Is Attending to Clinician Distress Our Job? Sara Johnson, Yael Schenker, & Anne Kelly

Eric 00:11

Welcome to the GeriPal Podcast. This is Eric Widera.

Alex 00:12

This is Alex Smith.

Eric 00:13

Alex, we got a full house today.

Alex 00:16

We have a full house. We are so delighted to welcome back a good friend, Sara Johnson, who’s a palliative care doctor. An early graduate of UCSF’s hospice Palliative medicine Fellowship, she’s now program director of the Hospice Palliative Medicine Fellowship at the University of Wisconsin. Sara, welcome to the GeriPal Podcast.

Sara 00:37

Thanks. Happy to be here.

Alex 00:38

And we’re delighted to welcome back Yael Schenker, who’s been a frequent guest on this podcast. She’s a palliative care doctor and researcher. She’s director of the Palliative Care Research center, or PARC, at the University of Pittsburgh and soon to be the chief academic officer at Deputy Denver Health. Yael, welcome back to GeriPal.

Yael 00:58

Thanks for having me.

Alex 00:59

And we’re delighted to welcome back Anne Kelly, who’s a palliative care social worker, frequent guest and host on this podcast. Check out the clips of Anne eating the hot wings on our 300th anniversary. And she’s also chair of the GeriPal Steering Committee. Anne, welcome back to the GeriPal Podcast.

Anne 01:19

Thank you. What a legacy there. Thanks, Alex.

Eric 01:23

We’re getting close to our 400th episode, Alex, and we’re going to have to think what we’re going to do. We’re going to ramp it up from hot links.

Alex 01:29

If you have any ideas for interesting podcasts. Our 300th was Hot One style. Ask us anything. And I kind of like the idea of doing that again. But if you have other innovative ideas.

Eric 01:42

My bowels will disagree with you on that. [laughter]

Eric 01:48

When do we expect our 400th?

Alex 01:50

Like in, I think I calculated in spring sometime. Yeah.

Eric 01:54

All right. Sometime after.

Anne 01:55

All right, we’ll get on it.

Alex 01:56

All right.

Eric 01:56

But we’re not talking about the GeriPal Podcast. We’re going to be talking about this question of is it our job to manage clinician distress? We’re also going to be talking about managing interprofessional conflict. Before we dive into those topics, I believe Anne Kelly has a song request.

Anne 02:16

Out of all the times I’ve been here, this is a real first.

Eric 02:19

You’ve never been asked?

Anne 02:20

I don’t think so.

Alex 02:22

And I for the 300th, I think I did your choice at the either the beginning or the end.

Anne 02:28

Well, this one is even more momentous because I’m delighted To request Dolly Parton. Here I am. And why I know is the following question.

Eric 02:39

Well, you’re a guest host. You’re asking yourself the same. You’re asking yourself the question.

Anne 02:43

I can be all the things. First reason why. Because I love her, and any opportunity to get her on this podcast is my delight. And fortunately, the song is, like, perfect for our topic today, which is sort of reaching out and showing up to support people who might need a little extra tlc.

Yael 03:03

Great.

Sara 03:04

We’re not doing that. I just want to name. That’s an option, too.

Alex 03:08

Or not. Right?

Anne 03:09

Or not.

Alex 03:11

I’m not here. Don’t. Nothing to see here.

Eric 03:14

Don’t look this way. If any of our listeners know Dolly Parton, have her come on our 400th podcast. Alex, hit it.

Alex 03:21

Yeah, we should. Yeah, I’m going to sing this more like Greg Brown meets Dolly Parton style, because I’m not going to try to do Dolly Parton. Here’s a little bit.

Alex 03:35

(singing)

Eric 04:40

Thank you.

Anne 04:40

That was so good. Thank you, Alex.

Alex 04:43

Thanks, Anne.

Sara 04:44

That was impressive.

Alex 04:45

Great lyrics.

Eric 04:46

Okay, let’s dive into this topic. So we’re going to be talking about, is it our job to manage clinician distress, how to manage interprofessional conflict? Kind of like when the suffering is coming from within. You never watch those horror films, like, the phone call is actually coming from within the house, when the suffering is actually coming from within our house, our colleagues.

But, Sara, I’m going to turn to you first because you’re the one that suggested this topic. Can you tell me why?

Sara 05:17

Yeah. As Alex mentioned, I was a very early trainee in the fellowship. And one thing that really struck me was I had been expecting kind of intense emotions directed towards me from patients and families. But the hardest part was the consulting providers and other healthcare professionals taking care of the patient.

And as somebody who doesn’t turn down a good discussion about things that I disagree with, I think it’s an important piece of learning for everybody in the field. And maybe you guys already know all that, But I think the biggest question in my mind is, like, how. What are the RVUs to be able to do this? That’s the key.

Eric 05:59

How do you.

Yael 06:00

Right to the heart of the matter. That’s the matter.

Eric 06:03

What’s the ICD 9 or 10 code for clinician distress?

