Coaching moment - The physician fears..."A patient who comes with a list of questions." A constructive reframing

An issue that arose today: “We learned to fear the patient who came to a visit with a list of questions.”

Why? We thought that this patient was excessively tuned into his symptoms. We thought we wouldn’t have time to handle his problems well. We thought his list of problems were not worth solving. We thought we could provide stellar care without knowing his concerns.

A constructive reframing: This patient prepared for the visit. This patient is less likely to raise a last minute, “doorknob moment,” concern. This patient is more prepared to take what we teach them, build on their fund of knowledge, and improve their self-care capacity, their ability to be a full partner in their care.

Picture, for example, the diabetic patient. The fund of knowledge that this patient can benefit from is enormous. Their ability to take in new knowledge is limited (See references to cognitive load theory in earlier blogposts) so we want each visit to potentially add to their knowledge and self-care skill. We want them to be thinking. We want them to be ready to absorb more. That is our leverage. Picture, for example, the “functional” patient. Have we thought about the colleague - the massage therapist, physical therapist, or psychologist - who might be capable (more capable than we are) of helping the patient move forward or are we writing that patient off? (Business people would describe the write-off as “thinly disguised contempt for the customer.” Carl Rogers would urge us to have “unconditional positive regard” for every individual we care for.

For specific information on efficient management of patients with multiple concerns (in our language, we call these patient “agendas,” a word that has no negative connotation, see Mauksch LB et al. Relationship, Communication, and Efficiency in the Medical Encounter; Creating a Clinical Model From a Literature Review. Arch Int Med 2008;168:1387-1395.)

"Wait...What??!!" moments - a bibliography

First a note - the articles I cite are not necessarily the definitive or signal articles on subjects in the “Wait…What??!!” blog notes. Rather, they are the gates that I have chosen to swing open for your entry. The bibliographies of these articles or a World of Science search can lead you to broader or more focused sources as you like. I hope this issue has piqued your interest!

Relationship-centered care. Beach, et al. Relationship-centered care; A Constructive Reframing. J Gen Intern Med 2006;21:S3-8. (This IS the seminal article!)

Cognitive load & Slowing down. Royce et al. Teaching Critical Thinking: A Case for Instruction in Cognitive Biases to Reduce diagnostic Errors and Improve Patient Safety. Acad Med 2019;94:187-194 and St-Martin et al. Teaching the Slowing-down Moments of Operative Judgment. Surg Clin N Am 2012;92:125-135.

Professional Identity. Chow, et al. A Conceptual Model for Understanding Academic Physicians’ Performances of Identity; findings From the University of Utah. Acad Med 2018;93:1539-1549.

Deliberate practice. Ericsson. Deliberate Practice and Acquisition of Expert Performance: A General Overview. Acad Emerg Med 2008;15:988-994.

Kindness. Hatem et al. The Educational Attributes and Responsibilities of Effective Medical Educators. Acad med 2011;86:474-480.

For a handy practical reference in dealing with lapses in professionalism, see the Table at page 258 and discussion in the chapter “When Things Go Wrong: The Challenge of Self-Regulation” in Levinson et al. Understanding Medical Professionalism. Lange/McGraw-Hill Education 2014.

Questions? Thoughts? Please drop me a note!

"Wait...What??!!" moments - Conclusion

Our starting facts were mild. But, the operative factors are the same as in more provocative cases, e.g., the student whose fund of knowledge seems inadequate, the scrub who hands the wrong instrument, or the patient who persistently behaves against his own best interest.

Regardless of our precise negative emotion, its volume, and the individuals involved, a set of rules apply, rules firmly supported by evidence. Our belief in the rules gives rise to our chosen actions.

Rule #1

Every health care relationship affects the patient, directly or indirectly.

Rule #2

Every interaction creates, strengthens, or changes the underlying relationship. (This is where each individual’s instincts or choices exert their power.)

Rule #3

Interactions with negative valence affect patient care and outcomes negatively, directly or at a distance.

Rule #4

Interactions with positive valence have additive positive effects on patient outcomes and are in themselves therapeutic.

Many nonverbal and verbal responses are available to us. Here, a colleague is oblivious and interrupts a sensitive moment. Yet, they are as devoted to the well-being of the patient and her family as we are. Lesser responsibility, yes; lesser motivation in choosing a healthcare career, no. We can support, educate, embarrass, or estrange our mission-driven colleague. We should be intentional in our goals and actions.

Recall what we know about working memory, this time from the perspective of our colleague. Our actions will focus or distract them. We will shape their interaction with the next patient or colleague. Our ability to take perspective from within that person determines whether we inhabit the rules and how skillfully we respond.

