Some thoughts and tips on managing conversations that we make difficult.

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Talking the Talk:
Communications Skills in Clinical Medicine
Michael Aref, MD, PhD, FACP, FHM, FAAHPM, HMDC
Assistant Medical Director of Palliative Medicine
Carle Health

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DISCLOSURES

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Disclosures
• I’m not a communications expert and I have no formal
training in psychology, sociology, or any other -ology
that would give me expertise to comment on this
topic.
• I also do not have any relevant financial disclosures.
• These are my opinions on this topic and do not
necessarily reflect the opinions of my employers or
organization.

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OBJECTIVES

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Objectives
• Identify difficult conversations.
• Discuss strategies for managing difficult conversations.
• Discuss the importance of goals of care as a recurrent
theme in challenging clinical communication.
• Review the concepts of the care conference as a tool
for communication.

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IDENTIFYING DIFFICULT CONVERSATIONS

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How do we make conversation difficult?
• Thanksgiving Politics Discussion Error
– Expectations and opinions that aren’t shared.
• Assumption of Intent
– Nearly 50% of the populace disagrees with you politically
• Dividing Emotions
– Fear, anger, grief
• Avoidance of Conflict
– Rather than facing the core disagreement with others we invent
drama, rely on assumption, and expended more negative emotional
energy than simply handling the conflict would
http://exclusive.multibriefs.com/content/what-makes-a-difficult-conversation-difficult/business-management-services-risk-management

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Which one is the difficult one?

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Conversations
Physical

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Conversations
Political

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Conversations
Cerebral

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We are not selected for communications
• Our advancement in education is often based on
(standardized) test scores and grades.
• The next single most important piece of
communication you will likely make is either:
– Written in an application statement
– During interviews

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Until one day…
• You have to talk to a patient.
– And you will continue to have to communicate with patients.
• And your family
– “Yes, dear.”
• And your colleagues
– “Intern John, can we talk about that last patient?”
• And your administration
– “I know our service costs a million dollars per year but it’s the right
thing to do for patients”
• And your boss
– “I would like your approval to expand our service.”

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Communication Difficulty = (c  b  e)n (n ≥ 2)
Emotion
Behavior
Cognition
Cognition
Behavior
Emotion

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What’s missing?
Emotion
Behavior
Cognition
Trouble always comes bubbling through the one you don’t cover
Unmet needs
Lack of
knowledge
Lack of
empathy

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MANAGING DIFFICULT CONVERSATIONS

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Crucial Conversations

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Your Behavior
– Dan Millman

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Your Emotion: Fear
F.E.A.R.
• False Expectations Appearing Real
F.E.A.R.
• Failure Expected Action Required

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Is the conversation necessary?
• Higher and better use.
– Will the time spent improve the situation?
• Good. Enough. Now.
– Potential versus capacity
• Stop the conversation you already had.

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It’s not enough to hear, you must listen
“All right now, remember.
A war is mostly run. We
run whether we are
defending or attacking. If
you can’t run in a war
then it’s already over.”
—Shichiroji, Seven
Samurai
“All right now, remember.
A conversation is mostly
listening. We listen
whether we are observing
or speaking. If you can’t
listen in a conversation
then it’s already over.”
—Me

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Silence
Type of Silence Clinician Intent
Awkward Often without clear intention (uncertainty), but also may reflect distractedness
or hostility, often masked by the clinician.
Invitational Wanting to give the patient a moment (or longer) to think about or feel what is
happening, often after an empathic response. The clinician deliberately creates
a silence meant to convey empathy, allow a patient time to think or feel, or to
invite the patient into the conversation in some way.
Compassionate Recognizing a spontaneous moment (or longer) of silence that has emerged in
the conversation, often when the clinician and patient share a feeling or the
clinician is actively generating a sense of compassion for the patient. The
clinician must:
• Give attention
• Maintain stable focus
• Have clarity of perception
J Palliat Med. 2009 Dec;12(12):1113-7.

