Eric: Welcome to the GeriPal podcast. This is Eric Widera.
Alex: This is Alex Smith.
Eric: And Alex, who do we have on the GeriPal podcast today?
Alex: We are delighted to welcome to the podcast, Tony Bach, who is a professor of medicine and palliative care physician at the University of Washington, and co-founder of VitalTalk. Welcome to the GeriPal podcast, Tony.
Tony: Thank you, Alex and Eric. Great to be here.
Alex: And we are also delighted to welcome back to our podcast, Wendy Anderson, who is a palliative care physician at UCSF in San Francisco General, and VitalTalk lead in the Bay Area, and a senior faculty member. Welcome back to the GeriPal podcast, Wendy.
Wendy: Thank you so much for having me. I’m so glad to be here.
Eric: And we have experts in communication. We’re going to be talking about communication in a time of crises, and we have a lot of crisis going on right now, but before we get into that topic, we always start off with a song request. Tony heard you got a song for Alex.
Tony: Yes. Time After Time. It seemed really appropriate as a theme for what palliative care clinicians are doing these days. But I kind of worried that Cyndi Lauper was dating me.
Wendy: No way.
Alex: So I’m going to do the Iron and Wine version, because I cannot sing like Cyndi Lauper, so no surprise, but here’s just a little bit from the beginning.
Eric: Nice. I can always tell how much Alex loves the song by how long is intro version of the song.
Alex: I love that song.
Eric: I do too.
Alex: It’s been played by many different people and it always sounds great no matter who sings it. Tuck & Patti have a great version by the way, now I’m dating myself. Jazz group from Backwell. Thank you.
Tony: That was a nice cover. Thank you.
Eric: So a lot is going on right now, today is… I always need to put in a date because this is going to probably be published in a week from now, and what our next crisis will be in a week from now, who knows. But we’re still dealing with COVID pandemic. Well, it’s coming to light for a lot of Americans, racial injustices. We have a Black Lives Matter Movement and protests, but it’s been going on for centuries in the US, so it’s not really something new, but it’s really coming to the forefront. And we were hoping we can talk about how do we, as Geriatricians, as Palliative care doctors, as clinicians talk to our patients about all of these different things. So thank you for joining us today, Alex, where should we even start?
Alex: Let’s start with the George Floyd, because that’s where we started our last few podcasts and that’s on everybody’s mind. I’m at the forefront with coronavirus, sorry to say, which is more prominent, but I guess the questions are, how do we address this with patients? How we address it, how we check in with patients about how they’re feeling and coping in light of George Floyd and the protests. And who should we talk to about this issues? Tony, I’ll hand it to you first.
Tony: Okay. We started off with the easy question.
Tony: Well, so I think it’s super important for all of us as clinicians to be acknowledging what is, I think, a historical and transformative moment in the history of the United States. I think it’d be weird for us to not give our patients a chance to say something about it in some way. And so that’s one part of it. The more communication part of it is that, when people walk into the room or when I’m seeing them on zoom or however much I’m seeing it these days, I am always interested in figuring out what someone’s emotional temperature is. Where are they? And the reality is, any one of us only have so much emotional bandwidth, right? And if a bunch of it is getting used up by something else that is happening outside our encounter, that’s important to know. And the act of acknowledging that as a clinician that actually helps people regulate their emotions and put it into context with what’s happening.
Tony: So what I’ve been asking people is, a lot’s going on to the news, how are you doing with all of it? I mean, to deliberately a little open ended and a little bit vague because it allows people to fill in exactly what they want to fill in. Wendy, what have you been saying to people?
Wendy: I think that the idea about the emotional temperature, taking the emotional temperature has been a really helpful concept for me too. It’s one of the first steps in the Calmer Talking Map, which we’ll talk about later, but it’s for about advanced care planning with patients who might get COVID, an art Elliott. And I think it’s just having that step there as a reminder that you should just be checking in really open- endedly. And then I think that the other thing that is helpful about some materials that were developed by VitalTalk around communication skills for bridging inequities, is the idea of being really hyper aware of looking for cues that patients are showing about, maybe they’re seeming angry, maybe they’re seeming mistrustful, and that might be body language. That might be something that they say. But with those cues, just really, I think having the bravery to say, “Hey, it seems like you’re a little angry, or it seems like you’re upset right now. Would you mind telling me what’s going on?”
