Alright, I’m going to come right out and say it: you need to speak your mind!


Patients and clients want it. In fact, they need you to be confident enough in your clinical expertise to have hard conversations, to push back against unrealistic expectations, and to communicate the value you bring to the table. You need to be able to say what you’re thinking in a confident, kind, and caring way.


It seems, for whatever reason, clinicians find it difficult to have “tough” conversations with patients or clients. Maybe it’s because, being in the service field, there’s an idea that conflict or confrontation is bad. Since healthcare has begun to move more towards consumer-driven models, some clinicians feels as if they should stand behind the principle: “The customer is always right”. There’s just one problem with that idea: it doesn’t apply in healthcare.


As I’ve written about here, as a licensed clinician, your role is to lead the patient or client engagement (I also did a podcast episode on this topic, if you’d rather listen). That means that you, collaboratively with your patient or client, guide the process of assessment, treatment planning, and goal setting. It requires that you not sit back passively and let patients continue with decreased engagement, inappropriate or unrealistic expectations, or ideas and behaviors that may actually be making their situation worse.


The Hard Skills


I’ve written and spoken a lot about the importance of building your interpersonal & communication skills as a clinicians (here, here, & here) in the past, but haven’t addressed the issue of “hard” conversations. I like saying that the “soft” skills really are the “hard” skills in healthcare. As clinicians, and scientifically minded folks, many of us find it easy to acquire information & knowledge and apply it to a patient or client’s situation. For example, it’s easy to understand the complex nature of the 4 components of the shoulder complex, assess a patient who presents to our clinic with shoulder pain, and then develop some treatment plan based solely on the biomechanical or pathophysiological dysfunctions that the patient presents with.


However, clients and patients are more than just joints and tissues. In fact, the Biopsychosocial Model provides a great framework for beginning to address the other factors at play with any patient or client that walks into your clinic. So that leaves healthcare practitioners with a situation to deal with: The technical information and skills related to providing healthcare treatment & services aren’t the only thing to be mastered. Because patients and clients are unique individuals, with a unique & subjective experience, on a unique road to recovery and healing, clinicians must learn and master interpersonal communication skills to effectively help them reach their goals.


This need to master interpersonal communication skills extends far beyond education, answering questions, and explaining things your patients. It must extend to the sometimes uncomfortable, sometimes difficult areas of expectations, appropriate recommendations, addressing behavioral change, and the importance of active vs. passive treatment strategies (I talk a little bit about this on my article on telehealth). Clinicians should act as leaders and guides, helping their clients achieve their desired goals. This often means that we need to address areas like harmful lifestyle habits, mismatched expectations about treatment and prognosis, and even the role that they (the client) must play in their own treatment plan. These conversations can be difficult. They can be uncomfortable. But they are absolutely essential for building rapport, establishing trust, and developing strong, long-lasting relationships with your clients and patients.


Difficult Conversations


When was the last time you had a “difficult” conversation with a patient or client? What was the topic or issue that led to the conversation? How did you handle it? What was the result?


Being a clinician myself, and spending much of my clinical work in the VA health system, I’ve had my fair share of “difficult” conversations with disgruntled patients. Most often then not, much of the anger or frustration expressed by these patients stemmed from differing or unrealistic expectations. I’ve written and spoken about this a lot recently, but it bears restating: if you don’t address client expectations at the outset of a course of treatment, you risk the client becoming dissatisfied, unhappy, disengaged, and possibly even angry with the experience they have in your clinic. Managing patient expectations should be a top priority.


So how do you go about actually initiating one of these difficult conversations? What if a patient says something during an assessment or during treatment that leads you to believe they have unrealistic or inappropriate expectations about treatment, etc.? There are plenty of frameworks out there, from the Radical Candor approach, to the Crucial Conversations guide. If you’ve read many books on this topic, whether it be a book about handling confrontation or a book on negotiating, it all boils down to a few basic principles:

  • Don’t shy away from the difficult topic.
  • Employ empathetic, active listening during the conversation.
  • Allow the other party to feel heard.
  • Provide context, and restate your objection/position/feedback.
  • Don’t make it personal.

