Consult-Liaison Education Informal-curriculum Medicine

Difficult Interactions (III).

(Note: If you found the previous posts in this series “woo woo”, you might find this one nearly intolerable.)

A final reason to stop talking in the midst of a difficult clinical interaction is so you can accept what the other person is doing.

When you accept someone else’s behavior, this does not mean that you necessarily agree with it. It doesn’t mean that you condone it, support it, or want it to happen more. It just means you accept what is happening.

We cannot control the behaviors of others. We can influence them, but we cannot control them. If we do not accept what is actually happening, we have no chance of influencing what happens next.

I worked in a residence where two men would occasionally pee in the elevator. They weren’t incontinent, there was no Foley catheter and bag that malfunctioned… they just periodically voided their bladders in that small space.

Willfully ignoring the yellow puddle in the elevator won’t resolve the problem. The odor would fill the elevator and other people would inadvertently step into the urine.

Wistfully wishing that they had voided their bladders elsewhere won’t resolve the problem, either. “Why didn’t they use the bathroom? If they really had to go, they could have at least peed into the plant next to the elevator. Should they wear adult diapers?” Trying to solve the problem before having a clear definition of the problem often only leads to frustration. You cannot define a problem until you accept that it is a problem.

It’s also common to realize that, when you’re silent and accepting what the other person is doing, the difficult interaction often softens. It is hard to argue with or resist someone when he is accepting what you are doing and saying in that moment.[1. It takes two to fight, two to tango, blah blah blah….] Furthermore, you are also practicing and modeling a useful skill. The other person might realize that he could use that skill at that moment, too.

To review: One reason why it is useful to stop talking during difficult interactions is so you can acknowledge the emotions you are experiencing. Another reason is to recognize and adjust the language you are using to describe the situation to yourself. A third reason is to accept what is actually happening so you can plan and take next steps. It seems like all of this would take a long time and result in awkward silences, but that doesn’t happen. For many people, staying silent isn’t a habit. It takes practice.

Medicine Observations


“There are images of my internal organs everywhere. Someone is collecting them.”

“How do you know that?”

“The sun produces radiation. It’s the same radiation that is used in X-rays. The sun shines, my body gets exposed to radiation, the X-rays go through me, and someone collects the images of my internal organs.”

“Doesn’t that happen to everybody, then? The sun shines on everyone.”

“No, I’m pretty sure it just happens to me. I’m going to die soon.”

“You’re going to die soon?”

“Isn’t this where they conduct executions? With the firing squad?”

“… no.”

“Oh.” He looked over his shoulder, his brow furrowed. He turned his head back. “I was wondering why they give me food every day. I guess I’ll never be normal.”

“Normal? What does ‘normal’ even mean?”

“What do I think a ‘normal’ person is like? A normal person is someone who is reliable. I’m not reliable because I do things like not take my medications and then I end up in situations like this. I can’t rely on me and if I can’t rely on me, no one else can rely on me. When I think about that, it makes me feel worthless. I’d be better off dead.”

He looked down, the furrow in his brow gone.

Consult-Liaison Education Informal-curriculum Medicine

Difficult Interactions (II).

Another reason to stop talking in the midst of a difficult clinical interaction[1. I focus on clinical interactions here, but this arguably applies to any difficult interaction we have with our fellow human beings.] is to recognize what you are thinking and adjust the language accordingly. The words we use to describe events, even if only in our heads, will influence both our emotions and behaviors.

Here is an example. Who would you rather work with?

Person 1: This is a 28 year-old woman who is manipulative and immature. She will do anything to get attention; she’s so dramatic. She never takes responsibility for what she does and everyone else has to clean up the messes that she makes.

Person 2: This is a 28 year-old woman who struggles to deal with emotions she feels like she can’t control. She has difficulties with relationships, but she’s doing the best that she can with the skills she has to get her needs met. If she knew how to work with people more effectively, she would. She might also have fears that if she tried harder, she might fail. No one likes to feel shame.

These descriptions could be of the same person. However, your reactions to each description might be noticeably different.

Some may argue that this is an exercise in semantics or, worse, indulgence in delusion. “But, Dr. Yang, she really is manipulative….”[2. Like I noted here, we manipulate each other all the time. I’m arguably manipulating you right now with these words. We often use the word “manipulative” when the manipulation isn’t skillful. People would do something different if they could in that moment.]

It’s our job to be more flexible than our patients. That’s why we get paid to do what we do. Yes, you could argue that these are just word games. However, would you rather be helpful or would you rather be “right”?

If describing patient behaviors in neutral, if not generous, language will help you maintain your professionalism and deliver quality care, then give strong consideration to what words you choose.

