Eric: Welcome to the GeriPal Podcast. This is Eric Widera.
Alex: This is Alex Smith.
Eric: And Alex, who do we have with us today?
Alex: We are delighted to welcome back Lee Lindquist, who’s a geriatrician and chief of geriatrics at Northwestern. Welcome back to the GeriPal Podcast, Lee.
Lee: Thank you so much for having me. You guys are awesome. Huge fan.
Alex: And we’re delighted to welcome to the podcast Alaine Murawski…Social worker and researcher, research study coordinator at Northwestern. Welcome to the GeriPal Podcast, Alaine.
Alaine: Thanks for having me.
Eric: We’re going to be talking about negotiation and conflict resolution with both Alaine and Lee. But before we do, Lee, I think you got a song request for Alex.
Lee: I do have a song request for Alex. One of my favorite songs, being here in Chicago, is Sweet Home Chicago. If I remember right, this is the song that you did on your very first podcast. So, I’m thinking that you’re going to be like a champ on knowing how to do this. But the other thing, too, is that a lot of my research is about aging in place. Most people think of their home as their sweet home, and especially if you live in Chicago, we love staying at home. So…
Alex: That’s good.
Lee: Thank you very much. Take it away, Alex.
Alex: Thank you. I’m glad I get a do-over. Second time’s a charm with this one, too. Let’s see what happens. (singing)
Lee: Yay! Although I’ve never heard that California line, so I think that’s a spin from you guys. I appreciate the switch.
Alex: Back from the land of California to my sweet home Chicago. Yeah.
Eric: I was thinking you were going to pick a song about negotiations.
Lee: Oh, that’s a good one. But you know…
Eric: You can’t always get what you want.
Lee: Yeah. Or something like The Reflex by… What?
Eric: The Reflex.
Lee: … Duran Duran or something? Yeah.
Lee: Maybe next time.
Eric: We Can Work It Out by the Beatles.
Lee: Oh, I’m not a Beatles fan. Don’t get mad at me. I know you guys are.
Eric: Alex. Alex is the Beatles fan.
Alex: The Reflex would’ve been very hard. Thank you for not picking it.
Lee: That’s what I was going to say. I’m like, let’s do one that you’ve known already, so especially during the holidays, you don’t have to work too hard learning a new song.
Eric: I think we need more ’80s songs on this podcast. I’m going to secretly tell people who we’re inviting to ask Alex to play some ’80s songs.
Lee: That’s got to be hard. That’s all I can say because there’s so much synthesizer action on it. So, it’s crazy hard, a little bit frustrating.
Alex: Big hair and a lot of keyboards. Yep.
Eric: So, let’s dive into the subject about negotiation and conflict resolution. I’m going to start off with you, Lee. How did you get interested in this as a subject?
Lee: Oh. I mean, it’s something that frustrates me on a daily basis, the number of times that I’ve had to argue with patients and even my own grandparents. My grandparents lived in rural Wisconsin and I lived downtown in Chicago. During my fellowship, we needed to get them more support. They totally were against it. They hated me. They said no. I said, “We have to move you to downtown Chicago. You’re moving into my two-bedroom apartment with my sister and me.” And they were not happy. But we had to negotiate it. We had them get very angry.
This is something that we see. So many times, family caregivers have to argue with their loved ones about getting more help in the home or moving them to a place that has safety, has close proximity to medical care. That’s what I see when I have clinic. I’m a geriatrician, so I see a lot of older adults in my clinic and I’m constantly recommending people, you’re going to need more support in the home and you need to have somebody there to help you out. Most of the time, we see seniors who are completely resistant to it. That’s where we kind of have to negotiate. One of my co-authors, Alaine Murawski, who’s a social worker, she has a lot of the similar experiences if you want to talk about it from a social worker perspective.
Eric: Yeah. Tell me, Alaine, how’d you get interested in this?
Alaine: Yeah. Prior to working with Lee, I was working at a senior center as a caregiver specialist. I was also working there at an adult day center for individuals with Alzheimer’s and other related dementias. While I was working there, Lee saw it from the older adult perspective; I saw it from the caregiver’s perspective, working with family caregivers who were trying their best to care for their loved one but were often met with resistance, whether it’s the person that they’re caring for or a disagreement of how to care for their loved one with a sibling or another relative. So, it’s really important to be able to learn how to navigate those negotiations because they come up all the time in caregiving.
