#14 No Difficult Convos
We are always trying to communicate more effectively in the physician-patient relationship because so much of the success of our encounters depends on this one thing. The physician-patient relationship encompasses four core ethical principles: autonomy, beneficence, non-maleficence and justice. The onus is on us to provide enough information and guidance for competent patients to make their own decisions regarding the treatment they choose to receive or decline. Our patients have autonomy, the right to accept or decline offered health care, and physicians have a duty to respect the decisions of their patients.
Of course, these lofty ideals are a lot easier said than done. Physicians frequently face challenges in broaching “difficult” topics with patients and their families. What makes any task or situation difficult are our thoughts about it. I find it difficult to run a mile. My friend runs marathons and finds it quite easy. Of course, she trains and practices daily. If we could manage our thoughts about challenging conversations and get some practice at them, these discussions would be dreaded less and achieve the desired goal of informing and persuading.
Our conversations are complicated by language differences, cultural barriers and our patients’ wishful thinking about how we can fix anything. As human doctors communicating with other human patients, we still crave approval. It makes us feel worthy. Approval is a euphoric drug that enables us to think positive thoughts about ourselves and our abilities. Disapproval feels like an existential threat.
Have you ever had this thought that if everyone just liked you and thought you were the best doctor ever, then you would be so confident and your practice would be so much easier? What would your practice of medicine look like if you did things so that all the attending physicians, nurses, and patients would like you?
Do you ever notice that if and when people disapprove of you, we tend to want to avoid them or we get defensive or want to judge them and disapprove of them for disapproving of us? Our brains are good at focusing on: How do I get people to like me?
Memo: you can’t control other people’s feelings and you do not have to. You can’t even get everyone to like you. Patients and co-workers think their own thoughts that make them like you or dislike you. Their feelings come from their thoughts, not your actions. You can be the sweetest and juiciest peach on the tree and some people just don’t like peaches. It’s not the fault of the peach.
What really makes our conversations with patients or their families difficult, are the feelings that come up for us when they get mad or disagree with us. Fortunately, other people can’t control our feelings either. They have every right to think and feel the way that they choose and we don’t have to make it mean anything about us. We can offer them our best medical advice but they don’t have to accept it. If we can release the need to control other people and to not be offended or defensive by their decisions and actions, we can feel better even in the midst of tense exchanges.
Those messy situations at the end of life are not helped by employing euphemisms. To avoid pain for the family and to protect themselves, physicians soft sell the end of life message. “Your mother is dying” becomes, “your mother is failing.” The family might think that if only mama or the medical team were trying harder, she might do better.
Vague messages create confusion, mistrust and unrealistic expectations among families. Although the medical team thinks less should be done, the family believes the care team should be doing more. We need to anticipate and accept the family’s sadness, anger, and disappointment. If we are confident in communicating our message and act in the best interest of the patient, we can better accept the negative thoughts and feelings of the family.
How can you set yourself up for success when you need to have a challenging conversation? You can test whether you should be giving feedback or relating news by how you feel. If I’m feeling upset, frustrated or angry with a patient or a family, I’m going to relate information and recommendations in a certain tone that will convey those negative emotions. If I can clean up my own thoughts and get to a place of compassion, acceptance and concern for the patient, I can feel good about how I show up, even if the patient or family is upset with me.
I can tell a distressed family that I understand their anguish over the decline of their father but I think that aggressive care and interventions will actually prolong his suffering. I can just let the patient and the family be mad at me. I can even tell them that I understand why they might feel that way. I can’t control their feelings because I can’t control their thoughts.
If someone is frustrated about how a situation unfolded, I highly recommend offering an apology. Apologies can be soothing. You know that you mean you are sorry about their thoughts. Even if the person is confused or wrong about what they think you did, offering an apology is the opposite of being defensive. It opens up communication instead of shutting it down. Many states have disclosure/apology laws designed to protect communications that provide information about disclosure of negative events and expressions of sympathy or regret from being used as evidence of malpractice in liability litigation or administrative action.
Lastly, I would suggest that you listen to the other person and consider the possibility that you could be wrong. One way to defuse an argument is to concede defeat by saying: you could be right. It’s not our natural response and it feels terrible to be wrong. Someone else’s disapproval or disagreement is not a referendum on your character or your expertise. You are still an excellent physician and you are worthy. You need to have your own back and remember that you are acting with beneficence and compassion for your patients and for yourself. Now summon your courage and go have that conversation!
This piece first appeared in Doximity Op-Med
