Stump the VitalTalk Communication Experts: Gordon Wood, Holly Yang, Elise Carey

Eric 00:00

Welcome to the GeriPal podcast …

Alex 00:04

You usually say your name. [laughter]

Eric 00:18

300 plus episodes and I forgot how to run a podcast [laughter]. Welcome to the Geripal podcast. This is Eric Widera, and only 300 and something podcasts in. I’m figuring things out still. I’m just so excited about our guests today.

Alex 00:41

We are delighted to welcome the VitalTalkers who all contributed to this book, which I’ll hold up for those of you watching on YouTube. It is called Navigating Communication with Seriously Ill Patients, Balancing Honesty with Empathy and Hope by Bob Arnold, Tony Back, James Tulsky, and our three guests today. First, Gordon Wood, who’s a palliative care doc and associate professor of medicine at Northwestern. Gordon, welcome to the GeriPal podcast.

Gordon 01:08

Thanks for having me.

Alex 01:09

And Holly Yang, who’s a palliative care doc and co director of the UC San Diego Scripps Health Palliative Care Fellowship and immediate past president of AHPM. Holly, welcome to GeriPal.

Holly 01:23

Thank you.

Alex 01:24

And Elise Carey, who’s a palliative care doc and geriatrician and associate professor of medicine at the Mayo Clinic in Rochester, Minnesota. Elise, welcome to GeriPal.

Elise 01:34

Thank you.

Alex 01:35

And welcoming back as guest host Anne Kelly, who’s a social worker in palliative care. Anne, welcome back.

Anne 01:41

Thanks. Happy to be here.

Eric 01:42

So we’ve got an exciting topic today. We’re going to be talking about a little bit about this book, VitalTalk and thinking that the navigating communication with serious ill patients by. It’s titled the VitalTalk Method. So we’ll talk about what that is. But before we jump into that topic, Gordon, I think you have a song request for Alex.

Gordon 02:02

I do. So my song request is The More You Say, The Less it Means by John Morland.

Eric 02:08

And let me know, why did you choose that song?

Gordon 02:12

So I think it speaks to one of the big lessons we’ve learned, which is that docs and other health professionals often sort of give way too much information and spend a lot of time talking. And one of the hardest things is to distill it down to a sentence or two about what is information, what does it mean? And then be quiet and listen. So I thought this was the perfect song for this podcast.

Eric 02:38

See, Alex, that’s what I was trying to do with my intro. I was trying to be even more quiet (laughter).

Alex 02:45

Because the more you say, the less it means (laughter).

Eric 02:47

Yeah, exactly. Here’s a bit of.

Alex 03:01

(singing)

Eric 03:51

Wonderful.

Elise 03:53

Nice.

Eric 03:54

We’ve got a lot to cover. We want to get into specific scenarios because we’re going to try to stump the experts with challenging communication scenarios around serious illness. But before we do, I’d like to start off with you, Gordon. Why did you all decide to write an updated book on navigating communication with serious ill patients? Did things really change over the course of, what, like a decade? That it felt like it was really important.

Gordon 04:24

So I think a lot changed. You know, a few things happened since the first edition was written. A global pandemic, some sort of awakening about the role of racism and privilege and power, and even just sort of the way we’re sort of teaching and the content has changed. You know, some of the foundational stuff that we teach in the course, things like Remap, which is a conversation map for how to discuss goals of care late in the course of an illness that was not in the original book. So I think lots of reasons to write an update.

Eric 05:03

Nice. And as we think about VitalTalk, some of our listeners may not know what VitalTalk is. And in the very top of this book, it says, the VitalTalk method. What is the VitalTalk method? Or what’s the VitalTalk approach?

Elise 05:19

Elise, I can start, and then I would love to hear what Holly and Gordon have to add. The fundamental philosophy is that we see communication skills as learnable and teachable, that it’s not something that you’re intrinsically born with or magical, that you can actually teach people to be better communicators by teaching them skills. And our goal is that we teach them skills. We teach them these frameworks or scaffolding that help them navigate these challenging communications, ultimately bring their best selves to them.

Because while we all may approach things similarly, we also bring who we are as humans into the room. Right, in these therapeutic interventions. One other thing, there’s also this focus on ongoing learning. So the very best communicators are always reflecting on their practice and trying to do better and thinking about what they could have done differently. So while we focus on skills and so forth in the teaching, we also helped deliberately focus on reflection. Right? So that people are reflecting on their own practice so that they can continue to get better, because that’s what we hope for over time.

Eric 06:21

Great.

Holly 06:22

I guess I would add some of it’s your own communication skills, and that’s what this book talks about, I think, bigger and VitalTalk as an organization and nonprofit is thinking about how we teach teachers to then do this work in their institutions and how we really bring a spirit of curiosity and of learning together, both as teachers and as people who are communicators with patients and families with serious illness. So the book is really about your own sort of skillset. And then there’s the extra, the other layers of the work that are important. So it’s a lot, but it’s good.