Tony: I mean, in other way we talk about emotion cues, we’ve talked about that for a long time. I’m starting to think about inequity cues, and actually racism cues. I mean, I did a bunch of interviews in developing these communication skills to bridge inequity. And one of the things that really stood out for me is in talking to black physicians, they said you should not shy away from the word racism. Like we meaning people within that community, talk about it all the time. And when you avoid it, you just look, they didn’t say this, but then what they meant was that you look clueless. Like you have no idea of the reality of my life. And so, that really changed me in how willing I am to be forward about the notion of existing racism in the healthcare system, as we see it.
Tony: And I was attending not too long ago in Seattle, on the palliative care service. And basically the people who are getting admitted with COVID, we’re basically immigrants and service workers, right? Like all the nursing homes, the people in the nursing homes, because we were the first place in the country. Like those people have come and gone. We’re really into the second wave and it’s, Oh, it’s glaringly obvious about how it’s being affected. And it’s heartbreaking. I mean, it’s so obvious.
Wendy: Same at San Francisco General.
Alex: Same at San Francisco General? This was terrific. And Eric, I knew that you actually sent around some materials to our palliative care team at the VA. I think it was a VA guide. What was that?
Eric: Yeah, it was a VA guide developed by doctors, Marva Robinson and Keisha Ross, I believe their names at St. Louis VA, and Dr. Ensley at Hines VA. And I’ll have a link to that on our GeriPal podcast, but the overarching question was discussing community trauma and response to Killington mistreatment of Black and Brown Americans. Both if a patient brings it up, and ways that you can actually bring it up in some ideas to be mindful of. I loved it because it was just a two pager. And I also felt like the palliative care community really rallied around COVID communication there. Like every day there was new communication thing coming up in the palliative care community. And I think part of it is probably our own inexperience in talking about this, and lack of knowledge, but there certainly hasn’t been that same robust response of… There’s, COVID pages on pretty much every palliative care site out there. We’re not seeing that same response with Black Lives Matters. And how to discuss this type of trauma with our patients.
Tony: Well, I think there is a way in which this is a challenge for palliative care clinicians who are concerned about communication because there’s a way it really falls outside the scope of what we have usually considered our work, right. And from the point of view of communication theory there’s the actors who are talking to each other, there’s the channel by which they are talking. And there’s the context in which that communication occurs. And I think what’s happening now massively in a couple of different ways is that the context has completely changed, the massive uncertainty related to COVID, and what happened and what’s going to happen. That’s been one shifting ground. And then this compounding issue of racial trauma, which is clearly related to COVID, right. There’s a direct line between them. And it’s a conversation that in our society has been super hard to have. Like, we honestly, our culture has been struggling with it for 50 years.
Tony: And so, it’s no surprise to me that awkwardness and discomfort comes right into the clinical encounter. And so, the rules and guidelines are not as simple because our patients are so affected at such a wide spectrum of ways, right. It’s the calculus that we all have, and having goals of care conversations has changed overnight.
Wendy: I think that the idea, Eric, you were mentioning the VA guide, and that just having some simple sentences that are kind of someone has made those words and UCSF, has a Diversity, Equity and Inclusion Champion Training Program. I feel like that was the most helpful part of that, was just having words for how could you respond if you witness something that doesn’t seem right to you, how could you respond to that? Because I think oftentimes we feel uncomfortable, but we just don’t have the words.
Alex: Yeah, absolutely agree. That was a terrific program. And the opportunity to practice, that language outside of a patient counter is critical and that’s part of VitalTalk training as well. I wanted to take a step back and say, we haven’t said what VitalTalk is, but many of our listeners will be familiar, but some of them will not. So could we just take a moment-
Alex: Tony and Wendy to talk about what is VitalTalk?
Tony: VitalTalk is a 501c3, that James Tulsky, Bob Arnold, and I started to scale the work that we were doing in research funded work about how to communicate better with patients who have a serious illness. Because we got to the point where we thought, well, we could write one more RO1, and it cost $3 million and take two years to get funded and five years to do. And one year to analyze and we would have trained 80 more doctors, 80 more oncologists, and there 25,000 practicing oncologists in the country. And we thought we need a way to have more impact. So Wendy actually came up with the best tagline for us. Do you want to talk about that?
Wendy: That every patient should be surrounded by clinicians who can skillfully discuss what matters most?
Wendy: Something along those lines.
Alex: That’s great.
