My Crucial Conversation: Dr. Jerry M.

On Monday, a woman was admitted to my hospital for same-day, vascular bypass surgery to repair a painful extremity below the knee that wasn’t adequately circulating blood. She lived in Mississippi and had traveled two hours to Memphis to see a doctor. The surgeon skillfully performed the procedure and the outcome was excellent. The next day, the patient and her husband were deliriously happy because the terrible pain in her foot was gone.

The case manager and physician had tentatively agreed that if everything was fine, the patient could be discharged Thursday afternoon. As the patient continued to improve, the case manager made arrangements for a Thursday discharge.

On Thursday morning, the case manager told the patient’s husband to come and pick up his wife, unaware that the doctor had written the following note: Patient doing fine, foot warm, pulse excellent, patient stable. Plan: Discharge Friday A.M.

Seeing the note, the case manager attempted to reach the surgeon and finally contacted him late that afternoon as he frantically rushed to his office. Running late he bluntly said, “I need to see this patient before discharge. I won’t be in until tomorrow. The patient is not going home today, and that’s that.”

Around 3:00 p.m., the case manager contacted me for help. I immediately called the surgeon and began our conversation by praising his success and offering my assistance. I explained that the patient’s family had driven two hours to pick her up and she was ready to go.

I offered to do the paperwork while he gave instructions to the couple over the phone, but he persisted, “No. I need to see this patient and I can’t be in until tomorrow.” And then defensively he raised his voice, “Is the insurance company putting you up to this? I mean, why are you pressuring me?”

Taken back, I responded by using the Contrasting skill: “Honestly, I don’t even know who the payer is. This isn’t about the insurance company; this is about meeting the needs of the patient and the family. They’ve had a wonderful experience. They think you walk on water. They were told they could go home, and I’m afraid cancelling the discharge could sully an otherwise wonderful clinical outcome.”

Floundering a bit, he responded, “Tell them I’ll be in, but it won’t be until 7:00.”

Reaching agreement, I promised to communicate his willingness to make a special trip back and personally give instructions. He came in that night, discharged the patient, and avoided tarnishing an otherwise wonderful episode of care.

In the health care environment, crucial conversations are real, they’re up front, and they happen all the time. This conversation was successful because I followed two of the quintessential rules: Mutual Respect and Mutual Purpose.

—Dr. Jerry M.