Eric: And Lee, you’ve done a little bit of research, too, into looking at kind of why older adults may refuse or don’t want social supports, like caregivers…
Lee: Yeah. A lot of it stems from people wanting to be independent, because if you ask pretty much anyone in this group, if I could send somebody to your house who will do your laundry, do your cooking, pick up around the house, help you do your daily chores, most of us would be like, “Yes, please. Let’s do it.” But once you get past that kind of sweet age, whether it’s in your 70s or 80s, you take the idea of somebody coming over because you’re not able to do things anymore. It’s that, quote, “loss of independence” that you hear so many times. But one of my favorite quotes that we got from one of our seniors was, “It’s not about being independent because no one is ever independent. We always depend on other people in our life. It’s more about being interdependent.” So, it’s just a change in how we support each other, and that’s where people have to get over that hump of accepting help.
But what we see so many times is that people say, “Oh, you need help,” and then the senior says, “I don’t want help,” or, “You need to give up driving,” and the senior says, “I refuse to give up driving.” What frustrates me is that so much of our education, either in medical school or nursing school or social work, we’re not taught to handle conflict. We’re taught motivated decision-making; we’re taught motivated interviewing. I mean, Alaine, you’ve been taught so much about autonomy. You can speak a little bit about what you’ve learned in social work school.
Alaine: Yeah. Autonomy is the number one thing in social work. In social work, it’s called self-determination of the client, meaning at the end of the day, I can provide resources to this older adult or to this caregiver, whoever it may be. But if they don’t want to do it, there’s only so much that I could do as a social worker to make them do that. So, it often is sometimes a brick wall when you’re trying to get those people support.
Eric: I think there is a lot of focus in med school and residency on motivational interviewing. If somebody who, they’re smoking and you want them stop smoking; even around advanced directives, are they ready to have goals of care conversations? How do you do motivational interviewing around goals of care, advanced directives, advanced care planning? What’s wrong with motivational interviewing, if anything, around this type of situation?
Lee: Yeah. I don’t think there’s anything wrong with motivational interviewing, but it comes down to the actual issue that you’re negotiating because it’s the difference between somebody living safely in their own home versus somebody burning down an entire condo building, which we see happen here in Chicago. So, if you want to keep smoking and you try to motivate them to stop smoking, perhaps in their 40s, I have no problem with doing motivational interviewing. But when people get into their 70s, 80s, 90s and they start having some cognitive loss and they want to keep smoking or they want to keep driving, or they’re doing things that are unsafe in their home or that are potentially hurting themselves, whether it’s that they’re falling so many times or they can’t do their own meal preparation or they don’t remember their medicines, this is where it gets to be dangerous. And that’s where it gets scary to me. You can try to motivate them as much as possible, but many times people dig their feet in or they don’t always have the rational cognition that this is the right thing for them to do.
That’s where it gets that we need something more. I was lucky enough as part of my K grant, I actually got to take some business school classes, and then I went on to get a master’s in business administration, an MBA, from Kellogg. I chose, not healthcare management, which a lot of my colleagues have done, but I actually chose negotiation and dispute resolution, which I thought was fun, as well as marketing. The dispute resolution and conflict, it was fascinating because in business schools they teach all of their executives, “This is how you negotiate; this is how you get to a win-win,” And then you see that for other people in law school.
But that’s something that we never get taught in medical school, and it’s not a bad thing to negotiate with somebody. I mean, it happens so much in the business world, and it’s these ideas that we can get to a win-win relationship. We can do it so that both of us are happy about the final conclusion. That’s something that I figured we could definitely go after is using those negotiation skills and then moving them over towards the healthcare setting.
Eric: Is there a formal definition for a negotiation? When we talk about it, what do we actually mean by the word negotiation?
Lee: That’s a very good statement. I don’t have it at my tail end, but I would say it’s not so much an opposition because it’s not about opponents; it’s about two people reaching and coming together to reach consensus. It’s trying to almost expand the pie so that everybody can win, and so people walk away feeling that this is the right decision for them. It’s more about a relationship because you want to have this discussion where you both realign your vision for the future and then actually move it forward so that you guys still have a good relationship, that you can move forward and be happy about each other. Because at the end of the day, when you’ve got a family caregiver and a patient, or you’ve got a social worker case manager and a patient, or if you’ve got even two family caregivers, you’re going to see each other at the end of the holidays or during the holidays, and they’re going to be in each other’s lives. So, you don’t want to crimp that relationship.
