Category Archives: communication

What Makes You Think You Can Trust Me?

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My friend, we’ll call her Anna, recently had surgery on her pancreas, and she has generously given me permission to share her story. As soon as I heard she was going, I sat up straighter and paid attention. The pancreas is a sensitive organ, and not a common target for surgery, unlike the appendix or gallbladder. “Eat when you can, sleep when you can, and don’t mess with the pancreas,” they told us in med school.

Doctors discovered a growth on Anna’s pancreas in 2014, when abdominal imaging was done for something else. It was an ‘incidentaloma,’ as we commonly call such findings. She had no symptoms, and further tests showed no abnormalities of pancreas function. Everybody agreed to watch it with periodic CT scans. Fast forward one year, she still felt fine, but the mass was still there and appeared to be growing.

Cancer! What if it’s cancer? This ominous question looms over every unknown growth that we find in clinical practice. Pancreatic cancer is particularly scary, because there is no good screening test, and people usually don’t develop symptoms until the disease is incurable. Anna’s doctors started seriously considering surgery. The pancreas sits in the back of the upper abdomen, behind and outside of the abdominal cavity—not easily accessible. It serves both digestive and endocrine functions, and manipulating it can wreak havoc in multiple systems—hence the ‘don’t mess with it’ admonishment.

What to do? The tumor did not have typical cancerous characteristics on the scan; most likely it was benign. But what if it wasn’t? It was growing, albeit slowly. Would this be the rare chance to catch and cure a cancer, and really save a life? And if it wasn’t cancer, what was it? How long could we safely not know? Which would Anna and her doctors regret more: Operating now, risking complications from the procedure, only to find out it was unnecessary? Or continuing to watch, and realizing when finally forced to take it out, that it had already spread? If only there were accurate and reliable predictive tools—crystal balls and such. In their absence, we are left with incomplete information, and our own (in)tolerance for uncertainty and risk. The key for effective decision making lies in all parties’ self-awareness of the latter, and our ability to communicate it. This can be overwhelming, especially when the situation is complex.

Eventually Anna told her surgeon, “I don’t understand everything you’re telling me, but I trust you and I will do what you recommend.” She said he looked up and sat back abruptly, as if shocked by her declaration of trust and willingness to put the decision in his hands.

How would your doctor respond if you said this to him/her? Why would this surgeon be surprised at my friend’s statement? My patients have told me the same thing. What makes you think you can trust me? I think it’s based mainly on two things: Honesty and commitment.

 

I tell the truth.

I learned a long time ago that bullshitting my way through a patient encounter is completely pointless. If I don’t know the answer to a question I need to admit it, period, right there in real time. But just because I don’t know, doesn’t mean I can’t help. I know a lot. I can estimate. I can make a well-educated guess. I can articulate my rationale, explain that while I don’t know for sure, this is what I recommend based on the information in front of me, my past experience, and my personal biases (that last piece is critical). If I’m missing data, I can look it up. How often does an unknown pancreatic mass turn out to be cancer, in cases like this? If it’s very seldom, why do I recommend surgery? Maybe because I watched one too long once and I have always regretted it. This kind of experience will always influence my decision making; I’m kidding myself if I think it doesn’t. My patients have a right to know. It’s not weakness; it’s honesty. When you know my biases, you can decide for yourself how my judgment is influenced, and whether you’re at peace with it. When I own both my expertise and my limits, with humility and not shame, you are far more likely to trust me.

 

I will stand by you, whatever happens.

In order to trust me, you must also feel that I will not abandon you when things go badly. Because if we know each other long enough, something will always go wrong. You will have side effects from drugs. Treatments will not have the desired results. The worst thing I can say to you is, “Well, there’s nothing more I can do for you, goodbye.” There is always something I can do. I can’t cure your disease or bring your loved one back. I can’t make your depression go away. I cannot change your behaviors for you. But I can ask, “How can I help you suffer a little less?” Whether it’s referring you to a specialist or simply sitting with you for a while, my commitment to you, to our relationship, earns me your trust.

 

And, it’s a two-way street.

Here’s an interesting question: How can I trust you, to trust me? What do I need in order to feel comfortable both driving and navigating on this patient-physician road trip? It’s a huge responsibility, after all. I was honest about how well I know the geography and what I think we can expect on the way. I have made a commitment to be your travel partner, whatever the road and weather conditions. I need to know that you have relinquished the wheel and the GPS in an informed way, and that you will stay in the front of the bus to point out hazards and road signs. I need to know that you will not automatically blame me, or leave me, when we run over a nail and get a flat tire, or hit a deer that suddenly lopes across the road. We each need to take responsibility for our own part in getting to our destination.

Anna’s tumor was benign, and now she’s missing two-thirds of her pancreas. I imagine sometimes she wishes she had asked more questions, or decided to wait a little longer. But I think she does not regret her decision to trust the doctors. Her medical team is still intact and monitoring her appropriately. They may take turns again driving and navigating on her journey.

Trust is the cornerstone of any meaningful relationship. The patient-physician relationship is no exception. It takes time and presence to cultivate. These are big investments, and if we are willing to make them, the returns can literally save us.

 

 

Warrior Pride, and a Plea for Preserving Our Connections

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My heart feels unusually heavy this weekend. Two years ago today a beautiful young girl named Claire Davis lost her life to gun violence and her schoolmate’s rage.  It happened at my alma mater, Arapahoe High School, in Centennial, Colorado.  It had been almost two years to the day after the tragedy at Sandy Hook, and not 18 months since the horrible theater shooting just across town, in Aurora.  I remember thinking then, what is happening to us?  How does this kind of thing happen so often, and what kind of pain moves people to commit such violence, against others and then themselves?

