Category Archives: communication

#AtoZChallenge: A Mantra For Mistakes

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This month’s topic of discussion with my awesome third year medical students was dealing with medical Mistakes and adverse outcomes.  The students are required to write blog posts each month, answering a particular question related to the topic.  It is then my job to facilitate a small group discussion around their responses.  I struggle with it every month, because their writing brings up so many thoughts and responses in me, and yet I know I need to hold that back and focus on fostering their dialogue, instead.  Every meeting feeds my soul, and I always walk away rewarded.

The conversation this time started out more animated than usual, which made me very excited.  It seems they felt like the topic had been well-flogged by now, starting from videos during first year orientation warning that we all commit errors and to just expect it.  And though the topic might have seemed tiresome, their energy in discussing was the opposite.

We recounted some of the stories they told in their blog posts, in which they consistently expressed empathy for patients, families, and care teams when mistakes were made or patient care was compromised in some way.  I wanted to steer the discussion toward reconciliation.  We all know that mistakes will happen; doctors are human, after all.  But then again, our errors often result in grave consequences.  Further, grave consequences happen even when no errors are committed.  So how can we best prepare for, prevent, and manage these situations?

One of the Stud(ent)s eventually offered that patients just want to be seen and heard.  Ding-ding-ding-ding, flashing lights, confetti poppers, and The Price Is Right you-just-won-a-brand-new-car! music immediately vibrated in my head.  I wonder if they noticed, but I think I was completely emotionally hijacked—in a good way for me, not so sure for them.  It’s because this is what I have been thinking and saying for years now.  Whenever I’m in a room with a patient, or when I’m practicing and teaching motivational interviewing, my chief concern is whether or not the patient feels acknowledged.  Because nothing I say or do will be accepted if they don’t feel I’m fully present.  I immediately jumped on the idea and professed my own list of what patients (and really, all of us) want: To be seen, heard, understood, accepted, and loved.  Then, assuming we all agreed on these as relationship goals between patients and us, I asked the group to list what actions they could take to achieve them.  When standing at the doorway before a patient encounter, what can we remind ourselves to do to make patients feel these five things?  At this point I was definitely seized—I could not hold back, I would not let go—I had to drill the list over and over—our ‘discussion’ turned didactic for a while.  *sigh* I got a little carried away.

The students take turns documenting the central ideas from our sessions.  Here is what the appointed Stud Scribe wrote:

THE MANTRA:

  • SEEN
  • HEARD
  • UNDERSTOOD
  • ACCEPTED
  • LOVED

Strategies:

  • greet the patient
  • sit down
  • make eye contact
  • tell them what you are doing
  • no interrupting, gentle redirection
  • reflective listening
  • prioritize problem list (together)

 

I love that word, Mantra.  It’s a reminder—an anchor, or a beacon—that keeps us focused on our central values and goals.  It gives us stability and bearing when we find ourselves adrift.  I did not suggest that word to our transcriber, but I am grateful he chose it, as it was perfect for the ‘M’ post in this A to Z Challenge.  That list really is a Mantra, isn’t it?

We mentioned the idea that malpractice lawsuits occur less, when patients feel their doctors have communicated well and truly care, regardless of whether errors are committed.  And though our principal objective in medicine should not be simply to avoid lawsuits, I think the incidence of malpractice claims can serve as a kind of barometer for patient-physician communication and relationship.

I think the Mantra and behaviors the students outlined are simple and effective, and can be applied in all relationships.  Kudos to the group for tolerating my little outburst and staying engaged.  I sincerely hope they found it helpful in some way, and I will try to control myself better next time.  Maybe they can forgive my Mistake this time, if I successfully practiced the strategies in service of our Mantra. 🙂

 