Eric 06:56

And who are you targeting with VitalTalk? Who do you want to read the book? Take the courses.

Elise 07:02

So healthcare workers for sure. I think the original focus was on oncologists, as you all may know, way back when, when it was onco talk. And for many years, I think there was a focus on physicians and then providers. And I think in recent years, we’ve also really tried to expand to the interprofessional team, both as teaching communication skills, but also as training them as teachers. Right.

Gordon 07:25

I think one of the exciting things that’s happened as VitalTalk has evolved is the sort of tent has grown and there’s more people from various backgrounds, professionally and otherwise, that are part of the sort of leadership and devising new curricula and revising things and bringing a bunch of different perspectives. So I think it’s anyone who cares for seriously ill patients.

Elise 07:48

Yeah.

Eric 07:49

And then just for background as we start thinking about questions to stump the experts, you mentioned, Elise, skills. And I read in your book, there’s skills, there’s roadmaps, there’s capacities. I think those are the three big ones. What are those? How would you define those? And how should I think about each one of those?

Elise 08:11

Yeah. So skills are more the discrete thing that we’re going to practice. So, for example, learning to respond to emotion by making an empathic statement. Right. The frameworks or scaffolding are things like remap. That is a general approach to a particular kind of conversation with seriously ill patients. And those frameworks we teach for people, for them to gradually, over time, they’ll be able to get better at that and maybe rely slightly less on the scaffolding as they progress. And the capacities are really work most of us do on our own.

Right. That’s kind of the internal dispositions, the things that we bring that are who we are and how we are in the world, and really trying to foster curiosity, self awareness, compassion, and an ability to remain balanced no matter what happens in the room, including with some of the challenges I know you are looking forward to throwing away later in this.

Eric 09:04

Podcast, it seems like you can, you can easily, but you can potentially teach skills, and certainly roadmaps or frameworks or scaffoldings, can you teach capacities?

Elise 09:18

I think we can help by helping people through self reflection, but ultimately, I think that’s internal work we all need to do. Whether that’s through, I do a lot with reading books, but whether that’s through reading books, therapy, getting feedback from our teammates and our friends, journaling, whatever it is for you. But yeah, that’s more internal work, right? That’s more work we each need to do on our own.

Gordon 09:42

Could I add something?

Elise 09:43

Yeah.

Gordon 09:45

I think the other thing that we see is that as you learn these skills and roadmaps and navigate through the conversation and do that more and more, it generally goes better. You get more back from the patients and it helps you grow some of these capacities. So the skills lead to development of the capacities. And then we’ve had colleagues that have helped us think about other ways to grow some of these. We’ve done work with medical improvised, we’ve done work in museum based education. And so there’s other ways to sort of grow these reflective practices and get at some of these things.

Eric 10:21

Well, recently I’ve been using more AI to help me through difficult conversations. And as we move to thinking about stumping the experts, and I’m going to turn to Anne right after this to start us off.

Anne 10:35

Okay?

Eric 10:36

But I asked Chachi Bt, I said to Chatty BT, I need to tell my patient they have cancer. What should I say? So what you have to be is what Chat GPT responded. So you got to be better than AI. So chat GPT, excellent. So the first thing, explain the diagnosis. Ready? You can say something like this. Chat GPT says since cancer cells were confirmed by histological examination, you have a cancer. So that is the bar.

Gordon 11:08

I think our jobs are safe.

Eric 11:18

So it goes on multiple steps, but maybe we can move from AI ChatGPT to stumping the experts. So what we’re going to do is we’re going to post some scenarios. We got some scenarios also from the Internets, but we’re going to start off because we talked about this yesterday, some challenging scenarios. And what’s the VitalTalk approach or method towards those scenarios? And do you have a scenario?

Anne 11:44

Yeah, I have a few in mind that I think will probably be very relatable to a lot of the folks listening out there. All right, experts, are you ready?

Elise 11:55

You all are experts, too.

Anne 11:57

Scenario uno.

Gordon 12:01

One absolute right answer to all these questions, and we will provide that.

Eric 12:06

Chat upt just gave it to us.

Anne 12:10

All right. I’m not going straight for the hardest one just yet. But let’s imagine you are breaking difficult news to a patient. And they respond consistently, very tangentially. They keep changing the subject. Maybe they make a joke. Maybe they say, oh, I hear you, doc, but hey, have I shown you pictures of my four year old granddaughter yet? She just had a birthday the other day. Hold on, just let me find these photos for you.

Eric 12:49

So how would you respond. I just told you you had cancer.