Yael 06:09

Yeah.

Eric 06:10

And what kind of emotions were you seeing when you’re talking about emotions?

Sara 06:14

I think a lot of, like, anger. And I. I think this is where this identity tension comes up that we talk with our fellows about early in the year because we want to be a good consultant. And like, what does that mean? It’s answering the question, but recognizing a big part of what we do in hospice and palliative medicine is we’re advocating and supporting the.

Advocating for and supporting the patient and the family. And there can be clashes. Right. When it seems like this person needs to, you know, change their code status or some other distress that’s coming out at kind of the situation. And how do you. How do you really navigate that identity tension of a good consultant and an advocate as a pallia care provider?

Eric 06:56

Yeah. That’s wonderful. And then you also suggested an article which brought in Yael. Can you tell me why you suggested Yael’s article which was titled palliative care consults for clinician distress? Part of the job. Question mark. Is it our job to manage this clinician distress? It’s published in jpsm. We will have a link to it in our show notes. Why did you think of Yael’s article?

Sara 07:21

Number one? Yael’s always going to say it better than I can,

Sara 07:27

but it was just really outlined in regards to the considerations. And also, I think the other piece for me is like, is it a question versus what part is it that we decide versus we meet the issue recognizing is it ever really going to go away? I don’t know.

Eric 07:44

Yeah. Yael, can I ask you. So why did you write this article on Is it our job? Palliative care consults for clinician distress.

Anne 07:53

Yeah.

Yael 07:54

So a lot of the things that Sara just said really resonate. And I wrote this with Billy Rosa and Bob Arnold, and really because, I mean, the same reason that I write everything it was happening.

Eric 08:10

To get on the GeriPal podcast.

Yael 08:12

Exactly. That was definitely the end goal. But it, you know, a lot of what Sara said, it felt like it was happening. It felt like to me, it was happening more often. Having been doing this, you know, for 15 years or so, it felt big and messy and hard, and I didn’t feel like I had the tools really to understand, you know, what was happening, to do a good job. It was something every time I’m on service that we spend a fair amount of time talking about.

And so really the goal of the article was to kind of start to wrap our arms around this issue and start a conversation. So I’m delighted to be having the conversation here. I think it’s really important.

Sara 09:00

I think that’s a really important point, is like normalizing because you do start to feel like it’s you in some ways. Right? Well, obviously when I was a fellow, I realized it was Eric whenever there was conflict.

Yael 09:09

But.

Sara 09:12

But I think the normalization is important because it. It.

Eric 09:14

So the normalization of conflict that. That this clinician distress that you’re seeing is taking lots of different forms, including potentially conflict with us and the consulting team. Is that what I’m hearing?

Yael 09:28

Yeah.

Alex 09:29

Yeah. I wonder if we could just kind of crystallize this a little bit more. Well, Eric, were you going to turn to Anne to help do that?

Eric 09:36

No, let’s actually crystallize. Like what are we.

Alex 09:40

Is there a case that somebody could present that sort of clarifies it for our listeners or.

Eric 09:48

I got a case. I mean, this happens.

Alex 09:51

All right.

Eric 09:53

And the article has three cases. I encourage everybody to read it, but I’d love your thoughts on this case. This is an amalgamation of multiple different cases looking back in the year where I’ve dealt with distress even recently from healthcare providers. We get a consult on a 78 year old who has widely metastatic cancer, who was admitted to the hospital with functional decline and has suffers a hospital cardiac arrest, is now ventilated in a minimally conscious state in the icu. He’s developing worsening renal failure.

Nobody wants to do CRT or dialysis in him. Not gonna be able to get any more chemotherapy. Cause he’s on a vent. Family is saying, we want everything done. We’re hoping for a miracle. Team is in distress that they feel like every time they do a venipuncture that they’re causing suffering and distress. And we get a palliative care consult and they don’t know what the question is for us, but they just say exactly what I just said about the case. Anne, does this ring somewhat true like.

Anne 11:03

A. Yeah, I think this is a really good example of consults that we frequently see where there is perhaps a clinical situation that feels really challenging, that brings up a lot of intense emotion, not just for the families who are experiencing shock, grief, fear, et cetera, but also for the clinicians caring for the.

Eric 11:25

Patient, and in this particular case, multiple goals of care conversations have happened. Family is pretty clear that he’s the type of person that would want continued life, supporting treatments, want everything done, even if it means keeping him in the icu. So, like, doing more goals of care conversations may move things forward, but, like, that’s been done multiple times.

So maybe a little bit of more expertise may help. But you’re really getting a sense now that the people that are suffering is not just the patient, but maybe the team, the nurses, the physicians, social worker. Yael, is this the kind of case that you’re thinking about?

Yael 12:04

Yeah, absolutely. I’m nodding away here, and I think. I mean, I think that’s the tricky part to kind of disentangle. When does helping the patient also help the clinician distress? And when have we kind of done the palliative care work of the case for the patient and the family? And the clinician distress lingers far beyond that. And we heard, you know, stories and kind of, you know, doing the work for this article and the HPM session we had of, you know, spending hours and hours on clinician distress, that was sort of above and beyond the care of the patient.