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GOALS OF CARE

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Cognition
– Spock

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Disease-Specific vs Goal-Oriented
Outcomes depend on perspective
N Engl J Med 2012; 366:777-779

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Speaking and Translating Caring
Goals of Care
• Identify what is important to and
priorities for the patient.
• Identify what they hope to
achieve by receiving care.
• Identify what they fear will
happen because of the disease.
• Life review and legacy building
are separate, equal, but not
independent parts of care.
Plan of Care
• Representation of the goals of care in the form
of
– Documentation
• Advanced Directive
• Living Will
• HCPOA
– Orders
• POLST
• Code Status
– Medications
• Starting and stopping
– Services
• Social Work
• Chaplaincy
• Hospice
• Home Health
National Committee for Quality Assurance: Goals to Care

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Unclear Goals = Unplannable Caring
Goals of Care
• “I’m going to beat this [disease]!”
• “My family won’t let me go to a nursing
home.”
• “We’re going to fight this!”
• “I’m going to get my miracle.”
Plan of Care
• These are general, usually not agreed
upon, often unrealistic, and do not
meet a timeline consistent with life
expectancy.
• The plan of care in these case is to
explore:
– “Tell me what [fighting, a miracle]
means to you.”
– “Help me understand more about this
by telling me how you feel about…”
And get a family meeting with all the key
partners in the patient’s care both family
and providers.
vitaltalk.org

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S.M.A.R.T. Goal
• Specific
– What does the patient mean to accomplish with this goal?
• Measurable
– What observable shows we are meeting the stated goal?
• Agreed Upon
– Are the patient, family, and provider all on the same page?
• Realistic
– Is this possible – physiologically, clinically, financially, humanly, etc.?
• Time-Bound
– When will this be observable?
General goals cannot be translated into a plan of care
Management Review. AMA FORUM. 70 (11): 35–36
National Committee for Quality Assurance: Goals to Care

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Clear Goals Lead to a Care Plan
Goals of Care
• “I want to be able to enjoy the
holidays with my family,
particularly my grandchildren.”
Plan of Care
• This is specific, measurable, can
be agreed upon, may be realistic,
and has a set time frame.
• Perhaps a chemotherapy
“holiday” or stopping
hemodialysis after the holidays.
Documenting code status and
likely involving some sort of home
nursing care, be it private duty,
home health, or hospice.

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CARE CONFERENCES

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Stages of Organizing a Care Conference
Denial – “I have already explained
everything to the patient and they
understand it all.”
Bargaining – “Let’s hold off on the family
meeting and wait for dermatology’s input.”
Anger – “I didn’t get into medicine
to…talk…to people!!!”
Sadness – “*sob* This is going to take
forever. *sniff*”
Acceptance – “I
will be there 15
minutes early!”

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The Bomb Squad

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V.A.L.U.E.
• Value family statements
• Acknowledge family emotions
• Listen to the family
• Understand the patient as a person
• Elicit family questions
Chest. 2008 Oct; 134(4): 835–843

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Care Conference Talking Map
Step What you can say
Gather for a pre-meeting “Let’s decide who will talk about what.”
“Could I propose a way to structure the meeting?”
“When the meeting ends, what would be a constructive outcome?”
Introduce everyone and the agenda “Let’s start with introductions. My name is [x], and my role is [y].”
“The purpose of this meeting is to talk about [z].”
“Is there anything that you would like to cover in addition?”
Explain what’s happening “Tell me what you took away from our last conversation.”
“Could I hear from everybody?”
“Here is the most important piece of news.”
Empathize with each person “I can see you are concerned about [a].”
“I am impressed that you have been here to support [patient’s name].”
Highlight the patient’s voice “If [patient’s name] could speak, what do you think she would say?”
“How would she talk about what is important to her?”
Plan the next steps together “Based on what we’ve talked about, could I make a recommendation?”
“I’d like to hear everyone’s thoughts about the plan.”
Reflect post-meeting “What did we learn?”
vitaltalk.org