Eric: Yeah. Alaine, how different is the, I guess, big concept around negotiation, negotiation training from normal day activities that happen clinically from social workers or what you see from physicians or other clinicians?
Alaine: I mean, I think in terms of negotiation, I think conflict comes up all the time when you’re working as a caregiver or working as a social worker. We just don’t always identify it as a negotiation or as a conflict, if that makes sense. All the time when I was working as a caregiver specialist, a lot of what I saw were people trying to avoid the conflict in general, where they had a small issue with an older adult that they were caring for, but they didn’t want to have a fight; they didn’t want to have a negotiation, so they would just push it aside and then it would snowball until eventually it became a crisis. At least in my experience as a social worker, I saw conflict all the time, but I don’t think that family caregivers, in my experience, always identified it as needing a negotiation to resolve the issue, if that makes sense.
Eric: Yeah. Let’s talk about kind of big principles. Let’s imagine it’s not an uncommon scenario, older adult doesn’t want somebody, a caregiver coming to their house. What are some of the big negotiation principles that you’ve learned in business school that we can use when thinking about negotiations with the older adult, their family?
Lee: Yeah. I’ll tell you, when I first started out, I was using very advanced techniques when we first started doing it with our nurses and our hospitalists and our social workers. But with our most recent project, we’ve actually trimmed it down. So, from my standpoint, what I always tell people is to get as much information as possible, so talk to other family members, make sure everybody is on the same kind of pathway. Yes. We need to get grandpa more help or grandma more help. Everybody’s aligned, and so make sure everybody agrees.
Then, the next step is to try to figure out who else is playing a role, so, what people are affecting that senior and making sure that you’ve neutralized them or you’ve kind of got them on your side, whether it’s friends, families, et cetera. It’s almost the next layer. Then the next thing is to look at the interests or the issues. That’s something that we try to figure out are what are the interests, what are the things that are going to affect the senior? For instance, when people have to give up driving, is it that they’re driving their friends around? Could they have somebody else get an Uber or some sort of black car that would pick them up and pick up their friends? How are we going to fix each one of these issues? Is it getting to a doctor’s appointment? Could one of the family members do this?
Then from figuring out what the issues are, then figuring out how people are thinking as far as what’s the best resolution or what you want to happen. Then, from there, we kind of play with this new strategy. Dr. Jean Brett, who was the founder of conflict resolution and negotiation at Kellogg, she’s on our most recent project. She trimmed it down to an IRP practice
Eric: Hopefully not RIP. [laugher]
Lee: I know. RIP around Halloween. No. I actually sometimes go RIP, but it’s actually IRP. Right, Alaine?
Lee: I is for interests; R is for rights; and P is for power. So it’s trying to get, when you talk to somebody, towards more of that interest stage where you are here to help that person; we’re on the same team. It’s kind of how we talk. Because as providers, as social workers, as geriatricians, we oftentimes use these power statements, saying, “You need this; you need more support.” Or, “It’s my right as a doctor, I’m going to report you and you’re not going to get your license renewed,” which you know yourself, if somebody told you, Eric or Alex, that you’re going to lose your driver’s license and I’m going to report you, you’d be like, “No way. You suck.” That’s our natural response.
But with this kind of twisting it towards more interest based, that’s where we can do more of a win-win situation. Subsequently, we actually got an NIHR01 grant, which is an nice sized grant, to create an, and I love this, it’s an AI-based, so an artificial intelligence avatar-based negotiation platform where people can actually negotiate against different avatars and do it on their own time. We’ve actually created a program called NegotiAge, and we’re recruiting family caregivers of people with Alzheimer’s. So, if anyone is interested in trying out this, please feel free to email us at email@example.com. Am I correct on that, Alaine? I always get these mixed up.
Alaine: Yep, you got it. It’s perfect.
Lee: But I’m going to throw it to Alaine because she’s all over this project, and this is just such a neat project for us.
Eric: And Alaine, anybody across the US can join this project?
Alaine: Anyone who has access to the internet and a desktop or laptop computer and is in the United States and is a family caregiver can email us and potentially participate. Yes.
Eric: Wow. Is this a randomized control trial?
Alaine: Yeah. It’s a randomized clinical control trial. Yeah.
Alex: GeriPal Podcast is brought to you by the movie Avatar. Avatar: the Way of Water. No. But actually, this podcast is coming out while the movie Avatar is released. I already bought my tickets, planning to go with my kids. 3D IMAX. Woo. It’s going to be awesome.
