staff, who leads the hospital’s PEARLS program.

What’s more, she adds, questions about communication form a significant part of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, whose results are publicly reported.

Conducted offsite, the daylong course typically has some 20 participants who are physicians or other care providers. It focuses on strategies for turning challenging conversations into productive ones. Its lessons are applicable, of course, to any difficult or delicate interaction.


How long does a patient speak in a typical visit before the physician interrupts? 18 seconds, says Colgan. “Providers want to make the narration a more efficient process. But when we interrupt, we divert their story. Who’s better at telling their story, you or the patient?”

In fact, it takes the average patient only about a minute to finish the list of concerning medical issues without interruption.

Colgan encourages providers to use mindfulness techniques to free themselves from distractions so that they can bring their full attention to bear on the next patient they’re seeing. One physician she knows, for instance, repeats the word “caring” to himself as a mantra as he washes his hands before moving to the next exam room. Another tells himself silently, “Listen!” A third thinks of washing distractions away when she scrubs for surgery.

Colgan says, “The practice of listening and understanding without judging or interrupting is difficult. But as William Osler said, ‘Listen to your patient, he is telling you the diagnosis.’”


A patient who is facing a distressing disease, confronting an unexpected outcome or simply trying to have their many questions answered should be approached using the PEARLS method of communicating:

Partnership: Emphasize that you and the patient are working together to solve his or her health issues.

Empathy: When patients get upset or angry, work to understand why and reassure them that you understand their concerns and will work to address them. Remember that the patient has come to your for help.

Apology: Let the patient know that you are sorry they are frustrated, angry, upset.

Respect: Show respect for their concerns and their fears.

Legitimization: Legitimize their concerns: “You are experiencing more pain that you expected post-op; that can be difficult. Let’s see what strategies we can come up with for managing that pain.”

Support: Let patients know that you, as their physician, want to offer them as much support as you can. Ask them about barriers to care and compliance. Let them know about other sources of support, such as disease education.

The PEARLS method is truly patient-centered, says Colgan. It is designed to promote patients and families as partners on the health care team, improve quality and safety, reduce medical errors and readmissions by information sharing with patients and families, improve patient outcomes and increase HCAHPS survey scores, which has financial benefits for the hospital.

Johns Hopkins Bayview Is Using PEARLS, Too

For more than a year, Johns Hopkins Bayview Medical Center has been planning a course to train physicians and other care providers in communication skills, including the use of PEARLS.  The initial focus was to train Medicine and ED physicians. Says Renee Blanding, vice president of medical affairs: “A lot of our patients come through ED and go to Medicine floors, so we decided to optimize those care providers’ communication skills.”

But the courses have also trained physicians and providers from other disciplines as well as nurses and administrators.

Blanding has personal experience with PEARLS: “The approach really worked. I had an intense conversation with another physician, who was very passionate about what he was asking for.  Using PEARLS, I was able to defuse the situation rather than escalate it.”