Tony: So that’s our vision.
Alex: So this is broadened beyond oncology now, I think a third of our listeners are geriatrics and palliative care or a third are palliative care and another third are geriatrics. But those who are purely geriatrics should also know about VitalTalk?
Tony: Oh yeah. So here’s my version of the geriatrics version of bad news is you can’t drive anymore, right? Like how do you have that conversation? It’s a super hard conversation to have, right. And the principles and skills that we teach in all these different VitalTalk conversations are generalizable in many different ways and we’ll help you through all the awkward, complicated, but really important conversations you can have as a clinician. Like you’re having conversations with patients that are turning points for them in their lives. And so bringing yourself to those conversations, bringing their values into those conversations, it’s hugely important and meaningful.
Wendy: And I think, as time has gone forward and particularly in the past number of months that what VitalTalk is actually changing quite a lot, and needing to change. And so, certainly we realized that we need to be focusing on all types of clinicians. So clinicians that work in really any arena where they’re caring for patients who have serious illness, and that really all clinicians who are talking with patients who have serious illness and their families about what’s important and about their clinical status, that they all need these skills. And then also that we need to be making sure that we’re creating skills that are right for all types of patients and all types of families. So that we really, are starting to think about how… Making sure that we have communication skills that work with all different types of cultures and populations and socioeconomic statuses.
Tony: I mean, we did workforce study about a year ago that indicated that there were probably 200,000 practicing clinicians, mostly provider level clinicians in the United States who could benefit from communication training about serious illness, because they all touch serious illness in different ways. And our best guess is we probably reached about 25,000 clinicians. So we got a way to get them.
Eric: And Tony, I know you also, you do some of this around the world, different languages, how much of this is stuff that spans different? Like what does it mean to do some of this VitalTalk training in other language? I’m just also thinking just even here in the US? Like how much of it is independent of the language and the culture and how much of it you really have to know, you have to tailor these communication skills very specifically to the culture and the individual in front of you?
Tony: Well, so here’s what I would say… Of course, we get asked this question a lot about different cultures and how open are they about serious illness or dying, but I’ll tell you that what I’ve experienced and going to a bunch of different places, right? Australia, Japan, Sweden, Germany, basically places with industrialized medicine, the culture of biomedicine and technological intervention is so strong that the things that we struggle with here in the United States are basically the same things that people are struggling with all over the world in industrialized countries. Right? And so in many ways, it’s the details and some of the situations that are slightly different, but the core issues are the same, how much technology, how much do we really do? What are the values that really underlie this? And then some of the smaller details about how do you reach people? What are ways to make people feel safe? What are common cultural values? Those things do differ, but the core things are really very similar around the world.
Wendy: The other thing we didn’t mention specifically about VitalTalk is that, I think one of the most important things is that it’s really a group of faculty and it’s a huge community. And we’re trying to grow that, continue to grow that community. And so really that’s the way that we reach people all across the world is through faculty. And VitalTalk have been through training, and that those people I’ve really been the leaders in translating this into other cultures and other languages. So clinicians who work in Japan, that are translating and teaching there. There’s a faculty member who works in Rwanda, who’s going through the process of figuring out what of VitalTalk matches and what doesn’t. So it’s really cool.
Tony: Well, and so, Wendy’s bringing up a really good point, which is that we’re at the point in an organization where we’re transitioning the leadership to a whole new group of really talented faculty, and we’re growing our reach in that way. I should not talk about the myopic, just me, James, Bob anymore. It’s really much bigger.
Wendy: No, you’re still the founders.
Eric: And it also seems like there are important themes that cross cultures and languages. What about with different crises? Like when we’re dealing with a COVID pandemic, are there specific set of skills that we just need to know around like this? Because I think there are some things that feel very different, the level of uncertainty with a novel virus is just, it skyrockets how people are going to do, which people are going to do better. Like that’s that component. But I’m also wondering when we think about communication skills, are there unique aspects that we should be thinking about with particular crisis like COVID?
Tony: Got it, Wendy, I’ll let you go first this time, do you?
Wendy: Yeah. I mean, I think the thing that has been really notable for me is that it’s interesting that we have these frameworks… I think the thing that’s been really notable is that the skills and the frameworks that work really well for communication in the setting of COVID, are the same as the ones that we had, but you actually need some help translating it. So you need examples of what does it look like when this framework is applied to COVID communication? Like, what does that whole worry statement look like when you’re talking about a patient who has COVID? Or I think similarly for the thinking about inequities based on race and other factors that the core principle is that you’re looking for cues and you’re responding to emotion, but you still need some specific language around that.