I think this is fascinating, especially given the recent news. There’s like news about Meta losing profits in avatars, potentially the idea of this simulated reality not being what we’d hoped it would be. But I think I love the creativity in the direction that you’re going here.
Can I ask a question, though? Just backing up a little bit about how we’re taking techniques learned from business about negotiation and applying them to healthcare settings with patients. I wonder if some of our listeners might be like, “Ooh, I’m not sure if I’m comfortable with that. Business. Their motivations are to make profit. Sure, they say it’s a win-win, but isn’t it really about them getting the customers to do what they want and so sell them their product?” Now here’s a deep stretch. We’re going to go on with the movie theme or the sort of Star Wars Andor: There’s this great speech, love that series, for our listeners, highly recommend. It’s a great speech. One of the guys, the nascent Rebellion leaders says, “I’ve been forced to use the tools of my enemy against them.” I mean, what do you say to those listeners out there who might be queasy about using the tools of business?
Lee: Well, you’re definitely not joining the Dark Side. You don’t have to worry about all of a sudden showing up with a black hood under your white coat. Yeah. I think negotiation gets a bad rap. This whole idea of persuading somebody to do something that they don’t want to do. From my end, it’s helping them to understand the interest and helping them to understand the reasoning behind it so that they can live safely because ideally, we don’t want people driving who shouldn’t be, which we’ve seen many patients still do that even though it breaks our heart. We really don’t want seniors living at home alone when we know it’s dangerous for them and it’s going to make them end up in the hospital and go to a nursing home. So, in my mind, I feel like negotiation is a way of getting the seniors to understand what they’re going to need in a less angry way.
Because so far we confront people, we yell at them, we say, “You need to do this,” and I feel like that’s so abrasive and that doesn’t help anyone. People who get in arguments burn out all the time, and it’s not a fun situation, and then we bring it home from work. I feel like these tools are just another way of communicating. So, it’s not like you’re going to be becoming the next Darth Alex or Darth Eric, but it’s more along the lines of just learning to communicate so that you’re not so angry and frustrated with people at the end of the day.
Alex: That’s great.
Alaine: I think also, too, with NegotiAge, what I like about it so much is it’s taking something that at least I personally feel is intimidating, like a negotiation, and taking it and making it consumable for people who have no idea how to approach a negotiation. It’s a way for family caregivers to learn how to negotiate in a safe way so that when they actually have that conversation with whoever they’re caring for or their sibling or whoever it may be, it doesn’t feel like a foreign thing that they’ve never done before.
Eric: And is it possible, okay, I’m going to throw this out there. Can we do a little role play just so I can get those three steps down? Maybe Alaine…
Lee: I’m still not the expert on this.
Eric: Well, you don’t have to be expert. Kind of big picture. Imagine you’re trying to convince Alex to give up the car keys.
Eric: Alex is adamant that he doesn’t want to give up his car keys. How would you think about each individual of those three steps? What would that look like?
Lee: Yeah. I mean, the IRP process is more about the one-to-one conversation. I always like to say, think about ahead of time and also coming back, what are you interested in or why do you want to keep driving, Alex? What does it mean to you?
Alex: Well, first of all, I love my car and I love using my car to get places so that I can get outside. I love being outside. Furthermore, my car is part of my identity. My license plate is GeriPal. GeriPal, right?
Lee: I’m not talking about getting…
Alex: How could I give up GeriPal?
Lee: … rid of your car, Alex.
Lee: You can keep your car. You can totally keep your car. You don’t have to get rid of your car. It just means that we’ll be able to have somebody maybe younger, maybe better looking, I don’t know, opposite sex, same sex, whatever you prefer, be your driver, drive you around places. If that would be of interest to you to have a chauffeur who would be able to keep your car ready for you at a moment’s notice. You’ve gotten to this time in life because you’ve made so much money doing GeriPal that you can easily afford a chauffeur to have the car waiting for you anytime you might need.
Eric: Okay. Let’s pause. Let’s pause. We’re understanding Alex’s interest, right?
Eric: So that’s the I.
Alex: And my underlying interest is actually not the car itself as much it is using the car to get outside.
Alex: So, you could use that to like…
Lee: You can still have somebody drive you there. You could still have somebody take you there. It just doesn’t mean that you’re going to lose the car because we do know, I hate to say it, but there’s so many people that their car is their identity, you know what I mean? They’ve had their car for years. “It’s my favorite car; it’s me; it’s who I am.” And that’s the same way with your driver’s license. When we see the rights and the power statement, and those are when this conversation kind of degenerates. You really want people to keep moving towards the interest statement. Right statements… and Alaine can chip in if you’ve got one at the top of your head.