And sometimes those two things can be in conflict, like Sara mentioned. And so I think that’s the tricky part to really disentangle. I think often our work is palliative care. Caring for these really complicated difficulties, you know, cases does help clinician distress. And I think there’s something beyond that that we need to think carefully about.

Alex 13:04

I. I still don’t understand what the conflict is. The conflict is between who and who and over what in this particular case.

Eric 13:11

Or are you saying in general, Alex? Both, I would say. Right.

Yael 13:16

I think often we have, in, like, in. In Eric’s case that the patient’s goals are clear according to the family. This is what the patient would want. The family is happy with the plan of care. The clinical team is not happy with the plan of care, and we’re called into the middle of that. I feel like that happens not infrequently, and at a certain point, we’re helping the clinicians more than we’re helping the patients. Maybe I would say even in that.

Sara 13:49

Initial call, there can sometimes be these comments. And again, not. I just want to name, like, I know all of our colleagues are doing the best that they can, but things along the lines of, you know, we really, we want you guys to make them come for care, or we are hoping that you can convince them to do XYZ when they’ve clearly said otherwise.

And certainly we’re going to see them and help support the patient and the family and the situation and just see if there’s areas that we can continue to make a shared plan that makes sense for everybody involved. But recognizing that just because you’re asking for something doesn’t mean I can necessarily give it. And so how can we convey that in a way that isn’t just like, well, you know, I don’t know what you want me to do. Even though that might be the feeling that comes up, especially when it’s like, you know, four on a Friday and the patient’s been in the hospital for 100 days.

Anne 14:44

I. I think going back, like the way you described that case example, Eric, I actually don’t know what conflict we’re going to see yet. What I heard is there’s high amount of distress. Yeah, there’s a high amount of distress for the clinicians who are caring for someone where they feel like the plan of care is not aligned. What they might recommend from their unique perspective. And until we get in there and learn more, we might find various sources of conflict that could arise, but it’s not gonna be one size fits all.

So, for example, I’m hearing there could be conflict directed toward us from the medical primary team saying, why can’t you find fix this or change that? There could be conflict from the family toward the medical team. And we’re trying to mediate between the two of them. Right. There could be different types of conflict that come up. But really the presenting problem here is high distress. And that’s why they’re reaching out to us to say help. SOS.

Sara 15:40

Yeah.

Alex 15:40

And so Yael’s article focused more on is it our job to manage the clinician distress? And I think that, Sara, you and Anne had an HPM presentation that was about managing conflict with physicians with other healthcare providers who like consulting palliative care. And when I think about that, I think about like, the most egregious case. Dan Matlock. Remember when he was accused of murder? Yeah, I think that was. And that made it on. He was like on npr interviewed about this. That’s conflict.

Eric 16:13

So accused of murder by a surgeon.

Sara 16:16

I think I’m on the wrong podcast.

Eric 16:18

Interprofessional conflict. So this just turned true crime goals were aligned with, you know, comfort focused care. Surgeon disagreed and accused Dan of committing murder. And if I believe if for this, this, the statement, if I remember, we’ll have a link to our show notes. What was it like if this was like World War II you would be accused. Like there it was just loaded with. With passion and energy and accusation.

Alex 16:49

Yeah. I guess that’s an extreme example of allying with the patient’s perspective and this being. Bringing you into conflict with this, the other healthcare provider.

Sara 17:01

I’m gonna zoom in. I think the piece that can sometimes come across is with the initial, like, call or when I’m leaving the room and they’re like, did you, you know, or did you guys talk about code status or these things when you’re just coming in fresh? And, you know, when we did our HPM presentation, one of the things that we talked about were the different types of conflict. And so recognizing there is kind of task or cognitive conflict, like what the situation is.

And maybe there’s disagreement, there’s process conflict, which I think actually can be really challenging for us too. It’s like, what’s our role? Or what’s everybody’s role in this situation? Is it our role to go and get the code status changed in the first meeting, the first five minutes when we meet people? Relational conflict. So being tension, misplaced emotional expression, which I think is what we’re talking a little bit here of, like, the moral distress of the team. And then I always like to add the hangry conflict. Cause that happens too.

Eric 17:56

What’s the hangry conflict? Just being hungry.

Yael 17:59

Yeah, yeah.

Anne 17:59

You’re just cranky.

Sara 18:00

Yeah, yeah.

Alex 18:01

Just a cranky conflict.

Sara 18:03

It’ll come up later in the show for me. But I. Recognizing, like, conflict isn’t always, like, we disagree about what to do. Like, sometimes it’s just in the tone of the call that you take or in what somebody’s asking you to do. And I have an internal reaction to. That’s not my job. And so can I sidestep? Can I come out of that reaction that I have on my own? So I’m not making the situation less productive, which I’ve done a few times. But can I stop and be like, wow, that sounds really tough.