#AtoZChallenge: Humbling and Honoring

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Though I was born in the United States, I grew up very Chinese.  Honor and respect for elders was one of the highest values in my family, as it is in the culture at large.  It would never occur to me to be on a first name basis with anyone in my parents’ or grandparents’ generation; they were all uncles, aunts, and surrogate grandparents.  Teachers, as well, always had a title.  In the presence of these zhang bei (senior generation), I would sit or stand up straight, pay attention, and never interrupt.  So it feels Humbling to find myself friends—equals!?—with so many of my elders—

Joe, my 7th grade math teacher,

Dawn, my 7th grade English teacher,

Kathy, Joe’s wife and the music director for the 8th grade play,

Barbara, my 9th grade geometry teacher and freshman volleyball coach,

Lisa and Jerry, my varsity volleyball coach and her husband, one of the football coaches,

Mary and Dan, my confirmation sponsors in college, pastoral associate and pediatrician, respectively, and

Keith, my clinic preceptor intern year.

I always wondered, what did they see in me, so young, naïve, and ignorant, that would make them want to know me as a friend?  Then about ten years ago I found myself befriending students and other ‘young people.’  I gradually realized the rewards of the exchange—new perspective, fresh ideas—connection across generations, cultures, experiences.  I felt a sense of mutual admiration and understanding, despite the age gap—an appreciation that bridged the separateness.

Somehow this reminds me of a morning I spent volunteering in a free clinic a few years ago.  As per usual, patients filled the waiting room and clinic workflow bore no resemblance to anything efficient or modern.  But the atmosphere pulsed with purpose and kindness.  First and second year medical students helped run this clinic, relishing the chance to hone their history taking and physical exam skills.  They saw the patients first, synthesized all relevant data, and presented a summary to one of a few attending physicians staffing the clinic that day.  After some discussion on pathophysiology and care plan, the attending led the team of students back to the exam room to finish the encounter.  If you have ever been a patient at a teaching hospital, it’s much like that, only much slower and often with profound technical barriers and almost no support.

That morning I walked in with my team to greet an elderly Pakistani man for follow up of his blood pressure and diabetes.  I knew he had been waiting a long time.  It was almost noon and he had not eaten all day, in preparation for fasting labs he knew he needed to have drawn.  Upon greeting him, I automatically apologized for the wait, put my hands together, and bowed slightly, while I thanked him for his patience.  I felt bad about the whole situation, and I wanted his pardon.  His face lit up and he immediately turned to the students and said something like, “See?  That is how you treat an old man!”  He was not angry or crotchety in any way.  He seemed honestly and happily surprised to be treated with Honor and respect—as if he suddenly felt seen and appreciated for who he was—a member of an older, wiser generation than all of us.

In Pakistan this gentleman had been a middle- to upper-class professional.  Here in the US his resources were drastically curtailed, such that he had no health insurance and depended on the free clinic to get treatment for his conditions.  I wonder if he was used to feeling like just another immigrant patient in a busy, understaffed clinic where there were few occasions for others to ask about and listen to his story.  Since I was a periodic volunteer, I had that chance.  I get to choose when I am willing to donate my time and energy to the free clinic—everything I do there is on my own terms.  The patients there have no such choices.  If they want care, they have to show up—early—on the day the clinic is open, regardless of what else is going on in their lives.  There are no appointments, and almost no continuity with providers.  It’s a completely different world from where I make my living, on the Gold Coast of Chicago.

I am Humbled by the opportunity to meet people from all walks of life.  Students arrive at medical school from diverse backgrounds.  Patients may hail from all corners of the world, many having come through experiences I can scarcely imagine.  It is my Honor to care for all of them, and I wish to maintain this perspective of respectful service.  I have those who support, teach, and guide me in life—older and younger.  So it is my privilege to give back—to offer my own knowledge, expertise, and maybe sometimes wisdom—and help make a positive difference in people’s lives.  I can’t remember exactly, but I think I said something to this effect to the medical students that day.

Physicians have power by default and design in the medical setting.  We can wield that power with more grace and efficacy when we remember Humility, and Honor our patients as whole, rather than broken or defective.  Be they students, friends, political opponents (yeah, stuck that in there), teachers, or patients, there is always something to learn from someone else’s perspective.  Cultivating the Humble and Honoring perspective, when I can muster it, makes all of my relationships infinitely richer.