Tony: I would say Eric, that the key things that I am seeing in terms of COVID, are the uncertainty has been magnified dramatically. The level of bad news has been magnified by what people are reading in the media, so that there is a way in which patients bring many more of their own knowledge, assumptions, and preconceptions into the exam room or into the zoom room. And those are manifest right away. And so, you have to really be nimble on your feet, on your communication feats, so to speak, to really respond. But the principles are the same when people are having a lot of emotion, it really helps to acknowledge it, when people are having a lot of uncertainty. It’s very important to acknowledge it and be clear about what you, as a clinician know and don’t know.
Tony: And then I think the thing that’s a little different is that there is this level of collective experience and collective trauma. In fact, that is coming along with COVID. And I think that the thing that’s a little bit maybe new is about how do we address collective trauma when in fact we’re all in the middle of being a little traumatized ourselves. I mean, it’s really felt like to me, I have not felt like this as a doctor in terms of my own sense of vulnerability. And heard honestly, since the AIDS epidemic, I mean the bad part of the AIDS epidemic, that when I was a resident and there were patients who were in their rooms who didn’t get food because people didn’t want to go into their rooms to give them dinner. And thankfully, I don’t think that quite happened during COVID, but honestly, if you look at what happened in some longterm care facilities, it may not have been that different honestly. And we just don’t know.
Tony: So I think there is this collective moment that we were all processing and I think what it means is that there is a level at which we need things to say, but there is also what we at VitalTalk have called capacity, there is your capacity to hold a situation. And in many ways it’s what the neuroscientists would call your ability to self regulate your own emotions that comes into play when you’re dealing with something this big and this intense. Many of us are feeling this in a very personal way, that every day I came home from work at the Safety net hospital, I get undressed in the hallway and put all my clothes into the washer. Like I know a lot of doctors who are doing stuff like that. And it really dramatizes the sense of the danger that you’ve been in and are still in, and the danger that you’re subjecting the people that you love to. And so, that’s different.
Eric: And it felt like in past podcasts that we’ve done, especially in a hard hit areas, it felt like the physicians and others that we’ve talked to were able to very state cognitively and think through their experiences. But the second we asked that question, so what’s it like to come home? There is a pause. And then there is, sometimes people not willing to go there. Sometimes people do, and the emotions just came out. And I felt like that line between usually how we think about work and the risks we take at work, usually don’t bring that risk into our family, and our home lives. And there was this that you felt that trauma?
Tony: Yeah. That’s one of the different things, and I ended up doing a little podcast called Decompress, that was designed for the 10 minutes between when you left work and before you got home. That was really all about figuring out how to gracefully, detach yourself from the day and prepare yourself to be with your family, to renew yourself, to really switch gears, because we’re trained to pick out all the bad stuff. Like that’s our cognitive training. It’s like we pick out what’s going to be wrong. What’s dangerous. What’s not quite right. And if you can’t turn that off, when you go home, actually it’s bad for you. So it’s a cognitive skill.
Eric: What’s it called again? What’s the podcast?
Eric: Decompress. All of our listeners should listen to Decompress on iTunes, and other places?
Tony: Yeah, it’s on iTunes.
Eric: Two tips of what we can do to Decompress on our way home tonight?.
Tony: Oh yeah. So one of the things you can do is to feel into your body. One of the easiest ways to interrupt all the ruminative cycles of thinking, thinking that we do is actually to shift your attention to your somatic sensations in different ways. These are often called mindfulness practices, but to just do that for a few moments, and then intentionally think about, “Okay, I’m leaving work, I’m putting this away, I’m getting myself ready. Like, what do I want to be like with the people that I’m going to be at home with?” So those two tips, shift your attention to the somatic, intentionally decide what you are trying to bring to home.
Wendy: And the podcast is only 10 minutes per episode, right?
Tony: Yeah, 10 minutes per episode.
Wendy: And there’s one every day. So you can actually listen to it on the way home.
Tony: Well, and I will say, I did it for six days a week. And then actually, I’ve taken a break because I was trying to figure out what’s the next. What is needed next? And so, it’s still up on the web, and the website is still up.
Wendy: And there’s a lot of them?