This sounds like a tough situation. And also start to set a little bit of maybe expectation. I like to set low expectations. So, like, you know, it sounds like you guys have. This is a tough situation. It sounds like you guys have had a lot of conversations. Certainly we will go and meet them and get involved. It does sound like they’ve kind of come to a decision.

So I wouldn’t expect there to be a change. Like, just setting like, this is what I’m going to do today. How does that sound? And recognizing we’re not going to leave them to just manage this on their own. But there’s a lot to unpack here, as Anne said.

Eric 19:13

Well, I guess that goes to your. I’m going to go to your article first and then I’d love to talk more about ways that we can manage this moral distress, the conflict. But Yael, I want to ask you is. So you make an argument like, is this our job to manage this distress in our consultants, in other healthcare professionals? Like, we’re not therapists. If that person starts crying and they, there may be a lot of different reasons.

That consultant starts crying from their bad day, they’re cranky, something else is happening at home. They’re having moral distress over the care that they’re giving. They feel like they are being bad providers by continuing to flog this person in their own words. Like, is that our job to fix it, or do we just advocate for the goals that we’re hearing from the patient and the family member? Again, we’re not therapists.

Yael 20:06

Yeah, I mean, I think the title maybe oversimplifies the issue a bit. And again, our goal is to spark some discussion. And I think we’re doing this right, and we all know that we’re doing this. So in a sense it’s a little bit of a moot point whether it’s part of our job because it’s happening. And we, we did this sort of informal audience poll at our HPM session. It was, you know, well attended. There are a lot of people there and the vast majority, like 80% said that they were frequently managing clinician distress.

So then, you know, my mind, you know, as someone who is fiercely protective of palliative care, of our field and of our, you know, patients and the fact that we’re a limited resource and sort of goes to, well, then how are we doing it? How should we be doing it? You know, Sara talked about sort of setting expectations. I really like that idea of sort of having some guidelines, some parameters around this. Who on the team should be doing this? What are the tools that we should have?

And are we teaching our fellows, our trainees, our interdisciplinary team members the right skills to at least start and then, you know, perhaps set limits? And then again, I guess the other piece, to me, I just want to say this is such a big and important issue. This isn’t just, you know, clinician distress. Right. We have this system wide epidemic that leads to all kinds of really bad outcomes and it’s getting worse. So it can’t just be something that palliative care kind of does in between and around the other things we

Do I really feel like we have to be advocates, we have to be collaborating, we have to be part of the system wide kind of efforts because clinician distress is a really serious, dangerous epidemic. So for me, that was sort of the important point. Not that it’s not part of our job, but we’re not the only people doing this work. It’s a system wide issue. We need support to do it well. We can’t do it alone.

Eric 22:14

Yeah, I love that.

Sara 22:15

I think as a specialty that really is around how do we sit with suffering? It can feel bad to not necessarily take the time. And so just to highlight that point around expectations of self and what your time and your energy for the day is a limited resource, as Yael said. So how can you help support somebody enough to make sure that the care is going to be good for this patient, this family? If there’s more that I can do, that’s a bonus.

But also recognizing there’s a, there’s a limit to that. And it’s sometimes a decision you have to make of am I going to talk further with this bedside nurse who is really dealing with the stress because of disagreement maybe with the family and the team, as well as what she’s needing to do to the patient. And so can I help to point that out to him or her? And can I help to pull in some resources or point those out to him or her? So to what degree, I think, is one of the questions that I think.

Alex 23:20

About with this, Anne, do you think it’s our job to manage clinician distress?

Anne 23:25

Yeah. You know, I’m sitting here chewing on everyone’s use of the word manage. And you know, when I go to work and someone reaches out to say, Anne, we need your help over here. They are not calling on me because I am their personal support system. They’re not calling on me because I am their mental health provider. They’re calling on me because I’m their colleague. And they think that I might have some skills to help them navigate a stressful or difficult situation.

And so we don’t have a social contract with these folks to quote, unquote, manage their distress or manage their behavior. And so I would argue that when there is serious illness involved and difficult clinical situations, we can expect there will be distress. There will be varying degrees of distress. Sometimes it’s more, it’s more intense or higher than others, but there’s always some layer of distress. And I think if we can sort of like take a big step back and think like, if that’s true, what’s our shared goal as a palliative care consulting service.

I don’t think that my goal is to make everyone else feel okay at the end of all of this or at the end of their day, but helping people navigate a very difficult situation that may not have clear answers. And there’s different skills that we use to help us maybe deescalate the intensity of the distress so that we can get our brains back online to work together to move forward in a way that feels productive and safe for everybody.

Eric 25:02

Can I ask, what are those skills that we can use to help deescalate?