Back to our patient, her understanding, recall, and capacity to participate in their ongoing care hinges on the valence of how we interact with them, the interactions they witness in their transit through our spaces, and our interactions that condition the behaviors of others within our spheres. None of these is neutral.

The operative action is: kindness.

It is tempting to imagine that a harsh response will provoke the desired understanding. Harshness is blunt and imprecise. Our goal is clarity, precision, and improvement.

We might invite them to join us to witness the discussion, reinforcing the learning points in a post-discussion debrief. (“Ms. Patient, would it be all right for your nurse to hear our conversation? It might help you and him to know details we are discussing.” Alternatively, we might rise to face them and smile, “Would you please give us time to finish an important conversation?”

Respect is the norm we wish to reinforce. In the first response we are clear that the patient has control. It clarifies that the colleague is an observer, not a participant. In the second, it excuses them until the discussion is complete. Both types of responses provide space for a respectful recognition and apology from our colleague.

Deliberate practice, discussion with colleagues, or coaching can acquaint us with many options for verbal and nonverbal responses.

A personal commitment to the deliberate practice of open, respectful interactions, even if we are being corrective and, when required, punitive, results in improved personal skill and a therapeutic health care environment for all.

"Wait...What??!!" moments - Part 7

Professional Identity. It’s best to speak in positive terms but I’ll start this definition of professional identity from the breach. When you finish this, please drop me an email to disagree, challenge, amplify. Your comments will generate a future post.

Please take a look at this 1-minute youtube video of Marcus Welby, MD. https://www.youtube.com/watch?v=SJBg6EYrXGs then let’s talk.

This popular (1960s) television doctor expected patients to come to him on his terms. He expected them to follow orders or risk his contempt. He freely shared his judgment, sure that it was good medicine. When his patient asked a question, impatient, he got louder.

If you asked him to describe a physician exemplar, his answer might be that the state of medical knowledge - alone - was the measure of the doctor. Today, we value patient autonomy, shared decision making, the therapeutic relationship, knowing the issues and motivations of our patient, and knowing that it is what is in them that gives them the power to make favorable (but challenging) changes.

So, what is our ideal professional identity? The answer is a series of questions: who am I and who do I aim to be? What qualities in myself do I prize and what qualities would I like to develop or refine in order to be satisfied with my journey as a physician? Who we want to be influences how we interact. Reflection and practice are how we get there.

Step one is to accurately identify one’s own inner frame of reference, one’s moral center. I say “accurately” because humans can be hyper-self-critical or insufficiently self-critical. I say “moral center” because ours is a moral profession, grounded in the outward concern forthe well-being of others. Intelligence, optimism/pessimism, insight, bias. Our depth of understanding of the characteristics that have helped or hindered us, who we are, is the start.

Our core personal identity is seasoned by society’s expectations of us as physicians (e.g., competence, respect for patient autonomy, honesty,) society’s hopes (e.g., empathy, patience, kindness,) and what we have absorbed - often unconsciously - as we have risen step-by-responsible step within medical culture.

As students, knocking on the door, to trainees, seeking competence, through to full membership in the profession, we have had sentinel experiences. Our first dissection in the anatomy laboratory, our first patient death, the exceedingly brilliant and empathic attending who we would want to be like, and the attending who publicly mistreated students or trainees, all of these shaped us, helped delineate the “Who am I” question. Reflecting on them in light of who we aim to be is decisive of how we act. Our professionalism arises from our identity.

“Have I accorded this individual’s gift of his body appropriate reverence? “How did I bear witness with this dying patient and her family? “What made that attending so knowledgeable and so kind? What drove this attending to speak that way? Was the act tailored to achieve the goal? Do I want to emulate that conduct?”

Questions of professional (and, really, personal) identity occur to us in the moment but, with greater clarity, we ask these questions of ourselves over the years. We use these questions to actively shape our personae, our personal and professional identity and the environment in which we act. In that way, we assure that we succeed by our own high standards. What follows from knowing ourselves and, increasingly acting more and more in line with revealed values is a deeper capacity to hear our patients and to be better physicians, colleagues, and friends.

"Wait...What??!!" moments - Part 6

DELIBERATE PRACTICE

It seems like magic when we observe a good communicator. How did they know to do what they did and choose just the right words? We wish we could be like that. The wish is brief, then we get back to our to-do list. We often judge our own relative amateur status, then move on, never giving ourselves the credit that we could get ever closer to our desired characteristic. We don’t sustain the thought. We don’t nurture the thought. The deliberate practice of reflection is giving our actions and our goals a “good think”.