Eric 13:03

All right, Holly, I’m going to start off with you. Thoughts.

Holly 13:06

Totally fine. Thoughts. So I think when people do, because people do that actually, right. They do this in real life, is to think about. Hmm. So they. I gave information and they’re going somewhere else. So I think just acknowledging that it’s often, that’s an emotional thing, right. When people do that. So I would just say this is, it’s really hard to hear this. It’s really hard to wrap your head around it. So just responding to emotion. But the other thing you mentioned, which is interesting, is sort of talking about the grandchildren and showing pictures.

I would sort of say, you know, ask them what they’re worried about too, at some point, because to me, they’re honestly, they may be going straight to their values without explicitly saying that, like, this is important. I heard that. And my grandkid, like, I need you to see this child and, like, how wonderful and special they are. So I think it’s a bit of both acknowledging it and the emotion that may be in the room, but also just seeing the family. And that is not actually tangential. It’s just a different way of showing us what’s important.

Eric 14:04

So they may not be actively avoiding the subject. They actually may be one step ahead of you at this point.

Holly 14:10

They might be. They just might not be telling it in a way that doctors are used to hearing it or other clinicians may be used to hearing it. So it’s a. Yeah, so I agree.

Eric 14:19

Elise Gordon, any other thoughts?

Elise 14:22

No. My thought was the same of sort of naming that it sounded like it was difficult to hear. I think Holly’s right. My hypothesis is that there, it’s really emotional and that she is thinking about her grandchildren. It’s possible she didn’t understand you, but I would respond to the emotions first and try again with an explanation if that’s clearly needed later.

Gordon 14:41

I like the word. At least he’s there of hypothesis. And so sometimes I’m thinking, like, what is the differential for what’s going on here? Like, have I not been clear? Is it emotion? What is the, what’s going on?

Eric 14:55

Yeah, it’s interesting because you got me thinking about capacities and thinking about that capacity of curiosity. I just gave this person really bad news. Huh? We’re now talking about they’re showing their grandchildren. That’s an interesting scenario. Is there any role for just calling out the elephant in the room there too, as far as that curiosity capacity?

Holly 15:19

Like, what would you say? I’m curious, I’m curious. What would you say? Give us an example what you mean.

Eric 15:24

Yeah, like, uh, you know, it’s interesting that I just told you you had cancer and you’re showing me pictures of your children. Can you tell me a little bit more kind of how you’re thinking about this?

Elise 15:36

Yeah, I think that would be not unreasonable at all, Eric, for sure.

Eric 15:41

Yeah.

Elise 15:41

As long as it’s gently done and done with curiosity, right? I know. I just shared some news and you’re showing me pictures of your grandchildren. Can you tell me what’s on your mind? Or can you tell me, as you.

Alex 15:51

Said, very different from Eric’s initial reaction, which is voicing his internal frustration.

Eric 15:58

I just showed you, I just told you you had cancer, and now you’re showing me pictures of your grandchildren.

Alex 16:08

Recognizing that internal, like, what the heck? The frustration that this isn’t, this isn’t focused on the biomedical stuff that I’m trying. I must communicate. That’s my job.

Holly 16:20

Yeah. So I would actually, that’s really important is like recognizing if you do have that right. So for people, when you’re out there being like, huh? And like trying to be thoughtful and just catching yourself if you are frustrated because you have twelve more people to see and just sort of being like, oh, this is like what’s going on there? Like I’m having, I’m feeling some sort of way about it and like what will actually serve in this situation? I, that is also part of it is the how to respond rather than react as we sort of think about our own stuff as we’re in a conversation.

And I think that’s also part of that idea of capacity, but sort of being able to sort of monitor yourself and your own reactions in the moment and then use that actually for the hypothesis building. Like, oh, that was not what I was expecting. Like, wait a minute, what’s going on here? And so what I love about Kelly.

Alex 17:09

How did our guests do.

Anne 17:13

I would say I feel very supportive, very heard, and ready to move this conversation for. But I was going to say, you know what? I just to highlight, I love this piece of the VitalTalk framework that you guys just highlighted in your response a moment ago is also the idea that emotion shows up in different ways and not always obvious ways. Right. And so that capacity to be very attuned to the idea that emotion is not always just reaching for the Kleenex to wipe away tears, but it can show up in lots of different camouflaged versions, which is what you guys highlighted just now.

Elise 17:48

Very well said, Anne.

Eric 17:50

All right, Alex, I’m going to turn to you. So. Didn’t stump them yet. We need to.

Anne 17:56

Let’s up the ante.

Eric 17:57

Let’s up the ante a little.

Holly 17:58

Okay.