Tony: Yeah. They’re whole, there’re 40 of them.
Eric: And I think that’s the interesting part is it constantly feels the landscape beneath us every week feels like it’s shifting, even in New York, it shifted from taking care of people in the emergency room to taking care of really sick people in the hospital, in the ICU to taking care of longitudinally, chronically critically ill patients. And each one of those carried a very different sense of what are we doing here, and how it affects us.
Tony: Yes. And I think psychologically that carry a lot of that is that we spent all this time, realizing that the threat was really going to happen, preparing for what the threat would mean, dealing with this massive amount of clinical work and really an unprecedented exposure to dying. And now, I think we’re after that in most places in the United States, and I think it’s actually now we’re starting to figure out how do we make sense of all of it? And so that’s why I feel like detaching yourself during the middle of the crisis was super important because ruminating and going through everything over and over obsessively, it turns out that’s bad for your mental health. So I wanted to make a really clear implicit point to clinicians about the danger of doing that. Right. Because first responders critical incident debriefing was actually found to be harmful for them in terms of psychological sequelae.
Tony: There were studies done in 9/11, and Haiti, the earthquake, if you do a typical critical incident debriefing for first responders, where usually train therapist, social worker goes through all the details. As you walk through everything about what you saw, what happened, how you felt right in the moment, actually the psychological outcomes are worse. And my own theory about this is they’re worse because if you ask people to do that when they don’t feel safe, when they’re they’re still super stressed, they haven’t eaten or slept, when they’re not psychologically prepared to do that meaning making work, actually, it just takes them apart further. And I think, we all have to be aware of this, and then it doesn’t stop there.
Tony: Then in the next phase, you have to figure out how do we make sense of it? What are the spaces that we need to create that have the safety where we can haul feel into that? It’s like the thing that you were saying, Eric, about people on the podcast, just like, you ask people and they’re like, “Oh my God, I’ve been trying not to think about that. And it’s hard.” So I think as a profession right now, I think the thing that we can do for each other and do for actually indirectly, the patients that we’re serving is figure out how do we do that work. So I feel like that’s where we are now.
Wendy: Just as far as the exposure, I mean, I think part of it is for people who are actually seeing patients in person, but there’s even a lot of exposure to all of the weightiness, if you’re doing telemedicine, which a lot of people are. And so, I think it’s just very sticky, right? And I think it’s also a time where it’s just magnified how having the exact right words, doesn’t make it feel any better. Being able to perfectly tell someone that they can’t come visit their dying loved one, that doesn’t make it feel any better.
Tony: And plus it seems like affront, right? Like I think paradoxically, all this telemedicine is making everybody realize that sometimes you really do need face to face. Like sometimes face to face really makes a difference. And the thing that’s really tiring about being on zoom is you don’t actually have all the same neurochemical good stuff that happens in your brain when you see somebody face to face, you don’t really look into their eyes. There is this tiny delay in how people react. It all makes it feel much less familiar and actually much less satisfying. Like we’re not all getting the same rewards that we get out of those face to face encounter. So in a way, I think we’re having to relearn, how do we communicate in an age of zoom, or whatever telemedicine platform you’re using.
Eric: Do you guys have any tips on how to do that via zoom or via telephone? What things are different and how should we shift our communication technique through when we’re doing this virtually?
Tony: Wendy, do you have a couple of thoughts however?
Wendy: I mean, I think one thing is that certainly when video is possible, if there’s any way for video to be possible, I do think that it’s better than telephone. Because then you at least have two senses that you can be using. And then I think that similarly, a lot of the communication skills are the same, but especially if you’re on telephone that oftentimes you have to make some assumptions. So for example, if you’ve just delivered really serious news, you need to assume that there’s an emotional impact, even if you can’t see it. And so you need to offer empathy, even if you’re not seeing an emotional reaction or you need to do even more to say, “I’ve just given you some information. I feel like it was a lot. What did you hear about that? And what are your thoughts about it?” So the checking in afterwards becomes even more important.
Eric: I also noticed that, it happened many, many times to me and I still don’t learn my lesson, but midway through a telephone call and then I learned that there’s six other people on the line.
Wendy: Yeah, totally.
Tony: Yeah. So I think there’s a really interesting point in that Eric, which I call is what is the virtual space that you are meeting in, right. Like, so I started to ask people, “Where are you? Who’s with you? Give me a picture of where you’re sitting.”