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Care Conference Talking Map
Step What you say
Gather for a pre-
meeting
Let’s decide who will talk about what.
Could I propose a way to structure the meeting?
When the meeting ends, what would be a constructive outcome?
Introduce everyone
and elicit the agenda
Let’s start with introductions. My name is [x], and my role is [y].
The purpose of this meeting is to talk about [z].
Is there anything that you would like to cover in addition?
Explain what’s
happening
Tell me what you took away from our last conversation.
Could I hear from everybody?
Here is the most important piece of news…
Empathize with each
person
I can see you are concerned about [a].
I am impressed that you have been here to support [patient’s name].
Highlight the patient’s
voice
If [patient’s name] could speak, what do you think she would say?
How would she talk about what is important to her?
Plan the next steps
together
Based on what we’ve talked about, could I make a recommendation?
I’d like to hear everyone’s thoughts about the plan.
Reflect post-meeting What did we learn?
vitaltalk.org/guides/family-conference/

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Pre-Meeting
• If you do this right, someone is going to need a tissue.
• Where is the meeting taking place and is the patient
participating?
• Is the meeting place clear of distractions and can everyone
sit down?
• What are the desired outcomes?
• Who is going to moderate the meeting?
• What is each person’s clinical communication
responsibility?

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Care Conference Talking Map
Step What you say
Gather for a pre-
meeting
Let’s decide who will talk about what.
Could I propose a way to structure the meeting?
When the meeting ends, what would be a constructive outcome?
Introduce everyone
and elicit the agenda
Let’s start with introductions. My name is [x], and my role is [y].
The purpose of this meeting is to talk about [z].
Is there anything that you would like to cover in addition?
Explain what’s
happening
Tell me what you took away from our last conversation.
Could I hear from everybody?
Here is the most important piece of news…
Empathize with each
person
I can see you are concerned about [a].
I am impressed that you have been here to support [patient’s name].
Highlight the patient’s
voice
If [patient’s name] could speak, what do you think she would say?
How would she talk about what is important to her?
Plan the next steps
together
Based on what we’ve talked about, could I make a recommendation?
I’d like to hear everyone’s thoughts about the plan.
Reflect post-meeting What did we learn?
vitaltalk.org/guides/family-conference/

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An AIDET Application
• Acknowledge
– “Nice to meet you.”
– “Great to see you again.”
– Not: “You look great” (the patient might not feel great!)
• Introduce
– “Let’s go around the room so everyone knows who is who. My name is [x], and my role is
[y].
• Duration
– “We have about 30 minutes to talk today as a group. I would be happy to spend more time
with you afterward if needed.”
• Explanation
– “The purpose of this meeting is to talk about [z].”
• Thank You
– “Thank you all for taking the time to meet today.”

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Sitting in the Right Setting
Actual and patient perceived time of provider at
bedside
1.04 1.28
5.14
3.44
0
1
2
3
4
5
6
Sit Stand
Actual
Time (min)
Perceived
Time (min)
Percentage of positive and negative comments by
provider posture
95%
61%
5%
39%
0%
20%
40%
60%
80%
100%
Sit (n = 20) Stand (n = 18)
K.J. Swayden et al./ Patient Education and Counseling 86 (2012) 166–171

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Impact of Physician Sitting Versus Standing
• 69 patient randomized to watch one of two videos
in which physician was standing then sitting or
sitting than standing:
– 51% preferred the sitting physician
– 23% standing
– 26% no difference
J of Pain and Symp Management 2005; Vol 29 (5). 489-497

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Agenda Setting
Step What you say
Ask about your patient’s
main concerns for the visit
“What are the important questions you wanted answered today?”
“Is there anything you wanted to ask your physicians about?”
“Do you have anything to put on our agenda?”
“Anything else?” (often the most important issue is not first)
Explain your agenda “There are two things I wanted to make sure we talked about…”
Propose an agenda that
combines the patient’s and
your concerns
“How about if we talk about your question first, then cover my two things?”
or
“Given these things, what is most important for you to cover?”
Be prepared to negotiate.
“Ok, I understand that the most important issue for you today is ___.”
“I hear that you have a number of questions. Could we prioritize them so that we cover
the most important ones if we don’t have time to get through all of them?”
Ask for feedback “Do you feel like we’ve covered the agenda? How did we do?”
vitaltalk.org/guides/first-visit/