Anne 25:08

Well, I think what Sara’s describing earlier is like when we, when we among. It’s not just Sara and I. We worked with other wonderful colleagues to present to hpm. And when we sort of sit back to think through this, we thought about how a lot of the skills we use are the same skills we use when we are caring for patients and families, but using the modifying those same types of skills to be applicable in supporting our own teammates and our colleagues in a more professional setting where the social contract is different.

You know, when Eric and I are working together on team, he’s not my doctor, I’m not his social worker. We are colleagues, but we have a shared language, a shared culture that we can sort of support each other and to talk through a difficult thing in a certain way way. But we use a lot of the same skills modified toward each other that we would for our patients and families.

Sara 26:04

Yeah, I need to go back to your point, Anne, about the manage, because that feels very like physician of us. So just to name that.

Alex 26:12

Appreciate you calling that out.

Anne 26:13

Yeah, like, I just. I just don’t think that’s a realistic goal for us or even an appropriate one.

Yael 26:18

Right. No, and it’s really interesting. So we should also link to the responses to our article. One of them was called Attention to Distress goes with the territory written by three social workers making this exact point. Then the other article that I love, that I don’t know if you guys have seen, but Carrie Brenner’s article about the holding environment for referring clinicians is a really great article in journal Palliative Medicine that came out a couple years ago and talks about this. Exactly. What we do in palliative care is create space for distress and hold it in ways that matter.

Eric 26:57

I guess one of the challenges, though, is creating space frequently takes time and you may have five other consults to see that day. How much energy do we put into holding that space for a healthcare team where we like Sara said, like, maybe we go back to the billing boys podcast. Like, can we even bill for. Like, what about productivity and everything else that we’re being measured for versus that this is actually really helpful for the patient that we’re caring for too, because that distress is going to bleed over into care. How do you think about that?

Sara 27:30

I mean, I think there is an…thinking about the trade offs here, right? Like, am I. I don’t know if you guys use secure chat, but we get a lot of communications. Like, there. The number of communications we get about a certain scenario, I think is very much proportional to the amount of distress that’s going on with somebody or the whole team taking care of a patient.

And so how can I help to get everyone on the same page about, this is where we are, this is okay, this is the plan. While also seeing if there’s a need to hold space, even if it’s not necessarily in the way that we think about, like sitting down in a chair, but just acknowledging it’s clear that you care a lot, because that’s often where some of this is coming from. And just to name, like, people are trying to do right by their patient, there’s certainly other things going on.

Alex 28:15

I’ll tell you where this comes up for me a lot is, oh, Anne is definitely going to resonate with this because she’s on all the time as the social worker. Whereas a lot of attendings flip in and out. But the teams change even more frequently than the palliative care. Attendings change, particularly in the intensive care unit. And then every new team comes on, experiences the same moral distress again about what are we doing with this patient? And then they consult us again or they find out we’ve been consulted.

They say, what have you been doing? We say, we just spent so much time working with the last team to, you know, talk through how this care is aligned with their goals. And we’ve talked about prognosis and this is. And now we got to do it again with this new team of distressed providers. How much of this is our responsibility? And it’s, you know, this is systemic thing, as Yael talked about, like, this is a product of our churn of providers over and over and handing off.

You don’t hand off the. Like, they hand off the handoff. The details about the, you know, the different organ systems in the icu. They don’t necessarily hand off the whole, you know, understanding of the goals of care, the management of the distress. Yeah, I see people nodding.

Sara 29:32

Yeah, I was a little worried, Alex, that you’ve never had any tension in the work that you’ve done. Smooth sailing.

Alex 29:39

I was being devil’s advocate earlier. I just wanted to draw it out, you know, like, what is the distress here?

Anne 29:45

But Alex, that’s a great example of how, like, the system itself is set up to, like, continue to breed distress. You know, sure, they’re giving sign out around, you know, the organ systems, but in a perfect world, shouldn’t we also be giving sign out about the conversations and discussions that have already taken place and the values that we’ve elicited and like, all of, like, filling in all the blanks of how we got to where we are so that when someone steps in, we can mitigate their distress on day one.

We can mitigate their distress when they have a better understanding of all the hard work that has been put in to get us to where we are today and have a sense that they have support to go through this together. So. And is that just our job? No. We can’t fix the whole system. But the idea is like, there are probably so many kinds of interventions that our system could be set up to do differently to help mitigate distress across, sort of multi layered.

Yael 30:38

And I think there’s something else that, at least in our system has been normalized to go back to the case that Eric presented in the beginning, which is we don’t really have a question. We’re not quite sure why we’re consulting, but it’s distressing. And so I think that raises a question for us as a service, and every service is different. It gets busy. It’s not busy.

There may be different decisions on different days, but figuring out how we can help to me feels really important. What is the consult question? How can we help? And. And that helps to set some, some parameters around what can be a really long discussion. You know, it’s like you can measure the distress by the number of texts there are, and those strings can get really long.

Alex 31:26

So I’m going to disagree with Anne partly to be provocative here.

Eric 31:31

Usually a bad idea.

Anne 31:33

I’m used to it.