Alaine: I was thinking in the perspective of the caregiver, a right statement would be, “I have to make sure that you’re safe, and it’s not safe for you be to be on the road.”
Lee: That’s a great right statement because it’s my right to take away your license or it’s my right to stop this. And that…
Eric: I feel like we often use the word safe, and I feel like it never works.
Lee: Yeah. Agreed.
Eric: “I want to keep you safe.” Like, yeah. But it’s just not a strong argument for taking away…
Lee: Yeah. That almost goes into the power statement because who are you to say that I’m safe? I know who I am and I’m safe right now even though I’m in Chicago. But the thing is, it’s more of a power statement. When we’re a physician, first of all, so we already have a power over that patient because we’re kind of monitoring their health; we’re overseeing their health, and we say, “I want you to be safe. I think you need to have a caregiver come in.” That’s the other thing, too, I always hate these terms that we use, like you said safe. I hate the idea of caregiver. Why can’t I hire a friend or you can have a chauffeur. You can have a housekeeper; you can have a pool boy…
Eric: And in one of your articles…
Lee: … or pool girl. Whatever you want to call them.
Eric: … you mentioned the word spin, that we can use a little spin when talking about this. So instead of a caregiver: a chauffeur, a driver.
Lee: A personal assistant.
Eric: Yeah. A butler.
Lee: You guys definitely need personal assistants for this GeriPal. You know what I mean? Especially to clean your house, get your pictures straightened.
Eric: I’m also thinking back to our last podcast that we did on transforming dementia care. We’re really thinking about moving away from the word caregiver, which is kind of a unidirectional description, to care partner, that we’re going to partner together. In some ways this is, again, language matters a lot.
Lee: Oh, absolutely.
Eric: Yeah. I wonder… I is interests. You said interest statements. What are interest statements?
Lee: Well, what we did for this project is that we convened a bunch of caregivers, family caregivers, and we gave them scenarios, and Alaine can talk a little bit about these scenarios, and then they came up with a dialogue, which we moved into the interest rights and power statements. So, I’ll throw it over to Alaine.
Alaine: Yeah. We had a family caregiver panel, and we asked them to submit scenarios that they thought were realistic conflicts that they would experience when they’re arguing with another person, whether that be the older adult they’re caring for, a sibling that is helping in the caregiving process, or a physician or a healthcare professional. Once they generated those scenarios, then we asked them what would a realistic conflict or negotiation look like in those different scenarios? Then we looked at each of those statements and we coded them into IRP, whether they were an interest statement, a right statement, or a power statement. So, that’s how we created this [inaudible 00:27:37]
Lee: It was interesting because so many times we’d hear people say the power statement, like, “I am your daughter, or, “I am your father,” or, “I am your Andorian princess,” whatever you want to go with. So there’s so many times where people said, “I am the boss; you can’t make me. Even as parents, a lot of us are parents that listen to this, is that we say these things to our kids, like, “I am your mom; you can’t make me stop, or you can’t make me have somebody in my house that I don’t want.” That is kind of a cutoff, almost, like it’s not going to fix any conversation. That’s why we have to move away from those power statements and those right statements over towards the interest and say, “Listen, totally get it. You are my mom; you are my patient. I get it. Let’s talk about how we can make this into your best interest.”
Alaine: Yeah. The way that we coded the dialogue is that power statements really don’t get you anywhere in the training. We’re trying to teach the caregivers that the interest statements are what’s really going to get the negotiation to be resolved at the end.
Eric: Any tips around creating interest statements?
Lee: Oh, yeah. I mean, connecting with the person and seeing what they feel is the most important thing for them. You talked a little bit about your car, Alex, that you love. Are you out there washing your car every weekend? Are you out there getting new stripes and flames put on your car? You know what I mean? This is where you kind of figure out what is the person really interested in, what means the most to them? When I’m in clinic, I can usually ask them, “What is the most important thing for you?” What matters most when it comes to somebody in your situation, is it staying in your home? Are you willing to move into a senior community? What’s going to happen down the road? That’s where you find out what really makes them tick. I’ll pass it over to Alaine, if you have anything to add.
Alaine: I was going to say, the way I always think of interest statements is their ultimate why. Why do they have that position in the negotiation? And then once you understand that, you can use interest statements to move the negotiation along.