Wendy: Mm-hmm (affirmative). I like that.
Tony: … because actually normally we take the shared space for granted and we know what the parameters are. We’re in our exam room, we’re in the hospital room, we’re in their home if there is home visit, and there is an assumed shared space that both people know, all the parameters about. When you’re on zoom, you’re in this new virtual space, and nobody knows what the parameters are. You don’t know what they are. They don’t know what they are, and you’re going back and forth verbally. And you’re getting about a 10th of the data that you get when you’re in a face to face encounter. Right? So you’re working with a smidgen of the data that usually have, you’re in nowhere land and you have to actually explicitly sort that out. And even before you get to that, then you have to deal with the technical crap about can they hear you? Can they see you? But I think the intro about where are you, is anybody with you? Is this a place you feel comfortable to talk to me about all this? And I mean, I think those precautions are super important.
Tony: And then, as Wendy was pointing out this issue about what is the emotion, you have to be like a super sleuth about that to interpret correctly what those silences and hesitations and all those different things mean, because it’s much harder and the signals that you are getting are much more ambiguous in terms of their meaning. Body language is much less specific than verbal language in terms of meaning. And this means you have to do even more interpretation and be explicit verbally about the interpretation. So that’s one of the reasons I think zoom feels limiting is because you actually normally are processing on a bunch of different channels at one time, gesturally, spatially, face sound, voice tone, all that. And even the voice tone gets flattened out a little bit on Zoom, right?
Alex: COVID has pushed us in so many ways and we should note that there are… I’ve seen on VitalTalk guides about communication in the era of COVID, and we’ll make sure to link to those in our podcasts show notes. Other ways that COVID has impacted us in emergency department. There’s a lot of time pressure to have these goals of care conversations rapidly with family members over the phone, or over video, who aren’t able to come in and see their loved one, because patients deteriorate so quickly with COVID. And a lot of times we know this people have not engaged in advanced care planning and they show up, or they have, and we don’t have the advanced directive when they show up and they don’t have capacity. We need to talk to either of them, if they do have capacity or their family members, that has been one pressing challenge, how do we have these really a fiction goals of care discussions, which are not ideal, right?
Alex: Ideally you get to know the patient, you form a relationship, you get to know their family over time and get to know what’s important to them. In this case, you just have to have the conversation quickly. Thoughts about how to have those time efficient, high quality goals of care conversations for patients who you just meeting for the first time, or you just talking to the family members for the first time.
Wendy: I mean, I think that what’s great about having these Talking Maps is that it does make it possible to have actually pretty good quality discussions in 10 minutes, 15 minutes. And we said, zoom or telephone isn’t ideal, but I think the one thing that I would say are the two highlights that have come through is that, especially if you’re meeting someone for the first time, I think our inclination, if things are really rushed is to just jump in with the information or jump in with what do you understand about things? And that actually, it just highlights how important it is to spend three minutes at the beginning. How are you doing? Tell me, what’s been going through your mind? What do you want to make sure that we talk about? What have you been worried about? Like really, we were mentioning earlier, just getting the emotional temperature, and really spending some time to respond, to make sure that people feel that you hear them.
Wendy: This might be something about racial inequity. Make sure that you say, there’s a lot of racism and inequity in our healthcare system if that seems like it’s coming up, but you have to relate with all of those things first. And then I think that the other things that have come up as key or are similar of making sure that before you talk about goals of care, making sure that you’re clear about the clinical status. We have this idea in VitalTalk about headlines, where you’re coming up with a one sentence summary of the patient’s clinical status and what that means. So for example, your dad has COVID in addition to his chronic obstructive pulmonary disease, I worry that means this COVID infection may be life threatening. And so the idea is staying that and stopping, which I think is the opposite of what we usually do, as we usually our medical student presentations. So I think that the headline idea is one thing that actually is helpful and can shorten your conversation a lot because you don’t have to give all of that detail. So those are two things that I feel have been really helpful.
Tony: The thing I’d add to that is that I think we, as clinicians need to be well, we need to be patient with ourselves and with our patients about what’s going to be possible in this moment. I totally get the concern about wanting to be efficient and wanting to be sensitive to the rapid decline that some COVID patients have. And I would say that from the patient’s point of view, the patient’s perspective, what I am hearing interviewing patients is that they are more concerned than ever that they won’t get the healthcare they need. Like my own theory about why people with heart attacks aren’t showing up to the hospital is because they don’t think the hospital’s going to be able to help them. They’re reading all these stories in the media about how overwhelmed everybody is. And they’re like, “Well, look, if I’m just going to be sitting in a hallway in the ER, I just assume sit at home.” Right. So I think we have to be mindful that we are facing levels of mistrust and perceptions of overwhelm in the healthcare system that are more than ever before.