#AtoZChallenge: Cursing, Curiosity, and Connection

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Welcome to my first attempt at the Blogging A to Z Challenge!  26 posts starting April 1, one for each letter of the alphabet (I get Sundays off).  I’m exploring meaningful words to apply to perceptions, attitudes, behaviors, and relationships. It’s a personal journey, part of my mission of self-assessment and development through writing.  Thank you for stopping by, and please feel free to comment! 🙂

 

Sometimes we get angry, and we need an outlet. But often we need to suppress, get through the situation with grace and smiles.  Sometimes the need for professionalism and control can turn into chronic repression, which can then lead to sudden and violent explosions, often on those we love most.  Psychology tells us that children (and adults, as well) do this because it’s safest to lose it among those who truly love us, and we know this subconsciously.  But the scars left on these relationships can be disfiguring.  It’s dysfunctional, and there is a solution:  Curse It All.

A colleague in mind-body medicine told me once that he recommended to his patients to tantrum. I was incredulous at first, but then I saw the light.  Venting, done appropriately, can be cathartic and liberating.  One day I became abruptly livid, I won’t tell you why, but suffice it to say it was over something small, that represented a chronic dysfunctional pattern in a longstanding relationship (Cryptic is also a word for this post!).  It occurred to me that this was the perfect opportunity to try the tantrum method.  I was home by myself, and I share no walls with my neighbors.  I took a pair of jeans, held them by the cuffs, and proceeded to pummel at the bed, all the while screaming expletives at the top of my lungs, stomping, and flailing wildly.  It took maybe 45 seconds, tops.  Afterward I felt a new calm, a lightness that had seemed impossible just minutes before.

Cursing, or swearing, has some interesting benefits. It can increase pain tolerance, strengthen bonds of solidarity, and help us convey conviction and passion.  So I endorse it, as long as we use these words strategically.  A follow up experiment to the pain tolerance study found that daily swearers, people habituated to the practice, had less analgesic benefit compared to occasional swearers.  We now also have access to adult coloring books, giving us a visual route to unload intense emotions.

sh-t storm coloring book cover

image from Google

But then there is more work to do. Sometimes it’s enough just to have vented, but I think we serve ourselves best when we can take some time and energy to evaluate.  The first step here is to get Curious.  I first learned this from my life coach.  In conflict, it’s so easy to only see our own point of view.  Emotional hijacking causes tunnel vision.  So once the emotions have dissipated by way of swearing and chopping bed with jeans, we can once again see and think clearly.  Curiosity asks open-ended questions:  What just happened here?  How did I get to this place?  Why do I fly off the handle like this whenever (fill in the blank)?  Advanced curiosity is where assumptions can also be challenged:  What story am I telling about the other person that causes me to react this way?  What other story can I tell that would help us both suffer less and get to mutual understanding?  These are well-established techniques in coaching and psychology.  I refer you to Rising Strong, Brené Brown’s newest book, in which she describes the process of using curiosity as the springboard for healing from adversity and living ‘wholeheartedly.’

 

Why is this important? Because humans live to be connected.  Anger can be blinding.  It arises first and so intensely when we have other, more distressing feelings underlying, such as sadness, shame, rejection, and guilt.  Anger serves to protect us from the pain of those emotions, and also keeps us from moving through them, healing them.  The repression-explosion cycle costs us energy and connection (to self and others), and ultimately keeps us from living truly, freely, joyful lives.  Cursing decompresses emotions, allowing us to open the door to relationships with curiosity.  Then, when we uncover the answers to the open-ended questions, we can start to reconnect with what we love about our partners, our children, our friends, our colleagues, and ourselves.

So go ahead, detonate those strategic f-bombs!  Find the padded space to rail and flail.  Then savor the possibilities of newfound clarity of mind and heart.  How much better could it get?  We never know, but it could be spectacular.