Alex 17:58

This is from GeriPal, listener Rebecca Sidore, probably well known to many of our listeners, who stopped by the office as we were brainstorming challenging questions for you all yesterday. This is from a real world scenario. I’ll change some of the details just to protect confidentiality, but the essence of the story is the same. We had a patient who completed an advanced directive that said that he wanted to split surrogate decision making equally between his wife and his son. Equally. 50 50. Says right there, 50 50.

And of course, the wife and the son cannot agree on the path of care for this seriously ill patient in the ICU with critical illness, lacks decision making capacity, has a poor prognosis for functional recovery, for survival. And you’re in the ICU family meeting, and it gets heated.

Eric 19:02

They’re yelling at each other.

Alex 19:04

Yep. They’re yelling at each other. And Anne and Eric, everybody chime in. What else do you recall from the situation that we should…

Eric 19:13

I think that’s a good, good place to go.

Alex 19:16

Okay. And Eric, you’re directing traffic. Who do you want to go to with this?

Eric 19:21

First I’m going to press my randomizer, Gordon.

Gordon 19:28

I mean, this sounds like conflict, right? Is the sort of task to manage.

Eric 19:35

You have a whole chapter on conflict. I keep on plugging the book there.

Gordon 19:40

That’s right. You’re better at this than me. So, I mean, I think the big thing we think about with conflict, which we learn from a book called Difficult Conversations, which is actually a non medical book, which is a great read if anyone hasn’t read it. It’s actually written by lawyers, and it’s about other types of difficult conversations. But what they suggest in conflict is to not try to convince and persuade the participants to get to what you think should happen, but to create what they call a learning conversation. And the main question you ask yourself is, why is this otherwise well meaning person acting in this challenging way?

And so having a sense of thinking that they are not there just to make your day difficult, or they’re not there to fight with each other. They’re both well meaning people acting in challenging ways. And then you try to think, why is that? And we think about, are they on the same. Do they have the same understanding of the facts? Is there emotion at play here? And how do they see their identity in this situation? And so I think that frame shift is the big thing that helps me, just thinking these are well meaning people that love this person. So how can I, you know, understand why we’re here better?

Eric 20:58

I love that book, too, because part of that I always remember from that book in the great series, too, is why would a reasonable, rational, indecent human being do this? Or say this? Which I also try to remember, but I often fail, like when somebody cuts me off on the freeway. Like, all right, why would it, like you put yourself like a. If I cut somebody off on a freeway, I’ll rationalize away. But we can’t see people’s reasoning when they act.

Gordon 21:26

Because your own emotions are faster than you’re thinking, right?

Eric 21:29

Yeah.

Alex 21:30

So how does this help you in the moment in the family meeting when the patient’s wife and son are yelling at each other? What do you do there?

Elise 21:41

I was going to start building on what Gordon said, I think, to remember that most likely both of them are coming from a place of love. Right. Most likely both of them are trying to advocate for their family member, and they have, maybe they have different values around how that should happen. Certainly they have different ways of doing that. And so one of the things we talk about in the book, in the family meeting section is something called unifying empathic statements. That can look a lot of ways. Right. It can look like, I can see how much you both love your dad, your husband. It can be kind of like what Eric had talked about earlier, of naming the difference, right. On the one hand, son, I see you’re worried about x.

And on the other hand, wife, I hear you saying that you’re really worried about him suffering and just naming that. And then I think the final thing is to try to get the patient in the room, because what we really want to help surrogates with is to help them speak on behalf of the patient. Right. To hear what the patient would say if they were able to talk with us. So I think once we’re able to settle down emotions, and you do have to settle down emotions, right? Then maybe to say something like, if your dad were here and you were saying all hearing all of this, what would he say? What would he tell us?

Eric 22:59

And can I ask you about the settling down emotions? Because on one hand, like in your book, another plug, by the way, you say the beginning, we often try to fix someone’s emotions and potentially quiet them. You say not to. Why not fix emotions? They’re angry. I’m gonna fix that anger. They’re sad. I’m gonna fix that sadness, because it’s not.

Elise 23:22

It’s not possible. Right. What we can do is we can empathize and help them work through it and help them calm down kind of the emotional parts of their brain so their frontal lobes come back on.

Eric 23:33

Okay, I got another question. This is, I’m gonna go to. This is my stump the question, because it’s similar. So Earl Quixota asks a question. What do you do when the professional interpreter starts to cry? And I guess I’m going to add to that. It could be any member. She could be like that trainee that’s with you. And they’re having tons of motions, but nobody else in the room really is. And you’re in this middle of the meeting where, again, we’re supposed to be the professional side. How would you handle that? Holly, go ahead.