Tony: And this racial inequity thing has just magnified that problem several fold, because there are story after story of a black person who came to the ER and was turned away, not once, not twice, three, four, five times, and then they come in and die. Right? Like that story is a meme in the media right now. Right. And so I think we have to be a little bit careful in putting our own desires for efficiency at the top of the priority list.
Wendy: I think it’s this whole pandemic and also other racial inequities, I think have really highlighted for me what is our job as clinicians, as palliative care clinicians. And I feel like advocacy has just come up as the clearest thing and that we really need to be sensitive to where patients or their families are and what they’re able to discuss. And so I think it is really important that we try, that we assess what their temperature is, that we give the information if they’re willing to hear the information, then we ask about what’s important. And if they say what’s important is making sure that I have every chance to fight this. And it’s all clear that we need to advocate for those goals. Even if there’s a question about what the goal is like, that’s our job is to figure out what the goal are.
Eric: Well, let me ask you about again, taking the temperature, because this came up in our palliative care team meeting. What if people, when you have a conversation, they bring up things that you may disagree with. Like a white patient saying, “I’m so mad at all these protests, don’t they realize All Lives Matter,” and saying these things and your heart starts beating. Like we’re not consulted to educate the patient about what these things mean, but we’re also talking about advocacy and how much is it advocacy for the patient and advocacy for a larger causes? How do we react to those things when we bring it up or somebody brings it up?
Tony: Oh, go ahead, Wendy.
Wendy: Well, I will say one thing and then I’m really curious about what you have to say. The UCFS staff, Diversity, Equity and Inclusion Training was so helpful to me around this because it was when patients say something that is harmful, just having some language to say, “It made me feel really uncomfortable when you said this?” And I think at the same time stating what language feels okay to you and what doesn’t feel okay to you? At the same time, as you’re saying, my job is to be your advocate. So making sure that you’re aligning and still caring for that patient, but just having some language, if there’s things that were said that make you or someone else in the room be uncomfortable.
Alex: So you like, “When you said this, it made me feel uncomfortable,” statement?
Wendy: I have liked that, I have used it a few times and it was words that I didn’t have before. And I also would love to have other examples of that-
Alex: More tools in the toolbox?
Alex: I like that one. Tell me more, what do you mean about this? I want to know what you mean when you say all lives matter and sometimes your patients will talk themselves into a space where it just doesn’t make sense anymore, and it will become obvious to them that this is uncomfortable, if you push them on it.
Wendy: Well, I think that’s great because you don’t want to yourself make an assumption, right. That you may have just heard something wrong and it had an impact on you. And so if you can get more information first.
Tony: I mean, I distinguish between views that I don’t agree with, right. Like coronavirus is a hoax to views that are personally could be harmful to me. Like all Asian doctors are blah, blah, blah, right. In my particular example. And so, if it’s a view that I don’t agree with, but that isn’t personally hurtful to me, I would be interested in what does that mean related to your health care? So does that have something to do with your situation medically that I don’t quite see, help me see that, right. That’s what I’d be asking about, because actually often there is something, you have to dig down a little bit, but it’s there. And then if it’s something that is about me personally, I would take exception to that. Like I say something small to say that I’m going to sidestep around this, and to give a little bit of a signal, that’s probably not something I want to get into.
Tony: And then I’ve been on the other side of it too. I remember time when I was at a VA clinic and there was a guy who’s very distant from me all the time and was begrudgingly doing everything that I suggested. And then finally about a year into this, his daughter said, “Well, he likes you for doctor.” And I said, “You’re kidding me, because he doesn’t seem that warm.” And he goes, “Well, he was a POW and a Vietnamese prison camp. And so he doesn’t like Asian doctors.” Wow. Oh. So the fact that he would even come back to see me in clinic, that was the stretch for him.
Tony: And that was as much as he could do. And I thought, wow, I am just not really…
Wendy: Oh, that’s super interesting.