Ericsson said that to become expert at any skill, one needed to set goals, critically focus on specific weaknesses, and devote undivided attention to improvement. That’s why we spent time tying knots. When we committed to lifelong learning and when we bought into the concept of relationship-centered care, we accepted - at least intuitively - that every interaction has the power to support or erode the elements of our relationships with teams or with patients. When we commit to deliberate practice of communication, we commit to having honest, constructive self-evaluation and open, direct, constructive interactions. With time, those interactions become System I, intuitive, part of who we are.

When we take time to judge the edges of our communication competence, the sources of bias and error in our thinking, the situations that went well and those we’d like to have gone better, we can set ourselves up for success because we learn to see those critical moments before they arise (fatigue, multiple admissions, work with that one colleague…) or recognize them when they arise , skillfully navigating to calm waters. We Think.

Or, in today’s academic coinage, “reflect”. With discipline, we reflect in, on, and for action. Reflection on action is thinking about something that has happened and taking its lessons. Did it go well? If so, why? The assessment prepares one for the next time. Reflection for action is preparing for the next time using the lessons one has learned, for example, the next time one must give tell a patient unwelcome test results, respond to a surprising or intrusive act of another, or the next time one must evaluate an employee’s performance. The practice of reflection on, and for action, will aid us in reflecting in action. Reflection in action is when it counts; that’s what we are setting ourselves up for. What do we observe about the situation, the others involved, and ourselves in the moment. How have people responded in the moment? Has someone’s history, presentation, or actions caused an affective reaction in us? What adjustments should be made as we continue the interaction in order to get the best result from it? Commitment to reflection in, on, and for action in interpersonal communication is the critical part of our education that, in many cases, took a back seat to basic sciences. No offense intended (indeed, thanks!) to our basic science professors!

"Wait...What??!!" moments - Part 5

Who are we? Our professional ideals, termed Professional Identity, is a complex construct. Ideally, to name a few qualities, in the situation presented in our January 7 post, informing our patient and her family of her Stage IV malignancy, we are kind and supportive, our language is skilled, clear. When our friendly colleague enters and interrupts, ideally, we communicate with her in a way that shows we are committed and caring in all of our roles. We want to gain control to support our patient simultaneously being kind, skilled, and clear with our colleague.

Skilled communication is not genetic. We learn it over time, often without instruction or coaching except for those lessons our parents taught us years ago.

In medicine, we have a compelling origin: at our core, in deciding to go into medicine, we wanted our lives to stand for something good; we wanted to do positive, productive, constructive work for others. When we sift through the complexities of today’s healthcare environment, this core is our evergreen. We do not want to shed it no matter what urgency or emergency confronts us.

Any new situation gives rise to dual responses to varying degrees: emotional and cognitive. Our goal in the myriad contacts - relationships - we have each day in healthcare is for our cognitive response to determine our reactions, not our emotional response. The clearest example is the code. We expect ourselves to be in control and thinking, not emoting, because we know the lives depend on it. Likewise, how we relate to others sets the stage for their cognitive/emotional response in future happy, irritating, or emergent situations.

Gaining skill and control and staying kind and supportive requires deliberate practice of reflection. I won’t go further this week because this is a moment when some of us say, “Oh, this is touchy-feely.” It is not. It is our emotional responses - not well thought out - not in tune with our professional ideals - that are touchy-feely and get us in trouble. Our cognitive responses, aligned with our professional ideals, are what allow us the continual improvement in skill that we seek in all areas of practice.

I will stop right there this week. Please: Can you accept my earlier premise that our work is done in the context of myriad brief or deep, single or longitudinal relationships? Does it ring true to you that we often wish we knew the perfect response in the moment? Does Cognitive Load Theory make sense to you? If you accept these premises, let’s move forward together next week to consider deliberate practice of reflection. Following that, we will flesh out the concept of professional identity, then problem-solve our response to this or any Wait…What??!! or Slowing down moments.

"Wait...What??!!" moments - Part 4

Let's flesh out cognitive load theory one further step. As physicians, we customarily use System I thinking as we go through our days. System I thinking is thinking on automatic, using heuristics, relying on patterns we have experienced over and over again. It is effective and efficient in most situations. When presented with information that doesn’t fit - or situations that disturb us - like someone insensitively interrupting a life-altering conversation - we have to switch to System II thinking which is more effortful, more conscious, and slower. Poised to proceed as planned, we are suddenly jarred to a different place.