Holly 24:06

The randomized, I’ve had that happen in a language where I’ve had zero ability to speak it. You know, like, if it’s Spanish, I can sort of understand when people are translating me wrong, but I’ve had it in a language where I have no clue. And I guess to start, I now try to warn the interpreters when I get them on the phone or the video. Hi, I’m a doctor. We’re going to talk about some serious things. Are you okay? So I kind of give them a warning shot so that they know what’s going to come so they’re not just, like, hit with it right off the bat.

Because of my experience, having the interpreter cry, make sure they’re okay with it, and then at least what I did with this particular scenario, it was not salvageable. The interpreter that I was speaking to was just too distraught to actually carry forward. And so we actually, I had to say thank you so much and get a different, you know, we’ll, you know, appreciate you. And we’re going to call another person. I think sometimes people can sort of, if you give them a break for a minute and just check in with them, they’re able to continue. So it just depends, because I’ll hear people get emotional. You can hear them start to get choked up on the. Or if they’re a video, when you can see them, you know? So sometimes it’s. You’re judging the capacity of the person to sort of self regulate or not, because at the end of the day, it’s a humanity. Right. That’s helping us, and that’s maybe not what they signed up for that morning. And you have no idea what’s going on in their life.

Right. So I think now I warn them, and, you know, I try to also just make sure they. I say thank you if I need to switch. So that’s been my approach. I’m curious if, Lisa and Gordon, if you’ve also had this happen to you, and when it happened to me, I called a friend and was like, oh, no, I made the interpreter cry. Oh, yeah, I’ve done that. And I’m like, oh, good. I’m not the only. I’m not the only person who’s done that.

Eric 25:51

Yeah.

Gordon 25:52

I mean, I think that what I’d say, just in general, about our own clinical team’s emotions, is that what I try to think about? Is it in the service of the patient, or is it becoming about the clinician? Because I don’t think it’s wrong for us to show emotion. It happens to me. It happens to many members of the team, and I think it’s usually well received by families. If they see that you’re that invested, if it becomes more about you and you can’t be of service to them, figuring out ways, like holly did, to sort of maybe take a break and come back at a time when you can be what the patient or family needs.

Eric 26:25

So if that therapeutic relationship reverses and now they’re supporting you. All right, Anne.

Anne 26:34

Yes.

Eric 26:34

I failed to stump the experts.

Anne 26:38

Darn it.

Alex 26:39

Stump them.

Anne 26:40

All right, let’s try this again, guys. Okay, scenario. The next scenario is you are facilitating a family meeting, perhaps in the ICU setting, the patient is unable to participate in this conversation. Their surrogate decision maker, an adult child, is sitting at the table with you and your team. You have broken bad news. You’re very concerned that no matter what we do, time may be short for this person who’s receiving life sustaining treatments and is critically ill.

And the surrogate decision maker turns to you and says, what would you do? What would you do? Would you give up on your dad right now? What would you do? And is pointing at you, by the way, for those who are not watching, either or not. They’re pointing. They’re pointing.

Alex 27:41

Finger pointing. Who does the randomizer?

Eric 27:46

Elise goes to you.

Elise 27:49

Yeah. This isn’t uncommon. Right. I think what we always endeavor to do is make a recommendation to families, with their permission, of course, that supports the patient’s values and the medical realities. And maybe you’ve done that and she’s, I’m assuming a she. I’m going to go with a maybe you’ve done that and the family member is still pointing to you and saying, yeah, but what would you do? I have said in the past, you know, it’s less about what I would do and much more important that we really do what would work for your dad. Right. That we match what’s most important to your dad with all your pointing. And I’m guessing you’re going to ask, well, what would you do if they still said, what would you do for your dad? Right.

Anne 28:32

If you want to go there, please.

Eric 28:38

Answer the question. What would you do?

Elise 28:40

No, I said what I would do. What I would do is I would kind of. Yeah, exactly. But if they. Oh, I see. You’re playing.

Eric 28:48

That’s role play.

Anne 28:52

You guys.

Eric 28:52

Yeah.

Holly 28:53

Yeah.

Elise 28:53

I think. I think I might say, I might name, like, I’m a little bit uncomfortable with that because we’re all different and we all approach things differently. Based on what you’ve said about your dad. If he were my dad and I felt like that was what’s important to my dad, I would probably do blah or recommend blah, which still gets you back to the values and recommendation, because ideally, given a recommendation that really is grounded in dad’s values. Right. So ideally you’re coming back to the same thing.

Eric 29:25

Yeah. So really, you know, based on what you’ve told me, if my dad had similar values, this is what I would do.

Gordon 29:33

I think the other thing that the way you phrase the question and makes me think is because if it’s with this emphatic pointing and maybe a crack in the voice and things like that, there may just be emotion there, right. And saying, I can’t even imagine how hard this is to hear to talk about this stuff or whatever it may be, that question may go away.

