One thing that all those years of education, medical training, and textbook studying can never quite fully prepare us for as physicians is crucial conversations with our patients. There’s an element to mastering these conversations that comes with being an attending physician, bearing sole provider responsibility, and having them ourselves. They may start off clunky at first in early practice, but we hope to continually improve with time.
In my practice as a solo ENT at a rural community hospital, I see many patients with neck masses that are malignant on workup. The conversation after a tissue biopsy with a patient and family certainly falls into the bucket of crucial conversations. And in the event of any complications, there are crucial conversations as well. As empathic physicians, so many of our interactions with patients are crucial, and mastering this art is the mark of any truly great physician.
Kim Downey blazes a new path for collaboration with physicians to bring her expertise both as a health care professional and as a patient, who has had many crucial conversations. Her wisdom from experience is invaluable and a worthwhile read, particularly for younger or early-career physicians who are eager to best prepare themselves for practice.
What is a crucial conversation? In the book, Crucial Conversations: Tools for Talking When the Stakes Are High, the authors describe it as a discussion characterized by high stakes, differing opinions, and strong emotions.
We all have crucial conversations throughout our lives. Doctors, in particular, have them all the time, including with their patients, bosses, colleagues, friends, and family members.
How you prepare for, speak during, and respond to a crucial conversation makes a huge and lasting impact on the outcome of that interaction.
In planning a crucial conversation, start by determining your motive: what do you really want out of the conversation? Keeping that in mind will help you show up for the conversation in a way that you will be satisfied with, no matter the outcome.
Determine the facts of the situation vs. the story you are telling yourself about the situation. Facts have evidence to back them up and can be substantiated. For example, a fact would be, “My patient did not pick up their prescriptions.” This is in contrast to a story such as, “My patient must be lazy and not care about their health.” We are better people, and better doctors when we routinely and clearly differentiate between fact and story.
A good question to ask yourself when planning a conversation is, “Why would a reasonable, rational person act this way?”
Find mutual purpose whenever possible. Is there a common denominator beneficial to all parties? The ability to maintain that vision during the conversation can serve as an important guidepost.
When possible, ask permission (not specifically related to patient conversations); “Is this a good time?” “When would be a good time to talk about XYZ?”
Start with a heart: begin by stating your positive intention. That is one way to create psychological safety, which is critical in laying the groundwork for a successful conversation. The intention is for the other person to be able to receive the information you are about to share from a mindset where they feel safe to listen and receive feedback without becoming defensive and shutting down, tuning out, or walking away.
Be transparent and sincere, demonstrating empathy when delivering the news. Given that the information you are sharing might be difficult to receive, respond with compassion.
As it specifically relates to offering an apology following a complication, Jean-Paul Brutus, MD provides a great response in his book, “Secrets & Lies from the Operating Room – Everything You Wanted to Know About the World of Surgeons”:
“I’m very sorry this has happened to you. This is not the outcome that any of us wanted for you. I’m disappointed. I’m disappointed that you have had to go through this. I know that you are feeling very upset, frustrated, and angry, and I would be feeling the same way. All I can do is say I’m sorry that you are in this situation and we are going to do everything we can to understand the events leading up to this so that we can avoid it happening again. In the meantime, I want you to know that I am here for you, if there is anything I can do.”
Having experienced a complication as a patient, hearing those words at the time of the complication would have made a world of difference to me. It would have gone a very long way in helping to mitigate a lengthy period of emotional struggle.
As a patient who encountered numerous health challenges in the recent past, I’ve had the opportunity to initiate crucial conversations with several physicians. The first few times, I spoke “on the fly” and was not satisfied with the outcome. I acknowledge my role in that. It is possible I might have been more satisfied if I had spent more time planning the conversations.
Another time, I showed up for the conversation well-prepared, yet still not satisfied with the outcome. My takeaway from that experience is that the only thing you can control is what you say and how you present yourself; you cannot control the reaction of another person.
Finally, I planned extensively for the conversation and was satisfied with the outcome. Using the suggestions above, I helped to create psychological safety for the discussion. I showed up with my best self, and the physician did as well. They really listened to me, offering empathy, compassion, and an apology as appropriate. I was nervous about having the conversation but was so glad I followed through anyway. I believe we both left the conversation with increased mutual respect.
Dr. Sarah Wittry recently wrote, “Healing is in speaking our truth, validating our experiences and those of others.” That rings true for doctors and patients.
Kim Downey is a physical therapist. Frances Mei Hardin is an otolaryngologist.