I remember high school with great love and (Warrior) pride. Classes were challenging but not overwhelming.  Our volleyball team never had a winning season, but we had fun and learned teamwork.  Our speech team, on the other hand, won consistently, and competed at State every year. The excellence of our choir concerts and musicals rivaled professional companies I have seen (no help from me).  Some of my best friends are teachers I met at Arapahoe.  Their dedication to education, of others and themselves, even now in retirement, inspires me.  I had my core peer group (fellow nerds), but I was friendly with people in almost every social cluster.  I was one of maybe seven non-white students in my class of 462, but I never felt singled out or threatened.  Looking back, it was the relationships, as usual, that made my time at AHS special.

Today, I see so much more vitriol and violence in our world than even just 2013. Our relationships deteriorate faster than ever.  We oversimplify our political views to post on social media, looking for the most searing and aggressive words to make a terse point.  It’s as if we think 140 belligerent characters will make someone with an opposing view say, “Oh, of course, you’re right, I change my mind.”  We reply to others’ combative posts impulsively, defensively, and with hostility.  What good does this do anyone?  It certainly does not lead to any meaningful discourse or mutual understanding.  We write things on social media that we might never say in person, or at least not without thinking twice.  As a result, we feel indignant, offended, and angry.  We ‘unfriend’ one another on Facebook, narrowing our relations to the echo chamber of those who share our exact views, collectively deriding those who don’t.

There is no substitute for a face-to-face conversation, and the time and energy it takes to have one. It requires a certain degree of tolerance, and an unspoken contract of civility and courtesy.  We must choose carefully with whom we are willing to undertake such a venture.  And perhaps most importantly, we must be clear about our objective(s).  Do we really expect to change someone’s fundamentally held political or religious beliefs?  How realistic is that?  What other purpose, what other good, could possibly come from such conversations?

I propose that we seek these personal interactions to deepen and strengthen our relationships—our connections.  Social media, and probably media in general, constantly work to divide us.  We need to sit down with one another to reunite, find our common ground, and rediscover our shared humanity.  I believe this can only be done in person. It gives us a chance to practice our best skills in patience, curiosity, and withholding judgment. We must listen to understand, and not merely to reply or refute.   In the best of these conversations, we ask more questions and make fewer sweeping, generalized statements.  We avoid accusatory language, and say more, “Help me understand,” and, “What makes you think that?”  The key is to really mean it, though—we need to honestly seek to understand our counterpart’s point of view.

In the best cases, we each walk away feeling seen, heard, understood, and accepted—even loved—despite our differences. We pledge to continue the conversation, seeking always mutual understanding, bringing always mutual respect.  Let us start with our real friends.  Let us make it safe for those closest to us to express their views without fear of ridicule and contempt. Let us request the same of them, and practice openness and reflective listening in the harbor of established connection.  Emboldened with the courage to stand firm in our own beliefs while generously allowing others theirs, then maybe we can venture out into social media again, and serve to bring openness, generosity, and respect to our virtual relationships.

Maybe you feel confused—how did a post starting with the shooting at my high school end up as a plea for kindness on social media? I suppose blogging is, at times, an exercise in stream of consciousness.  Thank you for sticking with it to the end.  Your willingness to do so gives me hope that we can all move toward patience, generosity, and compassion.

The Marvel of Words

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November Gratitude Shorts, Day 6

Today I give thanks for the gifts of language. To have such a vast array of words, in so many languages from around the world, to express our ideas, thoughts, and feelings—how magnificent!

My friend tells me a story about an exasperating conversation with her boyfriend. I start to remember a similar encounter with my husband.  Before long we’re laughing together, saying, “Yes!  That’s exactly how I feel!”

I read a blog here on WordPress where the author has written my thoughts better than I ever could have. Articles I find on Facebook, my friends’ posts, books that I read or listen to—words are what connect us.  By the way, audiobooks are my new favorite thing, especially when read by the authors. The Art of Possibility, Start With Why, Bossypants, Leaders Eat Last, Rising Strong, Big Magic—it’s like driving to work or sipping coffee in the intimate company of these amazing writers, sharing their divine truths with just me.

There is almost always a precise expression for our experiences:  Queasy. Slothful.  Euphoric.  Hung over.  Resonant.  Cosmic.  Mind-blowing.  Oblivious.

Then there are figures of speech that perfectly capture a concept:

Peeing in the ocean.

Needle in a haystack.

Mess with the bull…

Bite thy tongue.

Own your shit. 

The only other language I know well is Mandarin, and I often find myself thinking of phrases that have no English equivalents. For instance, “shang nao jing” literally means “wound brain scripture.”  It’s used when we feel severely mentally taxed—but trust me, ‘mentally taxed’ just sounds lame in comparison, and does not capture the full meaning.  One of my favorites, “yuan fen,” loosely translates to “fate; destiny that ties people together.”  The Chinese is much more elegant and efficient.  Similarly, my slack foreign grasp of the meanings of “ohm” and “ubuntu” probably fall miserably short of their native speakers’ understanding.

But no matter, language bonds us. I don’t paint or play an instrument.  Though I appreciate art and music, they are not my media for relationship.  The most rewarding moments at work are always when I’m talking with my patients—hearing their stories, getting to know them, relating.  It’s probably no accident that I ended up in primary care, where every encounter carries such potential for rare connection—through words.  And I’m forever grateful for the privilege.