Elise 29:56

And how hard it is to be faced with making decisions. Life or death. What feel like life or death decisions for your dad? Yeah.

Eric 30:02

Yeah. Okay, Alex. Still haven’t stumped them.

Alex 30:06

Okay. This question.

Anne 30:07

They really know what they’re doing, don’t they?

Eric 30:10

They showed the book.

Gordon 30:14

Did we mention our book?

Eric 30:17

Tell me more.

Alex 30:22

This is by recent GeriPal guest and current palliative care fellow at UCSF, Brianna Williamson, who says that there’s a patient who has cancer encasing their belly and they’re getting TPN and they’re hospitalized, and their oncologist keeps saying, like, well, you know, if they can get this and then if they can get that and if that works out, then they could have their wish to go home in like three weeks. And it’s a lot of if, if. And you’re kind of on a different page about what that might mean. I mean, how do you negotiate that with the oncologist who is the one who consulted you, by the way, Eric, who does that go to?

Holly 31:08

Holly, you know, this happens all the time, I would say, and legitimately so. Right? Because your oncology colleague is saying whether it’s this case or another one of if they can get to a functional status that is reasonable, then I would absolutely treat them.

Elise 31:27

Right.

Holly 31:28

But right now they’re not where they have an infection or in this case they have TPN and they’re not doing well. So I usually try to find that person and talk to them, ideally face to face or definitely on the phone, not epic chat, because that is not the greatest way to have this conversation and just ask them and just say this is a really hard case. And just sort of acknowledge that because this person’s probably had a longer relationship, this patient, than I have. And so they, they are deeply invested in how they do. So just talking that it is hard and, you know, and then just asking them how likely do you think it is that they’re going to do these things? Because I understand that you’re, we’re all hoping that they get there.

And I’m really worried. I use the hope worry. I’m really worried they’re not going to from what I’m seeing and just see what they say, honestly. So, because sometimes what we’re doing is we’re caring for the patient, but we’re also caring for our colleagues to make sure we’re coming to the patient with a unified voice, because if we’re all over the place, it just makes the patient confused and not trust us, not as an individual, but the medical team as a whole. And so wanting to get our stuff together so that we can acknowledge the uncertainty and move forward. So I usually have a private conversation.

Eric 32:40

And I really love the chapter on, you know, conflict with colleagues, which you pose as different in a way because with patients, you can acknowledge emotions because you’re in this professional role. There’s this therapeutic relationship. But, you know, with your colleagues or, like, family members. I always go back to Alex’s take out the trash video where he uses the nurse pneumonic with his wife when she asks him to take off the trash, which failed to miserably because potentially, like, using those same skills in that scenario may feel somewhat condescending. Are there differences when you’re talking with colleagues and using some of these communication skills?

Holly 33:24

Yeah, I mean, I think you sort of spoke to it, but we don’t have the same social contract with our colleagues as we do. Your patients expect you to care for them, their mental well being, their physical well being. Your colleagues are not asking you for that. They’re asking you for a consultation. So we usually come at it by when there is emotion, talking about the case being difficult or challenging or hard because it’s still emotion. But I’m not my colleague’s therapist. I’m not their doctor.

Eric 33:49

So more of a third person approach.

Holly 33:51

Yeah. And that way it’s less threatening. And they’re not like, get out of my head. Right. I mean, yes. I’m a surgeon.

Eric 33:58

I don’t feel emotions.

Holly 34:00

Right. I mean, unless they’re coming to me for that because they know, trust me. Right. That’s a different situation of when it’s a friend situation, you know, or close work colleague, as opposed to someone that you’re just working with together on a team. I don’t know. Elise Gordon, other thoughts about that?

Elise 34:15

No, I think that’s right. It’s the third person neutral but also focusing on the situation instead of the person. Right. So instead of. I can see how this is upsetting, which is something you might say to a patient, saying, like, these cases are really tough. Right. These situations are really tough. So those two things, third person neutral and situation based.

Eric 34:35

So let me ask you another question, because on Twitter, Sandra, she asked kind of a similar question. Like, you have a provider, a trusted provider for a patient who is super optimistic on the view, and you’re consulting and you’re sitting down with the patient. Like, how do you build trust with that patient? We talked about the doctor, which she also asked, but how do you build trust with the patient and the oncologist, whoever it is, has a way too optimistic view when they’re talking to the patient. Oh, the randomizer.

Alex 35:08

Randomizer.

Eric 35:10

Randomizer.

Holly 35:11

Yeah.

Eric 35:12

It’s going back to Holly.

Gordon 35:16

It is truly random.

Holly 35:18

Yeah, yeah.

Eric 35:20

I just press it on your book.