Alex: Reminds me quite a bit of Getting Past No, Getting to Yes, those books and the difficult conversations books. Oh, yeah, there it is. Getting Past No: Negotiating Your Way from Confrontation…
Lee: Yeah. Awesome book. So many times, people ask me, “What is one book I should read about negotiating?” I love these Getting Past No, Getting to Yes by… Well, I don’t even know if you can see it that well, but William Uri, U-R-I. Just a fantastic, easy read. I laugh because it’s over on our nightstand because one of my kids, who’s the 13-year-old, has read it now.
Lee: So she is loving negotiating because she wants an iPhone. I’m like, “No, you don’t need an iPhone.” So she’s hardcore learning how to negotiate from my books, which I think is fascinating.
Eric: Yeah. She’s going to be all like, “What if I’m walking home and I get lost, I need to call you, mom?”
Alex: Yeah. Safety.
Eric: Wouldn’t that be worrisome for you?
Lee: Yes, yes. It’s about safety, mom, my safety and helping you. Don’t you have interest in my safety? It’s interesting…
Eric: Just think how much less worried you’d be if you could always look and find my phone and see where I am.
Lee: What’s fascinating is when we did negotiation training with hospitalists and social workers and with nurses, we found that they actually showed improvement with dealing with their patients, but then they also used it in their real life. They were negotiating like apartment rents; they were negotiating like rental car perks. What you can learn from this curriculum, you can actually move over into other parts of your life because that IRP can translate into so many different situations.
Eric: Alaine, any other kind of big pearls when we think about interest statements or just negotiation in general that you’ve learned?
Alaine: I think overall, the biggest thing that I’ve learned, and I know we’ve already talked about this, but understanding where the other person is coming from. When I think of family caregivers, at least understanding that the older adult that you’re negotiating with they’ve lived full lives; they’ve been fully independent people. So, when you’re trying to negotiate for more help for them, it could be a lot for them to give that up. So, just come with that understanding that where they’re coming from, it might be a little difficult to give up that independence.
Eric: Yeah. I love that, too, because, again, far too often we’re coming in there with our own thoughts about safety, that that is the key argument, that we want them to be safe and it just often falls flat because that is not their primary interest. Their primary interest is to be independent, often, or not to be a burden to others, not to be a burden to society. The amount of things that they value, the passing on a legacy, including financial legacy to their grandchildren, to their sons and daughters, and not spending all their money on caregiver support.
Alaine: Right. Exactly.
Lee: One of the fun things, too, with this project is that, going back to the avatar-based thing, it almost becomes a game because we actually made it that you have a limited amount of time because most of us are busy people. So, you get to negotiate as part of this webpage. It’s called negotiage.org and…
Lee: .com. Thank you, Alaine. The fun part is that it gives you how to do the negotiation. It has some videos, but then when you’re in the research project, it actually goes through different scenarios. So, it’s an easy senior who’s willing to go, “Sure, I’ll do it.” And then we go to a hard senior who absolutely says, “No, no,” very stubborn. Then we have the provider and then we also have another family member, but we put a time limit on it. The time limit on most of these is between 7-10 minutes. So, you really have to negotiate hard to get these things done. It’s almost like a game, and you can keep coming back and trying it so that you get better because one of the tenets of negotiation is that the more you negotiate, the better you get and the easier it is, which is why you see sometimes some of these sports people hiring negotiation people or my agent is my negotiator. That’s just one of the fun things, that there is a games-type feel that you can learn so it goes faster for you.
Alaine: It doesn’t feel all the time that you’re in a negotiation, if that makes sense. It feels more like a game when you’re actually doing it.
Lee: Oh, my god. But the avatars are so amazing. We worked together with Dr. Jonathan Mel, and he is a interactive… What’s the name of his program? It’s IAGO, and it’s interactive.
Alaine: It’s interactive arbitration guide online. IAGO.
Lee: The avatars actually are very human-like and they are irrational; they’re emotional; they’ll yell at you. Okay? They actually completely work towards you with emotions and everything. Your goal is to get to either accepting help in the home or having somebody come to your house and be there for a couple hours a day. But it’s just so wild how much they’ve done. It’s not the avatar on the water thing, by any means, but it’s just such a fascinating way to negotiate. The reason we did it, we used to be doing it in person, naturally COVID changed all that, but because we know family caregivers are very busy, this way they can negotiate whenever they’ve got free time. So, whether it’s at 2:00 in the morning or at 6:00 AM, go for it. Learn how to negotiate better.