Surgical literature has a term for these moments: slowing down when you should. When a surgeon begins a routine procedure and encounters aberrant anatomy, she slows down to inspect and proceed carefully, respectful of the new perils the situation may present. An attending surgeon assesses a trainee as to whether he appreciates the new situation, slows down, studies, and proceeds with care. Like almost all operations, many human interactions in the course of our days, require us to smoothly switch between System I and System II thinking. Some slow down moments are foreseeable, some not.

Slowing down when we should, switching between System I and System II, is a sign of expertise, of practice. Using what we have framed so far, we will next focus on a deliberate practice that helps us build the types of responses we want to Wait…What??!! moments. It may sound like you don’t have time for this. Bear with me. When we relate this to your professional ideals, it will become System I, automatic, a part of who you are, even when sleep-deprived or interrupted.

"Wait...What??!! moments - Part 3

While your patient and her family are gobsmacked, you are constantly assessing whether they seem to understand or not, whether you can add more information, whether they need time, whether it is time to add support or silence, whether they are in a position to make choices. Your thoughts are more deliberate and deliberative than your patient’s and her family’s; you’ve been through this before.

When that new healthcare worker comes through the door, it’s not surprising that some bits and pieces of information the family have heard can be lost or misplaced because of the surprise and the jarring difference in mood, the new demand for attention that the well-intentioned person brought into the room. Their working memory has been overwhelmed; their cognitive load has been exceeded.

Cognitive Load Theory - yes, there’s a lot of research behind this - holds that working memory is limited while long-term memory is practically unlimited. We must work in order to digest information, put it into long-term memory, and free up working memory.

There are three types of load. Any time we encounter new information, there is mental energy we expend in order to process the information and memorize or develop a framework for thinking about it, termed “germane load.” The inherent difficulty of the information is termed “intrinsic load.” Finally, the way in which the information is presented - is it logical or haphazard? Is it in plain language? Is it coming in the midst of jarring interruptions? - is the “extraneous load.” For our patient and her family, the intrinsic load itself may exceed working memory because we may be talking about cell types, medication efficacy, treatment side effects, - things we integrated and developed heuristics for years ago. How can we be alert to whether others’ (or our own) cognitive loads are at capacity? How not to make them overflow and lose valuable content?

Once stored, we, our patients, and others involved in health care have characteristic ways of using information. Now that we have this framework, next session, we will take a bird’s eye view of ways we think about how we use our working or our long-term memory. With this background, in later posts, we will use what we have learned to decide our responses to Wait…What??!! moments.

"Wait...What??!!" moments - Part 2

What is happening to us and to the family in our scenario? Everyone in the room, meaning the physician and the family, is in a thinking, learning state. What is happening in our constant thinking/learning/teaching health care environment?

When we are thinking/learning/teaching, we are using working memory to understand the bits and bytes that we see/hear/say. Take the family: you are giving them a fair amount of information and the information is both complex and freighted with meaning for them. They likely are thinking “Why did this happen?” “What can be done?” “How long do I have?” “How will I explain this to others? Or not?” There are so many simultaneous thoughts and questions; I call this cognitive noise until the thoughts can be teased apart.

Working memory is limited. This family can integrate a limited number of new facts - actually single digit amounts - until they can place that information securely in long-term memory, freeing up more working memory so that they can react, figure out what questions to ask, deal with the embarrassment they may feel by being seen in a vulnerable state, deal with vulnerability while carrying a self-self-expectation of competence. Next post, we will look at the thoughts going through your mind, then begin the framework.

A mini-course: Effectively Handle “Wait…What??!!” moments

You are carefully sharing with your patient and her family the tissue diagnosis from her open biopsy the previous day. The news is not good. Your patient lies pale and weak in the bed having difficulty accepting the information while her husband appears stunned and tears are spilling down her daughter’s cheek. Suddenly, another healthcare worker barrels through the closed door without a knock, and cheerily, playfully introduces themself and communicates their agenda. You are momentarily stunned; let’s call it a “Wait…What??!!”-moment.

“Wait…what??!!”- moments happen frequently in busy clinical practice. This month, let’s look at what happens to us in Wait…What?!-moments. We will build a framework for thinking about these moments so that we can respond to them in the moment in ways that help and that feel positive to us. We want to respond consistent with our ideal professional identity.

In the following weeks, we will dissect what is happening with the individuals in this room. We will consider these individual reactions in a framework that will help us be intentional and constructive when we respond.

Please send an email if an aspect of what you read in coming weeks intrigues you or if I need to expand on what you see. My goal is to make this as useful as possible to you. Thank you for your attention.