Reprinted from the winter 2025 issue of The Ohio Family Physician.
By: Kirti R. Shanker, MD, FAAFP, Assistant Clinical Professor of Family and Community Medicine, The Ohio State University Wexner Medical Center
Family physicians serve as trusted guides during some of the most challenging moments of a patient’s life. The ability to communicate clearly, empathetically, and effectively can profoundly impact patient outcomes and satisfaction. Yet, navigating these “tough conversations” can be stressful for both the patient and the physician. Navigating through these tough conversations is at the core of how primary care physicians coordinate these discussions.1,2
Tough conversations in the practice of family medicine frequently revolve around serious illness, behavioral changes, end-of-life planning, and care transitions. These discussions can evoke strong emotions, including fear, guilt, denial, or grief. For physicians, the challenge lies in balancing honesty with empathy, ensuring that the patient’s feelings are heard and supported, while delivering the patient and their caregivers accurate, useful information.2
Major changes in treatment planning, such as moving care from a primary care physician to a specialist, hospital discharge after a long-term hospital stay, or transitioning adolescents to adult care, can add confusion and complexity if not handled adequately. Miscommunication is common during these transitions and can lead to medication errors, missed appointments, or confusion about follow-up care. This is why coordinating care through the primary care physician helps maintain consistency, improves medication accuracy, and ensures compliance.
End-of-life discussions can be especially challenging. Thoughtful preparation by the physician can be helpful, but the trajectory these conversations take is often difficult to predict. At the most fundamental level, patients want to understand their illness, the symptoms they are likely to experience, how their illness can affect their daily living, and what their treatment options are. These conversations include their end goals, potential risks and benefits of different treatment options, and prognostic expectations including approximate timeframes. Discussing these with transparency and empathy, while offering support in their physical and emotional health, are key elements in the discussion. Involving family members is inevitable in many cases and increases the complexities of the discussion. Involving everyone at the beginning in order to understand the patient’s perspective provides a meaningful starting point for shared decision making.3
Navigating Care Transitions
Change is intimidating and smooth transitions require early planning, clear communication, and follow-up with the patient and their care team.
Hospital-to-Home Transitions
The discharge summary and the primary care physician coordinator must provide a roadmap for patients so they have a written summary of their new list of medications, treatments, and clarity on which appointments have been set up. Additionally, the social worker is a critical point person in coordinating future appointments with all physicians, as well as other ancillary services.
Specialty Referrals
Coordination with specialists is often complicated because many of these physicians are new to the patient. Ensuring continuity of care across the board and avoiding duplication of testing is essential. However, the primary care physician serves as the hub in coordinating care. Inaccurate or untimely communication in healthcare is consistently reported among the leading causes of preventable adverse events, including medication errors and misdiagnosis. This is especially true for patients living in challenging socioeconomic environments. It is important that we place a strong emphasis on transparency in communication, improving access to resources, and strengthening coordination during these transitions.
Adolescent-to-Adult Care Transitions
Engage adolescents early, educate them about self-management, and communicate the new expectations to their families. Tools such as transition checklists, care navigators, and electronic health record notifications can reduce errors and anxiety during transitions.4,5
Family physicians play a central role in guiding patients through life’s challenging moments. Mastering tough conversations and transitions requires preparation, structured communication, empathy, and attention to follow-up. By adopting these practical strategies and prioritizing both patient and clinician well-being, we can turn difficult discussions into opportunities for trust, understanding, and improved outcomes.