Eric: I got a question. So part of this is you’re trying to reach an outcome like extra support in their home, something important to the caregivers, to the family members, to the healthcare providers. Why the focus of this on the caregivers instead of training the older adult on negotiation skills to get what they’re interested in?
Lee: Well, that’s like part two. I’ve got another grant going in that’s looking at the family members, and also part three, looking at providers, looking at nurse practitioners and physicians. From my end, I actually went after the family caregivers because those are the ones that I see the most frustrated. Those are the ones that are dealing with the senior that just keeps saying no and closing the door.
Then the other thing is that the scenarios are not just about getting somebody help in their home. We know so many times that the family caregiver is the patient advocate, where they’re the ones that are advocating, “Okay, does my mom really need this medicine? Does my mom really need to have this done?” One of the scenarios is what to do with a patient who’s losing weight, who has end-stage dementia. As a family caregiver, you have to argue against the provider not to put in a gastric tube, which we know is not ideal for people who have severe dementia. That’s why we went after the family caregiver, just because many times they are the patient advocate and they have to be the patient’s voice many times.
Alaine: Yeah. I was going to say in my experience as a caregiver specialist, the family caregiver is often very stressed and overwhelmed. I think if they know how to navigate this negotiation, it could be helpful in the long run because they are often doing a lot of the heavy lifting of caring for someone.
Eric: I guess my question then, Alaine, is part of this is you are giving people potentially a good amount of power on how to influence ultimate outcomes. Even doing things, I mean, we had a podcast on the words that we use like spin and other things around… God, why am I blanking on the word, Alex?
Alex: Are you talking about cognitive psychology, or?
Eric: Yeah, and behavioral…
Alex: Behavioral economics?
Eric: Economics, yeah. Like, we are…
Alex: Like heuristics and cognitive shortcuts.
Eric: That we’re decisional architects is…
Lee: Ooh. That’s fancy sounding.
Eric: So, rather than thinking about people make decisions rationally and you just give them an answer, they’re autonomous, is in truth is that we sometimes overstate our level of autonomy. The way decisions are posed and the frameworks that we use and the way we design decisions influences how people make decisions. Part of this, when I think about negotiations, and I’ve read some of your work, too, when we’re talking about nursing homes, instead of, “You need to go to a nursing home.” No one wants to go to a nursing home. “Let’s talk about ways we can keep you in your home.” So, that decisional architecture shift gives people a lot of power. I guess the question is, when we’re thinking about this, why the focus so much on the caregiver and giving them the tools rather than, let’s say, the older adult, how do you negotiate to do things like maintain your independence, for Alex to continue driving his GeriPal car, or what really matters is being outdoors to him?
Lee: Yeah. From my standpoint, the grant itself that we got funded is actually for family caregivers of patients with Alzheimer’s disease. It’s almost to the point where if a person has mild cognitive impairment or they’re safe at home, and I’m using the word safe because if they’re independent and they’re doing good, which I love my patients when they’re doing good and they’re aging in place successfully in their own home, then there’s not much you need to negotiate. When something happens, whether it’s a crisis and they fall, or they’re hospitalized or something happens that they need help, that’s when we kind of have to think about switching it up. Is the memory loss getting so bad or is it worsening progressively that they need more help? Are there things that they’re being taken advantage of that you have to step in as a family caregiver?
That’s the same thing when you’ve got a person that’s got moderate or severe Alzheimer’s, and they just want to go to the physician alone and they are not capacitated or they don’t have the capacity to understand these instructions, that’s when you have to negotiate with the provider. “This is my mom, but I’m here to help.” I think that’s where I’m coming at, that ideally we’d love to have everybody across the world have negotiation class because then we could have much more kinder conversations. But it almost gets to a point where the family caregiver sometimes has to step in, much like when we talk about role reversal, the child has to step in for the parent or the parent steps in for the teenager who’s up to no good. That’s where the family caregiver is the target on this. But in general, I’d love everyone to have negotiation training. That would be sweet. Everybody except my teenage daughter, how’s that sound? And my son. Because that makes my life easier.
Alaine: Yeah. Just to add onto that, I think in my experience as a caregiver specialist, when caregivers have come to me in that role, it’s because a crisis has occurred; problems have been pushed aside time and time again, then one day you go to mom’s house and it’s such a mess that you just don’t even know what to do. So, while it would be great that all older adults are trained in how to negotiate, realistically, most of the time, the family caregiver is doing a lot of that advocating and setting up a lot of those resources.