Please note that you can still use neutral language even when you feel angry or frustrated:

She’s screaming and trying to bang her head against the wall right now because that’s the best that she knows how to cope with the situation. I’m getting really annoyed with this… and if she could do something different right now, she would.

What is happening and how you feel are both “true”.[3. Using neutral language in your head during difficult interactions can have the added benefits of making you slow down and reducing the intensity of your emotions.] Remember, you feel what you feel. Own it.

To review: One reason why it is useful to stop talking during difficult interactions is so you can acknowledge the emotions you are experiencing. Another reason is to recognize and adjust the language you are using to describe the situation to yourself.

One more reason to follow before we all resume talking.

Nonfiction Observations


She was a petite woman. She thrust her shoulders back and her dark hair cascaded down in waves towards her slender waist. Her burgundy and white dress gently bounced with each step she took in her four-inch heels. Her arms and legs had the girths of tree saplings. A designer handbag swayed on her left shoulder and pearl-accented earrings dangled from her ears.

It was crowded at the buffet. With purpose she walked past the glistening hunks of prime rib, the pink slabs of baked salmon, the heaps of bacon, the blobs of scrambled eggs, the bowls of romaine lettuce and spinach, the rounded cubes of honeydew, pineapple, and cantaloupe, the bundles of fried egg rolls, the vats of noodles, the pot of egg drop soup, the bowl of quivering red jello, the trays of walnut brownies, lemon cake, and chocolate mousse pie, the racks of barbecue ribs, the oozing discs of pepperoni pizza, the rows of chocolate chip cookies, and the limp triangles of French toast.

She carried her plate with both hands, her fingers tightly gripping the edges. Her eyes scanned the buffet, but she was not looking at the food. The only item on her plate was one roasted red potato.

Consult-Liaison Education Informal-curriculum Lessons Medicine Observations

Personality Disorders to Difficult Interactions (I).

I successfully delivered my talk on personality disorders recently. The second half of the talk strayed from personality disorders to a discussion about how to manage difficult interactions with people. The two topics are peripherally related, as you will recall that individuals with personality disorders often have difficulties with interpersonal relationships.

To be clear, though, just because you have a difficult interaction with someone doesn’t mean that that person has a personality disorder. There are plenty of people without personality disorders who behave in unbecoming ways.

Think about the last time you had a rough day. It is within the realm of possibility that, during that slice of time, you behaved in ways that suggest you have a personality disorder. It may not happen often, but it happens to all of us at some point.

Most of us rely on “gut feelings” to identify when we’re having difficult interactions with people. There are behavioral cues, though, that can serve as “red flags” to alert you that an interaction isn’t going well:

1. There are frequent interruptions. The other person keeps interrupting you… and you keep interrupting the other person.

2. There is a lot of repeating. You keep saying the same thing over and over again… and the other person keeps saying the same thing over and over again.

3. Many words are spoken, but nothing is really said. The literature describes this as “disengagement”. You’re just saying things to end the conversation. (e.g., “There’s nothing else I can do. Sorry. There’s nothing else I can do. Sorry.”)

Though emotional cues are valuable, sometimes it is easier to recognize these behavioral cues. We may not realize how we’re feeling until it reaches an uncomfortable intensity.

Once you recognize that you are in the midst of a difficult interaction, what can you do?

A useful first step is to stop talking.

The reason why it is important to stop talking is because when you stop talking, you can then self-reflect. I know that sounds “woo woo”. Hang in there with me.

Acknowledge the emotions you are experiencing. If you do not recognize and acknowledge what you are feeling, those emotions will likely manifest themselves in behaviors that you may not like.

If I refuse to acknowledge that I feel angry with someone, I might speak in a tone of voice that sounds sarcastic and condescending, give an icy glare, or say something biting and rude. Acknowledging what I am feeling gives me the opportunity to adjust my behavior accordingly. It gives me choices as to how I want to proceed.

To be clear, people aren’t stupid, so the other person probably knows that I feel angry. Acknowledging my anger, though, can cue me to take a deep breath, relax my face, or do something else to prevent the situation from getting worse. If I’m not paying attention to how I feel, I won’t do any of those things.

The other important aspect about acknowledging your emotions is that it grants you permission to feel what you feel. People sometimes have this idea that you must like all of your patients (or clients or customers or…). However, you won’t like all of your patients. That’s okay. That’s not the expectation. The expectation is that you show respect and provide the best care you can to them. That doesn’t mean that you have to like them.

You feel how you feel. There may be days when you feel anger towards people you like. And that’s okay. You will be much more effective if you acknowledge how you feel to yourself because you will be giving yourself choices. Those choices can give you significant influence over the rest of the interaction.

This is one important reason why you stop talking. More reasons to follow.