Now that’s all good and nice, but it’s how do you do it that really makes the difference, especially when communicating with patient and clients.


Don’t Shy Away


One of the greatest pieces of advice I ever received in my career (and probably life) was that, in order to truly be a successful leader, you must not shy away from doing the hard stuff. In this case, the hard stuff means those difficult conversations. Humans tend to avoid conflict. This stems from our evolutionary roots, and the fact that societies have formed around the ideas of being nice, not rocking the boat, or going along to get along. And for the most part, those ideas help keep society running smoothly. That’s why we can live in a place surrounded by people we don’t know, living different lives, and making different choices, and still smile & wave as we walk past each other on the sidewalk. As a rule, most people avoid conflict and try to “go with the flow”, in order to avoid any visceral feelings of discomfort, anxiety or unrest that arises from conflict.


Now, this tendency to avoid conflict at all costs is actually damaging when it’s applied to one-on-one or individual relationships. Unlike interactions out in society, one-on-one interactions and relationships requires trust, understanding, and meaningful dialogue. Translated to the clinical context, where a client or patient is interacting with a clinician, a simple smile and wave aren’t enough to establish any meaningful relationship. To build trust, a meaningful exchange or dialogue must occur. Clinicians, who should establish the leadership role in that relationship, best do this by tackling potential stumbling blocks head on at the beginning. Allowing incorrect ideas, assumptions, or expectations to linger only increases the difficulty to address them later on in the course of treatment, and increases the likelihood of a major conflict or negative patient experience.


Employ Empathetic, Active Listening


Now, in order to truly hear and recognize when a potential conflict may arise, you must always practice active listening. Whether you’re completing an initial assessment or running through a routine treatment session, you must always attune your ears to hear what a patient is truly saying. This involves empathy as well -trying to understand the point of view your patient holds, or trying to understand where they’re coming from. When you’re actively engaged in listening to your patients and clients, you’re able to pick up on those “red flags” that need to be addressed. And in order to address them in a way that is collaborative, that builds trust, and that strengthens your relationship with your patient, you must be armed with the information & context that only comes through active listening and empathy.


For example, if a patient says something either during treatment or an assessment that makes you feel like there are mismatched expectations, you should not allow that expectation to fester. Now, how you address it requires that you’ve truly heard the patient, understand their point of view, and then frame your objection in a way that reflects that. You could say something like, “It seems you have [insert expectation/idea] about [treatment, scheduling, etc.]. I just want you to know we actually [insert your objection here]. How does that sound [or: is that consistent with what you had in mind]?” This simple exchange establishes that 1) you were listening 2) that you feel there’s something that requires further dialogue 3) you’re open to hearing more about this patient’s point of view. This all falls flat however, if you don’t make the effort to actively listen and understand your patient’s understanding or point of view.


Allow The Other Party to Feel Heard


Now, along with empathy and active listening comes the lynchpin here: allowing the other party (in this case, your patient) to feel heard. As I’ve said before, most patients are used to being talked at in a healthcare situation, rather than engaging in dialogue. While patient-centered care is supported in the literature, many healthcare organizations and clinicians still rely on a hierarchical approach to healthcare; one where the clinician is at the top, issuing edicts to the patients below them. This dynamic ruins the possibility of truly collaborative relationship-building between clinicians and patients. The first step to overcoming this, is to allow your patients to feel listened to, heard, and valued.


Asking questions like, “Is that consistent with your understanding?”, “Does that sound like what you were thinking?”, or even “Tell me if I’m missing something here.”, prompts the patient to provide more information & background to the conversations and also gives them the feeling of being heard. Ultimately, in any conversation, argument, or negotiation, humans want to be heard, especially in matters that are deeply important and meaningful (like their health, their treatment, their goals).


Provide Context & Restate Your Position


After you’ve provided the opportunity for your patient to clarify their point or provide more background or information, the next step requires that you do the same, if necessary. Maybe the patient explains that they have an expectation about treatment that doesn’t align with your philosophy of care, or scope of practice, or organizational guidelines. After you’ve asked those questions that prompt the patient to provide more information for you to truly understand their position, you are then responsible for providing the same type of context and information to the patient. This helps you both understand the other’s position and move forward in the relationship from the same understanding.