Eric: My last question is, okay, you got a magic wand. You can have providers, clinicians, social workers, physicians, nurses, do one thing different around conflict resolution.
Lee: I would say be kinder. I think that’s the key thing because we oftentimes go front, “You’re wrong. I’m right. You’re wrong. I’m right.” If we just took a step back because I know it’s a very tense situation, and said, “What are your interests? Why are you talking about this the way you are? Or what do we need to change?” I think just that kindness aspect and kind of being a little bit more objective is a better way of conquering any problem. If I have a magic wand, the Cubs win in 2023, of course beating San Francisco in the World Series. But, you know.
Eric: Can I just go back to what are your interests? Do you have a opening statement that you’re like, how do you say that in a way that makes sense to people?
Lee: Oh, I love the what matters most. So, what matters most? But then the other thing, too, is I usually ask, how do you think your cognition is doing? How do you think your memory is doing? If they say my memory is doing perfect, then whatever. But if they say their memory is a little off, then we can kind of play with it.
Alaine: Mm-hmm. Yeah.
Eric: All right, Alaine. The magic wand is running out of most of its power because it was used on the Cubs and that would require a tremendous amount of energy. What are you going to use it on?
Alaine: I would say similar to Lee, but a little different. I think understand where the older adult is coming from or try to understand why it might be difficult for them to give up that independence, or why it might be difficult for them to let help come into the home or to give up the keys to the car because I think if you have that understanding, it’s a lot easier to get somewhere in a negotiation.
Alex: I have one last question. How does this compare… Yeah, like advanced care planning sort of training or serious illness conversation guide or the work that… Boy, now I’m forgetting the name of it. We had Aanand Naik on this podcast talking about… What is that called? The conversation? What is it? The goals?
Eric: Patient priority.
Alex: Yes. Patient priorities care. He’s going to kill me for forgetting this. I don’t know if you’re familiar with these sort of…
Lee: Yeah. Those are all about planning and finding out what the patient wants, which this is a corollary of. But the big difference is that we’re not talking about what people want in the last moments of their palliative care or their hospice. This is more about, like I said, the fourth quarter, so the 10-15 years before you die, what are we going to do to make your life better? It’s similar principles, but just getting to accomplish something so that you can have a long-term relationship with that person instead of anticipating your death.
Alex: Right. I guess for me, the key underlying principle, as you’ve just reiterated, is getting to understand their interests, what their goals, whatever you want to call that: interests, goals. That is foundational to each one of these methods. And I would say that the key method in training is that it’s not enough to ask one question. You usually got to probe deeper and don’t jump to trying to make some sort of connection to, “Well, here’s the solution, then, if that’s your interest,” right away. You almost always have to probe like one level deeper, one level deeper, one level deeper until you have a robust understanding. Because people are complex, right?
Lee: Yeah. And never give up. For negotiations, we keep going back to it over and over again. It’s not a one and done. That’s just one of the things. Just like the Cubs, we don’t give up.
Eric: Tell your daughter the same thing. Hold on hope. That iPhone’s coming.
Lee: Thanks, you guys. Thank you so much.
Alaine: Yeah. Thank you.
Eric: Well, before we leave, Alex, you want to give us a little bit more of… What was the song name again?
Alex: Sweet Home Chicago.
Eric: Sweet Home Chicago. Don’t Tell Ken Covinsky.
Eric: All right.
Lee: Yay! Awesome song. Great job singing it, Alex. Much better second time.
Alex: Yeah. Much, much better.
Eric: Lee, Alaine, big thank you for joining us on this podcast.
Lee: Thank you so much…
Alaine: Thank you.
Lee: Keep on doing this, you guys. You’re the best.
Eric: And quick plug. First, I’m going to plug, Lee was on a previous podcast with us on… What was the title? Fourth Quarter? Preparing for the Fourth Quarter of Life?
Lee: Fourth Quarter Planning..,Plan Your Lifespan.
Eric: Okay. We’re going to have a link to it.
Lee: Oh, yeah. Our other website is planyourlifespan.org, and that’s getting a brand new overhaul starting in 2023.
Lee: But if you’re interested in participating in this research on negotiating for family caregivers, please feel free to email us at firstname.lastname@example.org.
Eric: And we’ll have links down on our show notes. Just want to thank you…
Lee: Thank you so much.
Eric: … again both for joining us, and thank you to all of our listeners for your continued support.