Alex: So we’ve got four minutes left, and I want to do a lightning round just to get a few more things in. So we’ve been doing this recently on podcasts. Eric, if you could summarize the situation we talked before about how healthcare providers are uniquely vulnerable in the era of COVID because the infection can be transmitted to us in part, that’s part of the story about the collective trauma. Eric, do you want to describe the situation?
Eric: Yeah. And early on, there was a big question about doing CPR. Does that put healthcare providers at increased risk? And the question is when we have these goals of care conversations, it’s a thing that the providers are thinking about. It’s part of how they’re also making potentially decisions and recommendations. Should that be explicit? That we’re not only going to be talking about potentially a lack of benefit for the patient in front of you, but it also puts others at risk and for some people, and we know this from past literature, is that when you talk about what’s important to people, it’s also not being a burden to society and to others that may influence how people make decisions, should it even be discussed. Should that implicit thing be an explicit discussion?
Wendy: So I knew about this.
Tony: You can go first. [laughter]
Wendy: You probably know something already, but I think what this really brought up for me was the importance of… At San Francisco General, our ethics committee has been so helpful through all of this. And I think that this pandemic has really highlighted for me the difference between palliative care and ethics, and that we often take on the similar roles, but the idea of decisions about protecting clinicians being made at the institutional level, ideally not on a case by case basis, because I think what I worry about and have seen with the case by case basis is that’s subjective. And it just, opens it up for people getting different treatment. And so, I think that has worried me. And so, I think it’s made me feel like we need to have those discussions with ethics, but me as a palliative care doctor, my job is to really figure out what are the goals for the patient and within the institutional context? How can I best achieve those?
Eric: Tony, it’s interesting.
Wendy: Yeah, what do you think?
Tony: I think there could be a place to say that we are reevaluating CPR because it puts providers at risk. I think that could be for some patients who have preferences that involve the care of everybody. I think that could be a legitimate thing. And I think the important thing is not to use it as another way to wine at the patient to make the decision that you want. The thing that I see with CPR, it’s like, “Well, do you want CPR?”
Wendy: It’ll break your ribs.
Tony: Yeah, it’ll break your ribs. It’ll hurt. And there’s this escalating horror story that happens, right. Which is what I think of as a not so skilled way to convince somebody about the decision that you think is the right decision for them. I think that, of course, our approach has always been, “What are the patient’s values and how do you match that?” And I think in a discussion raising the issue of the risk to the whole team and everyone in the hospital, I think that’s totally legitimate.
Eric: Alex, any other lighting question?
Alex: Last lightning round question-
Alex: Here we go. How do you feel about informed dissent? We had another consult, Eric and I were doing a consult in New York. We were talking with a family member and we said, “Things have shifted. Now we’re talking about how to care for your loved one while they’re dying.” And one of the things that we do not think we should do at this time, and that we do not plan on doing is CPR, because we feel that your mother is dying. And if we did CPR, it would be ineffective because we’ve already tried all of these intensive care unit type treatments. And unfortunately they haven’t worked the way we want to. And then the family members who’d said, again and again no, we want to be… They said, okay, let me see. Okay, she’s DNR. It was informed dissent, how do you feel about that?
Wendy: That language has been some of the language that after consultation with our ethics committee that they recommended. And I think after the case has been thoroughly reviewed, I feel like it’s been really helpful to have that language.
Tony: So I’m a little ambivalent about informed dissent. I think there are situations in which the case is quite medically clear, and actually we should just tell him and stop pretending that we’re offering something might be a benefit. I think the difficult situation is that a formed dissent can turn into a way of not really having the whole conversation with a patient and family. That’s when I get a little uncomfortable, we had a bunch of cases where people change their minds later, and what it meant to me was they didn’t have a good discussion to begin with. So I do think I have a little bit of a note of caution about it.
Eric: Well with that, I want to be mindful of our time. I want to thank both of you. We’re going to have links to VitalTalk, I really encourage all of our listeners to the VitalTalk website. Download some of the COVID, specific communication skills and also some of the other tools that they have, including how to deal with our other big issues that we’re dealing with.
Tony: Fighting inequity.
Eric: Thank you. And before we end, maybe we can do a little bit more of Cyndi Lauper.
Eric: Wendy, Tony, thank you for joining us.
Alex: Thank you so much.
Tony: Thank you guys, it was a pleasure to be here.
Wendy: Thank you.
Eric: And thank you to Archstone Foundation for your continued support and to all of our listeners for joining us, everybody stay safe.