Alex 31:35

We are not. It’s not part of our contract that we care for the healthcare teams. I was taught that it is that our job is to care for the patient primarily, as Yael said in our article, and as I think we’d all agree and all our listeners would agree. It’s also our job to care for the family and it’s our job to some extent to care for the teams, like when we have experience a difficult death. I remember last time I was on service There was a prolonged CPR event in the icu and we debriefed with them and we debriefed with the primary.

We debriefed with so many teams. We helped, I’m not going to say manage. We help support them and process the strong emotions that they experience throughout that difficult situation. And that’s part of our job, I guess.

Anne 32:23

And I, you and I are not in disagreement there. Well, you know, I agree with everything you just said. I think the idea though is that somehow, yes, Anne, we, we have a different social contract where I am not that intern’s personal therapist. So when we have a profession in a professional setting, we’re helping to create space that feels supportive and safe and we’re offering an opportunity to process.

That doesn’t mean that that person’s done caring for themselves and that they are done, that they may not go find their own private place to continue navigating their own grief and their own distress in a way that’s more personal and less public or sort of prime for the professional setting. Right. And so I do think we have a job to sort of role model good mutual, like good self care and mutual support for people, but somehow to think that we’re responsible for all of it is just not realistic.

Alex 33:18

Yeah. Our holding space is not that big.

Anne 33:20

Right. And we might, and we might invite someone to participate in a debrief, but that doesn’t mean that they want to or that they feel safe coming to talk to a bunch of strangers in a public setting. That intervention is not going to be a one size fits all panacea for people. Right. We’re just, we’re creating opportunity, but we can’t guarantee it’s going to be as effective or helpful for everyone across the board.

Sara 33:41

Or desired.

Anne 33:42

Or desired. That’s right.

Sara 33:44

One thing, Anne, that you had brought up a little earlier was this idea of managing distress. And I think, and this might be TMI in regards to me, but I think the other piece is really like self awareness for us on the palliative care team. Right. In terms of where is just use myself as an example, like my identity and wanting to do the right thing or help be, you know, have palliative care be liked.

Like how is that playing into my own interpretation of the conversation or the ask and how could that potentially be contributing to just my perception of the situation or how I might respond and recognizing, at least for me in medical training, like self awareness, self regulation isn’t necessarily like a formal toolkit that you’re taught, whereas I think that’s different in other specialties.

Eric 34:32

How so? Like, how is it different, you think?

Sara 34:35

Well, this is just what my social worker told me and what I’ve learned so much from our interpretive colleague. But just recognizing that they, I mean, there was a situation. I mean, I’ve loved every social worker I’ve ever worked with. All of our interprofessional team members are amazing. And I think there’s a lot that we as physicians have to learn and take away from that.

In regards to you, do you do have feelings? Your feelings are valid, even if they feel like they’re negative. And what can you kind of do? Like, can you sit with your own suffering at some point? And so I just wanted to name that. I, I. My understanding is there’s difference. I think Anne could speak to that.

Anne 35:15

When I hear you saying, like, this isn’t just about other people. Like, these people need to learn how to tend to themselves. The truth is, we all do. And if we are going to be hoping that other people work on their muscles to navigate these situations, then we too, should be kind of keeping our side of the street clean and doing what we can do to help be thoughtful around embodying the same skills that we’re hoping to see from others around the healthcare system.

And so it starts with us. And when we practice ourselves, we realize it’s not so easy. And so. And when we do that, we can also have empathy and understand sort of get a sense of where people are on that spectrum and where we are when we’re in a difficult conversation where people may have blind spots that are hard for them to see, how that’s playing into the situation or the conversation that we’re in.

Sara 36:01

Yeah. And I want to give an example of that, recognizing that sometimes, you know, we all have these moments where we say something in a way or. Well, I think we do. Probably not, Alex, but in a way that comes off maybe negative or not ideal or it’s not productive for the conversation. And can I pause and name? Like, look, I. That came out wrong.

The reality is, like, right now we have X number of consults, and I’m hearing this is a really difficult case. And then we can start to move forward from that shared perspective. So I can at least bring forward, like, I haven’t had anything to eat. I’m very hungry. Just having more conversations about. We are humans.

Anne 36:36

But. And that’s, that’s what we do with our patients and families. We name the emotion, we hold space for the emotion that helps settle the brain. And when we have a sense that we feel, like, safe and connected. Then we can go into sort of more meat and potatoes. Like, we do the same thing in clinical situations. I think the challenge is sometimes. Well, I shouldn’t say that challenge.

One of the challenges is sometimes we feel. I feel. It can feel annoying to feel like I have to use those same muscles with my colleagues. Like, when I go into that, I want to be able to hit the ground running. It can feel like an extra task to do that. Use those same skills with people who you’re expecting kind of be right there on par with you.

Eric 37:16

Well, and I gotta ask that, because we talked about this. I forgot what other podcast we talked about this is that we do have this social contract with this patient. Right. And the family member. But with our colleague, it was the vital talk. It was the vital talk.