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Care Conference Talking Map
Step What you say
Gather for a pre-
meeting
Let’s decide who will talk about what.
Could I propose a way to structure the meeting?
When the meeting ends, what would be a constructive outcome?
Introduce everyone
and elicit the agenda
Let’s start with introductions. My name is [x], and my role is [y].
The purpose of this meeting is to talk about [z].
Is there anything that you would like to cover in addition?
Explain what’s
happening
Tell me what you took away from our last conversation.
Could I hear from everybody?
Here is the most important piece of news…
Empathize with each
person
I can see you are concerned about [a].
I am impressed that you have been here to support [patient’s name].
Highlight the patient’s
voice
If [patient’s name] could speak, what do you think she would say?
How would she talk about what is important to her?
Plan the next steps
together
Based on what we’ve talked about, could I make a recommendation?
I’d like to hear everyone’s thoughts about the plan.
Reflect post-meeting What did we learn?
vitaltalk.org/guides/family-conference/

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Teach-Back
A Priori A Posteriori
• Patient has seen a specialist or
been referred from another
physician.
• Minimum: Review documentation.
Ideally speak with other physician.
• “To make sure I provide you with
the best care, it helps me to
understand if you can tell me, in
your own words, what Dr. X, the
[specialty] doctor, explained to
you.”
• You are finishing your visit and
want to assess that the patient has
increased understanding of the
clinic situation.
• “We talked about a lot today and
sometimes I can get a little
technical. For my benefit, if you
were to explain the most important
points of today’s visit to your
family, what would you tell them?”
JBI Database System Rev Implement Rep. 2016 Jan;14(1):210-47

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Care Conference Talking Map
Step What you say
Gather for a pre-
meeting
Let’s decide who will talk about what.
Could I propose a way to structure the meeting?
When the meeting ends, what would be a constructive outcome?
Introduce everyone
and elicit the agenda
Let’s start with introductions. My name is [x], and my role is [y].
The purpose of this meeting is to talk about [z].
Is there anything that you would like to cover in addition?
Explain what’s
happening
Tell me what you took away from our last conversation.
Could I hear from everybody?
Here is the most important piece of news…
Empathize with each
person
I can see you are concerned about [a].
I am impressed that you have been here to support [patient’s name].
Highlight the patient’s
voice
If [patient’s name] could speak, what do you think she would say?
How would she talk about what is important to her?
Plan the next steps
together
Based on what we’ve talked about, could I make a recommendation?
I’d like to hear everyone’s thoughts about the plan.
Reflect post-meeting What did we learn?
vitaltalk.org/guides/family-conference/

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Emotion
– Maj General James Mattis, retired

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E.M.P.A.T.H.Y
• Eye contact
• Muscle of facial expression
• Posture
• Affect
• Tone of voice
• Hearing the whole patient
• Your response
Academic Medicine 2014;vol 89 (8): 1108-1112

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Articulating Empathy
Tool Example Notes
Naming (1) “It sounds/looks like you are scared / sad /
frustrated”
Naming the emotion will usually decrease the
intensity of emotion
Understanding (<5) “This helps me understand what you are
thinking”
Use to convey acknowledgement while avoiding
implications that you understand “everything”
Respecting (1-2) “I can see you have really been trying to follow
our instructions”
Give the patient/family credit for what they have
done, praise is a motivator
Supporting (1-2) “I will do my best to make sure you have what
you need”
Commit 100% of what you can commit to without
committing to things beyond your control
Exploring (∞) “Could you say more about what you mean
when you say that…”
Open-beginning statement with a focused end
www.vitaltalk.org/sites/default/files/quick-guides/NURSEforVitaltalkV1.0.pdf

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Four Basic Human Emotions
Happy
Sad
Scared Angry
J Exp Psychol Gen. 2016 Jun;145(6):708-30

