Pic 0: The screen displays an image of Kai and the following information:
Appointment with Kai:
Prior to the appointment, the provider and the care team reviewed Kai’s profile.
It’s his first time coming to this care team.
He is requesting an early refill for his opioid prescription.
At his previous provider’s office he requested an early refill, which he received.
Based on this information, the provider and the care team added extra time to his appointment in anticipation of having a longer conversation. The provider and the care team have put together talking points and printed informational notes.
Pic 1: The screen changes to an image of Kai’s medical chart, which includes the following information:
Name: Kai Davis
Age: 56
Sex: Male
Chief Complaint: Pain prescription renewal
Medical History: Hypertension
Surgical History: None
Family History:
Allergies: No known
Medication: Percocet, amlodipine
Pic 2: The screen changes to a scene in an examination room with the provider and Kai sitting across from each other.
Andrea: Hi, thanks for coming in. I’m Andrea, and I use she/her pronouns. How would you like me to refer to you?
Kai: Kai, he/him, and you sure didn’t make it easy for me. I had to wait weeks to get in for a prescription refill, and then, the only appointments were in the middle of the day. And you know what I do during the day? I work, which I’m not doing right now because of this.
Andrea: I’m sorry the timing of your appointment is inconvenient, but the care team and I noticed that you were requesting an early refill, and also that you’d gotten early refills other times in the past.
Kai: Yeah, I have some bad days every month, days where I need to take a little bit more to get through work.
Andrea: Okay, before we go on, how many bad days do you usually have per month? And how much extra do you take?
Kai: Are these questions necessary? I don’t have a lot of time.
Andrea: Well, I know you’re here for the refill, but I wanted to talk a little more broadly about your health right now.
Kai: (agitated) I already had to sit in the waiting room for half an hour. I don’t have time for that! I’m not interested in talking about anything other than how I can get my refill.
Andrea: Someone should've brought this up with you by now, for your safety.
Kai: Well, they haven't. My pain is still really bad. I should just walk out of here and find someone who will fill my prescriptions.
Coach: Kai is feeling defensive. The provider should try to find ways to calm the situation by showing empathy, partnership, and validation.
Andrea: For your safety, you have to take your medication as prescribed.
Kai: Forget this! I'll find someone else This is a waste of time.
Coach: Kai became too escalated and left. Let’s go back and look at another approach the provider could use.
Andrea: I can't help you until I understand why you're concerned.
Kai: Right, I'm sure you've never had to worry about putting food on the table. Cushy job like this, you have no idea what I have to deal with.
Coach: While it’s true that the provider needs more information to help Kai, it would be more effective to frame this as an open-ended question to elicit a more open response from Kai.
Kai: (sigh) Y'know, with the last guy I saw, I didn't even have to come in. I'd just call and ask, and he'd give me the refill. But for you I have to take off work and deal with this.
Andrea: Your old providers may have just given you refills whenever you wanted, but that's not how we do things here.
Kai: Then maybe I'm better off finding a place where they do things like I’m used to. The pain was still bad. I had to start taking more. Okay? End of story.
Coach: Being too direct can feel impersonal and evoke a defensive response. Let’s see how the provider can reset expectations and build rapport with Kai.
Kai: (somewhat defeated) Listen, are you going to give me the refill or not?
Andrea: I want you to know that I'm in this for the long term. I want to make sure that you can still work five, ten years down the road. I also want to emphasize that these opioids aren't healing anything, it's just blocking you from feeling your body's limits. So that when you do push yourself over that limit, you could be doing more damage. And in the short term, that may feel okay, but you could have a serious injury that might leave you in a position where you can't even walk.
Kai: (processing) Okay.
Andrea: So that's why we're having this discussion, so I can see what the best option is.
Kai: I still think this is pointless. I just want my meds.
Andrea: I'm the provider, and you're crossing a line. I don't want to have to fire you as a patient.
Kai: Who do you think you are? Maybe I should find a provider who actually cares.
Andrea: The reason we're having this discussion is because I do care about your safety, and I don't want you to overdose.
Kai: Overdose, are you kidding? I'm not gonna overdose.
Coach: When de-escalating, the provider should remember to use the Calm and Assess steps. The provider can try showing empathy or asking an open-ended question to help validate Kai’s feelings and get to the root of his problem.
Andrea: Being on a higher opioid dose than prescribed increases your chance of overdose or even death.
Kai: Well, I've been fine so far.
Andrea: The thing is, you might take that extra dose and then go out with some friends and without thinking about it, you have a beer or two, and that could be enough combined to cause an overdose. So, the more you take, the more dangerous other things become.
Kai: (unsure) I don’t know about all that. I just want to feel like I did before.
Andrea: The reality is, you shouldn't be doing any manual labor when you're taking opioids, because your risk of falling or hurting yourself is much higher.
Kai: Oh, now this, too? I don't know what you want me to do. I can't quit my job.
Coach: Instead of telling Kai what he should or shouldn’t be doing, the provider should try using empathy to validate how he’s feeling.
Andrea: (transitioning) I don't want you to suffer or to be in pain all the time. So, I'd like to talk about some other approaches to addressing your pain because giving you additional opioids is not a solution, and it's not something we're comfortable with.
Kai: (relenting) Doesn’t seem like I have a choice.
Andrea: The pain just isn't as important as what you're risking by taking more medication than prescribed.
Kai: I should've known. You people never actually care. You have no idea what I have to deal with.
Andrea: I've been doing this for a long time, so I like to think I have some idea of the difficulties of dealing with chronic pain.
Kai: (semi under breath) Could've fooled me.
Kai: I don't wanna hear anything else. I've already tried everything, and nothing works but the meds, so I'm not leaving till I get them.