Holly 35:23

Spitting out a name. Throw a darn at it. Yeah. I think it’s important to. If you can have the person come with you if it’s really super different, and you have to have that conversation before you walk in the room again. You still have to talk to your colleague before you walk in the room and just sort of understand, like, help me see what you’re seeing, like, because maybe I’m off. Right? Because that’s a real possibility of, like, oop, they’ve been taking care of this person for a while. They may know something that I don’t. Help me. Like, I need to understand what the situation is from their perspective.

But then if it’s something different and it’s just how we communicate or what the patient is hearing, because sometimes the person has said something, but the patient is picking what they want to hear out of it because it’s hard to hear hard things, you know, is making sure they know. I’ve talked to the person that they trust, or having that person come with me is usually where I’ll start. And I don’t often abruptly contradict. I will sort of get an understanding of what they know, what they’ve heard. You know? Has anyone ever, you know, are there other things that you’re worried about to see if they surface? Some of the other things that might have come up in the conversation that the patient’s actually trying not to focus on because it’s hard.

Eric 36:30

Yeah. Or they say, I’m worried he’s not telling me the whole truth.

Holly 36:34

Right. Sometimes people are just literally optimistic and they have a hard time, and then you can sort of be that person. I had a patient that told us once many years ago. I’ve talked to my oncologist for the oncology stuff, and I come to you to deal with the stuff that I’m worried about, that I don’t want to talk to the oncologist because I need them to be my cheerleader, and I need you to handle the stuff that is hard, that I don’t want to forget about. So sometimes people actually clinicians in a different way, and was a very insightful patient to sort of verbalize that, which was interesting.

Eric 37:02

All right. And we’re continuing to fail. Okay, give them a harder one.

Anne 37:06

All right, we’re gonna pivot a little bit. So let’s chAnnel our VitalTalk. Teaching the teacher skills a little bit. And let’s say we’ve met with a patient along with a trainee that we are helping to teach and mentor. And in that patient encounter, our trainee really does some inelegant stuff. And we get through the encounter, no one’s hurt, no one’s harmed, and, boy, were there things that were really hard to kind of hang in there with. And we come out of that patient room, and we do a quick debrief and check in, and we ask our trainee, how did that go? And they say, great.

Holly 37:55

Great.

Anne 37:56

We did everything we needed to do. We got a plan.

Eric 37:59

Got the DNR, high fives. Boom.

Anne 38:02

I’m just gonna. If it’s okay with you, I’m just gonna run down and go talk to the intern and let them know what’s going on. Is there an opportunity for us to still sort of find a way to find a teachable moment with this person?

Alex 38:14

Oh, and their pager went off five times, and they feel like they need to get out of there. All right, now we’re just upping the eric randomizer.

Eric 38:22

Elise.

Elise 38:24

So that has happened a little bit. Right. I generally prepare trainees for the fact that we’re going to debrief afterwards. I also prepare them for what will happen in the meeting, that if they’re leading a part, that I may step in, and I’ll ask if I can add something when I do that, and I’ll hand back the conversation as soon as I can. And if they don’t want it, they can hand it back to me, and I prepare them for the fact that we’ll debrief it. So, outside the room, I would say, well, good. I’m glad. That felt good for you. What did you do? Well, I’d add some stuff. I went, well.

And then ask them, looking back, are there things that you’re worried about or wish you might have done differently? And if they say no, I would actually ask, well, is it okay if I add something that maybe we can talk about? And then I would name. I would pick one thing, like you named, and there are many. You saw many things blow up. I would pick the one that I perceive to be the most important so that we could debrief that and practice that new skill for next time.

Eric 39:19

And can I ask, what if one of those things that you notice is, like, one of the big blind spots we have, like, a nervous tick? Like, every time they deliver bad news, they’re, like, smiling when they’re delivering bad news. That anxious tick?

Elise 39:34

Yeah, I think.

Eric 39:34

But it’s also, like, if you bring it up, it’s also. It’s somewhat embarrassing.

Elise 39:40

Yeah. So you’re saying it’s kind of personal. So I think to deep personalize that as much as possible. Right. So the depersonalization of what you’ve just said is that in our presence and our talking with people, our nonverbal communication is really important, too. And unfortunately, we can’t see our own faces. And so sometimes we need to get feedback from other people about what’s happening and to say in that moment that all of their words were good and their tone, but their face didn’t match. And so let’s think about how we can practice that. Right.

Eric 40:08

Great. Okay, Alex, do you got another one? If not, go ahead, Eric, go ahead. This is one from Corey Rolfson on Twitter. This is a complicated case. You got a patient IPF, a family meeting happens. Patient, the power of attorney who’s out of state. They confirm patients DNI. After a very long 1 hour consult, you’re exhausted. But right at the end, grandchildren arrive. They’re furious. There’s four of them. They’re yelling, saying that the patient, it’s not DNI. You’re leading questions. They’re fuming. Nursing is calling the security, and things are devolving. The patient’s now hyperventilating. At the end of this family meeting, there is racial discordance between the teams. And this happens months after George Floyd.