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Care Conference Talking Map
Step What you say
Gather for a pre-
meeting
Let’s decide who will talk about what.
Could I propose a way to structure the meeting?
When the meeting ends, what would be a constructive outcome?
Introduce everyone
and elicit the agenda
Let’s start with introductions. My name is [x], and my role is [y].
The purpose of this meeting is to talk about [z].
Is there anything that you would like to cover in addition?
Explain what’s
happening
Tell me what you took away from our last conversation.
Could I hear from everybody?
Here is the most important piece of news…
Empathize with each
person
I can see you are concerned about [a].
I am impressed that you have been here to support [patient’s name].
Highlight the patient’s
voice
If [patient’s name] could speak, what do you think she would say?
How would she talk about what is important to her?
Plan the next steps
together
Based on what we’ve talked about, could I make a recommendation?
I’d like to hear everyone’s thoughts about the plan.
Reflect post-meeting What did we learn?
vitaltalk.org/guides/family-conference/

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Identify Commonly Missed Opportunities
• Listen and respond to family members
• Acknowledge and address family emotions
• Explore and focus on patient values and treatment
preferences
• Explain the principle of surrogate decision making to
the family – the goal of surrogate decision making is to
determine what the patient would want if the patient
were able to participate.
Chest. 2008 Oct; 134(4): 835–843

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Three-step Approach to Patient- and Family-
Centered Decision Making
Assess prognosis
and certainty of
prognosis
Assess family
preference for
role in decision-
making
Adapt
communication
strategy based
in patient and
family factors
and reassess
regularly
Shared
Decision
Making
Parentalism
“Doctor Decides”
“Do you want a
recommendation?”
Autonomy
“Family Decides”
“Do you want
some time to talk
with your family
about this?
Chest. 2008 Oct; 134(4): 835–843

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Care Conference Talking Map
Step What you say
Gather for a pre-
meeting
Let’s decide who will talk about what.
Could I propose a way to structure the meeting?
When the meeting ends, what would be a constructive outcome?
Introduce everyone
and elicit the agenda
Let’s start with introductions. My name is [x], and my role is [y].
The purpose of this meeting is to talk about [z].
Is there anything that you would like to cover in addition?
Explain what’s
happening
Tell me what you took away from our last conversation.
Could I hear from everybody?
Here is the most important piece of news…
Empathize with each
person
I can see you are concerned about [a].
I am impressed that you have been here to support [patient’s name].
Highlight the patient’s
voice
If [patient’s name] could speak, what do you think she would say?
How would she talk about what is important to her?
Plan the next steps
together
Based on what we’ve talked about, could I make a recommendation?
I’d like to hear everyone’s thoughts about the plan.
Reflect post-meeting What did we learn?
vitaltalk.org/guides/family-conference/

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Care Conference Talking Map
Step What you say
Gather for a pre-
meeting
Let’s decide who will talk about what.
Could I propose a way to structure the meeting?
When the meeting ends, what would be a constructive outcome?
Introduce everyone
and elicit the agenda
Let’s start with introductions. My name is [x], and my role is [y].
The purpose of this meeting is to talk about [z].
Is there anything that you would like to cover in addition?
Explain what’s
happening
Tell me what you took away from our last conversation.
Could I hear from everybody?
Here is the most important piece of news…
Empathize with each
person
I can see you are concerned about [a].
I am impressed that you have been here to support [patient’s name].
Highlight the patient’s
voice
If [patient’s name] could speak, what do you think she would say?
How would she talk about what is important to her?
Plan the next steps
together
Based on what we’ve talked about, could I make a recommendation?
I’d like to hear everyone’s thoughts about the plan.
Reflect post-meeting What did we learn?
vitaltalk.org/guides/family-conference/

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Reflect Post-Meeting
• Every care conference is an opportunity to improve
the patient-centered care for that patient.
• It is also a way for each of us to improve as
clinicians.
• If I can improve my practice with every interaction,
I am going to have a much more fulfilling career by
retaining what I do well and improving that which I
do not.

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THANK YOU