Sara 37:30

Yeah.

Anne 37:30

With the colleague, it’s a different.

Eric 37:31

It’s a different social contract. So using some of this, you know, the frameworks that we use, like nurse statements. I mean, I think back to Alex’s take out the trash video.

Yael 37:42

I was just thinking of the takeout.

Eric 37:43

To try it with your wife. To not. Doesn’t work. And sometimes using the same skills with.

Anne 37:51

Our colleagues, you have to modify them. Yeah, well.

Yael 37:54

And I think is we don’t feel good at it, or at least I don’t feel good at this. And that is very.

Eric 38:02

Well. How much training have you had in this?

Yael 38:04

I’ve had zero training, and it feels important, and I don’t feel good at it. And I don’t always know that I’m the best person to be doing it. And so those are worries, and I think we need to name those and keep talking about that.

Eric 38:23

Well, let’s talk about a path forward then, because, you know, part of it is social workers and chaplains. I find that guy, you know, other mental health professionals are really, really. They have a lot more training in this.

Alex 38:35

Right.

Eric 38:35

When we think about, you know, some of the other professional team members, nurse practitioners, physicians who may not get much training, what is the path forward look like? What would the training look like, Sara? And you’ve done a little bit of this, right? A hbm.

Yael 38:52

Mm.

Sara 38:54

Well, so I want to name that, I think from a learning theory standpoint, or like adult learning theory, that transferring skills to another setting is really hard. It’s kind of like watching my kid. He’s doing his math problems, and it’s like, you know, division. And then all of a sudden it’s in a. Like a paragraph form, like a story problem, and he’s like, I don’t know how to do this. And so recognizing that transferring skill to another setting is hard. It’s not easy to do.

Eric 39:21

And that’s something like conflict with patience. We do every single day conflict with our colleagues, like, ah, run away.

Sara 39:29

And maybe tension is the right word to kind of get back to Alex’s point that since we’re not talking about crime, that that tension, we’re very attuned to it. And then when we think about kind of the path forward, one of the most helpful things that I have ever heard is actually from Bob Arnold, and that is one of Yael’s co authors, and he has a paper on this, too. It’s this asking yourself.

So it’s like the pause and what does this kind, hardworking, smart provider. Why might this person be thinking differently than me? Like, just pausing to recognize that you can assign good intent to them, but just kind of this internal mantra. And so from my standpoint, I think a pause and just kind of an open curiosity is a great first place to start in terms of, like, tell me more about that.

Eric 40:20

I love that it kind of gets to the concept of the fundamental attribution error. When somebody cuts in front of us, we assign to them that it is just part of their innate personality, that they’re just bad people, versus when we.

Sara 40:35

Do that, that person is.

Eric 40:36

But, yeah, when we do that, we assign intent behind, oh, I’m trying to get, you know, to my child’s daycare before they close. And, you know, they get mad at me. So that’s why I’m. I’m doing this. So it’s easier. Easy to see our. Why we do our behaviors, but it’s hard to see why other people do it. Is that right?

Anne 40:53

But when we get curious and learn more and hear that there’s a reason behind, more often than not a reasonable, understandable reason behind why they’re doing or thinking what they’re doing, then we. It breeds compassion in us and empathy in us.

Sara 41:08

Out of curiosity, like, sometimes there’s a very clear piece of medical information or factual information that I don’t have, and I’m making an assumption. So taking a pause and that open.

Eric 41:20

Curiosity and when you’re dealing with conflict. Did I hear Reid write that during the HPM session, you did something called space? Does that sound familiar?

Sara 41:30

That’s right.

Eric 41:31

What’s that?

Anne 41:33

So space is an acronym for a framework that we as a group came up with to offer a framework to navigate conflict. And, Sara, do you want to walk folks through it?

Sara 41:44

Yeah, I Want to just mention to our collaborators in this project. So Ethan Silverman, who is with Yael in Pittsburgh and their program director of their fellowship, Cassie Gray, who is our clinic manager. Nurse clinic manager here. And then also Andrew o’, Donnell, an ICU nurse. And so we had created this framework as we were thinking about a toolkit for people to utilize. And so space is very apt because a big part of this is a pause. Right. So the first one is self awareness. And this recognizing, like, I’m feeling something in terms of, like, tension or a little bit of discontent, maybe I’m hungry. But just pausing.

Anne 42:25

Self awareness, taking stock. What am I feeling?

Eric 42:27

And to build that. That muscle. Are you just always remembering to pause? Like, what’s one skill that I can work on today to help build self awareness? Is there one?

Sara 42:38

I’m gonna punt Eric’s therapy stuff to Anne.

Anne 42:42

Well, you know, what do I know? I don’t know much, but I know that the idea is practicing noticing feelings in ourselves. If I can begin to notice something, then I can. That’s a muscle in of itself to notice something and not be on autopilot. Right. If I can notice that I’m having a feeling or I’m having some type of discomfort, can I take a pause, a breath and first take inventory? What am I experiencing?