Gordon 41:03

So Gordon saved the easiest one for me.

Eric 41:08

Wait, wait, hold on. I gotta press the randomizer. Sorry.

Gordon 41:13

The hospital is also on fire. There’s a bomb in the building.

Alex 41:18

Oh, and our podcast is ending. We only have five minutes left.

Gordon 41:25

So, I mean, this is hard, right? You know, hearing the story made me think of a few things. You know, some of the simple things are, you know, setting up your meetings. So who are the important people who needs to be part of this? I know I’ve had a whole discussion and then realized that someone else needs to be part of it, and then you have to do it all over again. And so I wonder if a better setup would have made that thing go more smoothly altogether. I think that’s one thing. Sometimes if things are getting unsafe and it’s chaotic, you need to sort of step back and control that chaos and come back at a time where you can have a more productive discussion.

Eric 42:04

So kind of reset it again, not turn back the clock, but potentially set up another family meeting maybe a little bit farther in the future when maybe emotions have calmed down a little bit. Yeah.

Gordon 42:18

Anything Elise or holly you’d add to that?

Elise 42:20

Yeah.

Holly 42:20

When I’ve had people that are really upset, I mean, I think you have to first figure out, are you under direct threat? Just because we had another anger thing earlier. So I think being aware and sometimes people are just upset. It’s the fight part of fight flight. Freeze. Right. And so I try to sort of tell people I want to hear from you. I want you to be here, and I also need you to stop yelling because it’s actually disturbing, like, the care on the unit. And I want. I don’t want to have you. I want you to be able to be in the hospital and be with your loved one. So just sort of trying to align rather than you need to calm down or get out. Like, that’s not helpful. Right? Like, so I think saying, hey, I want you here.

And in order to do that, I need, like, let’s all just take a breath. Can I get you, can I get you some water or something? I’m happy to talk about what’s going on. And I think the challenge with this, too, when there’s family that comes in at a, like, who knows where is understanding whether or not they, the power of attorney actually wants them involved or not. Yeah, I think that’s actually a really important question. Sometimes yes, sometimes no. And your approach is going to be different depending on what happens there. So I’ve had families that all want to agree, and I’ve had people, like, they don’t get to say anything. They need to be out of this conversation.

Eric 43:31

And it’s hard, like, when you have, like, a VitalTalk roadmap, you’re in that roadmap, your hour long meeting. You just finished the end of that roadmap, and you have a family member just jumping at the very, very end of that roadmap. They don’t. They haven’t seen anything that happened beforehand.

Alex 43:46

Okay, I got a lightning round question. In your book, you talk about how there are sometimes when, so generally with most trainees, they. Things fall apart when they don’t acknowledge the emotion in the room, and then they can’t advance the conversation forward because that emotion hasn’t been brought out. And yet there are other times when the patient really is asking for information, and your attempt to name the emotion comes off poorly. What are your clues to you that this is a time to name the emotion versus this is a time to, like, give some factual information.

Eric 44:27

Randomizer. Holly.

Holly 44:31

Well, if I’m not sure, I try to name the emotion first and then see what they say, and then I will just talk about information. If they’re very clear, like, so what do we do now? And that’s calm, then I don’t. I’ll just try to go with the information. So I think if. If I’m at all questioning, I try a theory motion piece first and then move on.

Eric 44:51

And any other lightning round, I think.

Anne 44:54

No, that felt like a lightning question for me just now. I was like, I don’t know.

Eric 44:59

But we failed. We failed to stump the experts.

Alex 45:04

Well, we joked beforehand about how we were gonna like have numbers and like hold up a number because you see, the olympics just happened.

Holly 45:11

Oh, that’s right.

Eric 45:16

Alex was going to rate you.

Alex 45:18

I don’t know, but for some reason it was shot down (laughter).

Eric 45:22

We can still insert that in the podcast. Alex, post production.

Alex 45:29

It was all tense. That was terrific. Thank you so much.

Eric 45:33

Well, before we end, Alex, a little bit more of what’s the song title again?

Gordon 45:37

The more you say it, the less it means.

Alex 45:57

(singing)

Eric 46:43

That’s such a beautiful song. Who sings that again, Gordon?

Gordon 46:46

John Moreland, an artist that Holly introduced me to.

Eric 46:49

That’s wonderful. Well, Gordon, Holly, Elise, thank you for joining on this GeriPal podcast. You too, Anne.

Anne 46:54

Oh, thanks. Happy to have been able to learn from these experts over here today.

Eric 47:00

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

This episode is not CME eligible.