A good framework that I like to operate from looks like this:

Restate the other parties position + provide your own context/info + restate (or deliver) your objection or feedback


Let’s take the example of a patient who has an unrealistic expectation for treatment. You as the clinician, after asking questions to understand their point of view may say something like, “It seems that your idea of treatment involves [insert their expectation]. In situations like this [insert context, maybe literature, best practices, organizational standards, etc.]. And in this case [insert objection and explanation].”

You can also add a final step of allowing the patient to respond/feel heard (thus beginning the cycle over) by adding a question like, “How does that sound to you?” or “Is that consistent/compatible with what you’re wanting to get out of treatment?”


Your goal with this is let the patient know you heard & acknowledged their position, provide some background information (if necessary), and then deliver your objection or feedback in away that leaves the door open for further dialogue and explanation as needed. You don’t want it to come across as, “I hear you, but this what we’re going to do instead.”. Again, the aim is to build strong, collaborative relationships with your patients.


Don’t Make it Personal


The final point on this matter involves not taking anything that is said during one of these conversations personally. Often times, especially in matters of health, treatment planning, and the like, emotions run high. A patient may have inappropriate expectations for treatment, but they likely stem from either past experiences, incomplete information, or some emotion (fear, anxiety, etc.) about their condition, diagnosis, or limitation. In these situations, patients may say things that, on the surface, seem to be personal attacks on you, your treatment skills, or the like. In all reality, these comments likely stem from an emotional reaction or position related to their current situation.


During these difficult conversations, practice extending the benefit of the doubt, or good will, to your patient. They’re likely dealing with a situation that’s difficult, painful, and even frightening. What they need the most is a competent, caring clinician who will take the time to listen to them, acknowledge their feelings, and then provide the necessary context and feedback to begin moving forward towards whatever the desired outcome of treatment is.




At the end of the day, clinician’s can’t hide behind technical skills, book knowledge, or certifications. This is a relationship-based profession. And relationships, built on trust and collaboration often require times of conflict & resolution. Learning how to navigate these difficult conversations provides clinicians the ability to ensure that they are able to properly lead their patients throughout a course of treatment to help them achieve their desired outcomes and goals. Mastering these conversations requires empathy, active listening, deference, and allowing the other party to feel heard. It also requires that clinicians don’t shy away from those difficult conversations when they arise. Those clinicians that rise to the challenge find themselves developing strong, long-lasting relationships with their patients; and their patients become more engaged in treatment, achieve better outcomes, and have more positive experiences in the clinic.


If you’d like to talk with me about your clinic, and how Rehab U can help you improve your clinic’s patient retention and engagement, reach out. I’d love to have a conversation with you and explore how we may work together.


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How do you handle difficult patient conversations at your clinic? Do you provide your clinicians & staff with any guidance or training on the subject?  Share any additional resources that you found helpful in the comments below!

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Rafael E. Salazar II, MHS, OTR/L (Rafi) is the president and CEO of Rehab U Practice Solutions and the host of The Better Outcomes Show. He has experience in a variety of rehab settings, working with patients recovering from a variety of injuries and surgeries. Rafi has worked in a variety of settings, from orthopedic and musculoskeletal rehabilitation, to academia, and even healthcare consulting. He spent the majority of his clinical experience working at Charlie Norwood VA Medical Center, where he was the lead clinician and clinical education coordinator for the outpatient specialty rehab program. In this role, he treated many veterans with chronic pain and helped to establish an interdisciplinary pain management program. He has worked on projects ranging from patient engagement initiatives to marketing communication campaigns to a multi million dollar project assisting the State of Georgia’s Department of Behavioral Health and Developmental Disabilities transition individuals out of state institutions to community residences. He also has experience as a core faculty member at Augusta University’s Occupational Therapy Program, as a Licensed Board Member on the GA State OT Board, and he serves on the Board of Directors for NBCOT. He works to help healthcare clinics and organizations deliver uniquely impactful patient experiences by improving service delivery through training & advisement and through courses & training programs.

Read his full bio Here. Read about Rehab U Here.

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