The Hard Conversations


NaBloPoMo 2018:  What I’m Learning

Life is about learning.  Learning requires acknowledging lack of skill, knowledge, understanding, or all three and more.  Boundaries, curiosity and non-judgment make it so much easier; too bad we tend to lose these natural traits (or they are trained out of us) early in life.  Then we have to relearn them as skills.  What happens when we reacquire boundaries, curiosity and non-judgment?  We get much better at having the hard conversations.  What makes conversations hard?  Not sure?  Just think of the conversations we avoid.  What are we actually avoiding?

I resist apologizing when I don’t want to admit that I misunderstood, that I made wrong assumptions that led to behaviors that hurt people, that I was not my best self.  I worry that people will think less of me and not trust me, not include me in the future.

I avoid giving negative feedback because I don’t know how the other person will take it.  Will they crumble in a heap of self-flagellating despair?  Will they lash out and attack me, verbally or physically, threatening my safety?  Will they disparage me to others, try to split our colleagues between us, sow discord and undermine our culture?  I worry that I will lose control of the situation.

We resist conversations about politics, religion, and issues like abortion because they can escalate in a nanosecond, filled with emotional tumult.  These are precisely the exchanges during which we blow past all of our boundaries for civility, language, tone of voice, and rhetoric.  We lose all interest in understanding what the other person thinks or, more importantly, how they feel.  We stop relating.  We judge everything out of their mouths as oppositional, ignorant, and unworthy.  We worry that we will lose our status, self-efficacy, agency, or our friends.

* * *

My friend Earnestine * has migraines.  Over the years she has worked out their patterns: timing, location, aura, duration, and triggers.  She hydrates, protects her sleep, and, most importantly, manages her stress with vigilance.  This way she generally avoids medications and keeps her symptoms under good control.  Recently she got caught in an unavoidably stressful situation with family.  A migraine hit her like a Mack truck out of nowhere.  She could barely walk, stumbling around, hanging onto walls and railings.  Her speech may have been slurred.  Thankfully she was able to escape to a friend’s house.  Her childhood friend, also a sufferer of headaches, offered her a handful of pills—her own prescription medications.  Earnestine struggled for the right words, and not just because her head was splitting.  If she refused, would she offend her friend, who has just rescued her from serious family chaos?  Would she trigger indignation, anger, resentment, rejection?  E found her personal values and boundaries tested, unexpectedly.  She felt ambivalent, as the core values of connection with a friend and right use of substances clashed.  She desperately desired relief from her pain, and she also needed to set an example for her boys, who were watching her response—what would she want them to do if one of their friends offered them ‘relief’?  Somehow through the fog, she found a way to acknowledge her friend’s generosity, and also explain that she was not comfortable taking someone else’s prescription medication.  She maintained her boundaries and stayed curious to monitor her friend’s and her boys’ responses.  Since that time, she continues to hold her friend in non-judgment, understanding that although she would not ever do the same, her friend’s intentions were loving.

I tell this story because I see it as a perfect example of boundaries, curiosity, and non-judgment in action:  Holding space for one’s own needs while attending to the needs of others and our relationship with them (both her friend and her sons).  Earnestine practices honoring her boundaries, which can, in some ways, be equated with her core values.  When they are challenged, she can stay in curiosity and explore the feelings that get triggered. She can withhold judgment on the feelings and simply experience them in the present moment, asking what they are trying to tell her.

This combination of boundaries, curiosity, and non-judgment, practiced regularly in small, everyday things, prepares us to face the harder situations and conversations with greater confidence.  We can trust ourselves, even if we don’t walk into any given situation knowing the right answer, to find it when we need it.  On the other side, these skills help us look back with fewer regrets, because we brought our best selves at the time.

I have learned to recognize opportunities to practice these skills, and now I resist apologizing, giving negative feedback, and talking about politics a lot less.  In fact, these are precisely the scenarios in which I can really test and hone my skills—sharpen them and improve my relational dexterity.  I almost look forward to them—sometimes.

It’s all a continuous journey, is it not?  Will we always face our fears with heroic courage and the perfect words and behaviors?  Hell. No.  AND, every day is a new chance to try.  What hard conversation might we come closer to doing better tomorrow?

*Not her real name

What Makes You Think You Can Trust Me?


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.