Eric 43:07

Okay.

Anne 43:08

Can I find words to describe it?

Eric 43:09

I love that. So s. Self awareness.

Anne 43:12

Yeah.

Sara 43:12

And it gives you then also a moment to decide, like, are you. You’re. Are you gonna do your initial reaction? So from that 4pm like, goals of care, consult or go. Things are clear from a patient family standpoint. But we’re being asked to come right now, and I feel this kind of, like, rage.

Yael 43:29

I just.

Sara 43:30

I can pause. And instead of being like, you know, well, haven’t you guys talked with them or something I can name, like, tell me more about that. So I can take a conscious decision to move in a different direction. But it’s that awareness.

Anne 43:42

S. Is self awareness.

Sara 43:44

P. Perspective taking. So getting more information, like, tell me how you’re thinking about this or, you know, we’re going to. I’ve also learned disclaimers are important. Like, we’re going to see the patient and can you tell me what you’re hoping that we can help with?

Eric 43:58

Particularly this sounds like your mantra. Why would a rational, reasonable, decent human being behave this way? Kind of. And then start thinking about their perspective.

Yael 44:07

That is.

Sara 44:07

That’s actually c. You’re jumping ahead.

Eric 44:09

Oh, shoot.

Sara 44:10

Oh, hey, what’s getting more about the factual, like, perspective and also, like, are there Other things that I need to know more.

Anne 44:18

Tell me more. How are you thinking about this? Help me understand how you’re thinking.

Eric 44:21

Tell me more.

Sara 44:22

Yeah, so kind of the ask, tell, ask. Right? So, like, tell me about exactly how you’re thinking about this. And then naming. And this is where the nonviolent communication framework, we kind of borrowed from that as well as long along with emotional intelligence frameworks from Dan Goleman. But just naming, like, I’m hearing. You guys are hoping that we can help with talking about goals of care.

Eric 44:43

Yeah.

Sara 44:43

And I am also thinking about kind of timing and for our team. And then I kind of name what. What I’m seeing or hearing or what I can offer.

Eric 44:53

This is part of the P still or have we moved on?

Sara 44:55

Sorry, we’ve moved on to a. To agenda.

Eric 44:57

Agenda.

Yael 44:58

Okay.

Eric 44:59

Agenda. We are naming what we’re hearing. What’s the path forward? So s P. A.

Sara 45:07

Curiosity.

Alex 45:09

Curiosity.

Sara 45:09

That one is this. Why is this kind, hardworking colleague thinking differently than me? So just trying to, like, where are the areas where I’m still unsure or I’m hearing distress or discontent? Like, tell me what you’re most worried about for this patient. Right. Or tell me how. What your team is thinking about with the continued ventilation.

Eric 45:28

And then E. E is evade the conflict and run away.

Sara 45:32

Yeah, it’s E. No, it’s empathy. It shouldn’t be eat, though.

Eric 45:36

E is always empathy in palliative care.

Sara 45:40

Yeah.

Eric 45:41

What do we do in E?

Sara 45:43

Well, I think it’s modifying and focusing your statements a little more around the situation, recognizing that most people aren’t going to that again. The social contract that you guys are talking about, it’s not going to be great if I’m like, gosh, you seem really angry. What’s upsetting you? That’s not going to work as well. Besides just naming. It’s clear you care deeply about this or hearing. You guys did a lot of work already.

Eric 46:07

Okay, Lightning question, then we’ll go to the song. If you had a magic wand, you can do one thing to improve palliative care training around this issue. What would it be, Yael?

Yael 46:20

I would make sure that everyone gets to sit down with Sara and Anne and talk this through and feel like they have some tools in their toolbox and collaborations and support to be part of the solution.

Eric 46:33

Great. Build those tools in that toolbox, Sara.

Sara 46:36

Yeah. Mine would be a standardized curriculum for interprofessionals in our field to help them have the tools. One, to normalize. This is going to come up. Two, to have some tools and Then three, continuing to grow. That in other specialties I think would be great as well. All of med ed, all of healthcare science professionals.

Eric 46:54

Yeah, we should probably figure it out ourselves before we teach others how to do it.

Anne 46:57

Yeah. I feel like we have a lot of room to grow just to develop the language around defining and explaining exactly what it is that we’re experiencing day to day. Because I think once we can define that together, we can sort of think through.

Eric 47:07

Is that your magic wand?

Anne 47:08

Sure. Or are you going to use waving it?

Eric 47:10

Or are you going to use the magic wand to play some Dolly Parton?

Anne 47:13

Good news is I don’t need magic for that. It’s on its way.

Alex 47:21

(singing)

Eric 47:53

Sara ,Yael, Anne, thanks for joining us on this podcast.

Sara 47:57

Thanks for having us.

Yael 47:58

Thanks for having us.

Eric 48:00

And to all of our listeners, thank you for your continued support.

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