Pandemic skills: Giving feedback successfully: I Like … I wish … What if … ?

Theater and acting: a life skill [icon from thenounproject.com]

During this pandemic, many of us have been stuck in front of our screens, like talking heads (Max Headroom, anyone?). If “sitting is the new smoking” (or perhaps not), then I’ve been “smoking” a lot.

Virtual meetings are draining, and I’m on them up to 8 hours a day, even busier now with all the EHR modifications, keeping up with policy changes, what Covid-testing is available, how we admit, treat, discharge, follow, track patients.

At the ends of long hours, long days, long weeks, our nerves are frayed.

I’ve observed that interactions between people have everything to do with the interpersonal skills of the individuals. Sometimes the conversation does NOT go well. Whether it is by email (worst for crucial conversations), by phone (slightly less bad), by online video meeting (slightly less bad) or in person (best, when possible), it is certainly worsened by the pandemic situation.

I’ve been taking a Story Skills Workshop (by Seth Godin and Bernadette Jiwa) that recently concluded. I have to say that I’ve learned quite a lot, and not what I was expecting to learn. I highly, highly recommend it. Seth and Bernadette offer a series of online lessons, released over time. There are about 6 expert coaches, and the instruction is to sign up for an interest group or ‘accountability group’. You’re given a story structure (the 5 C’s: Context, Catalyst, Complication, Change, Consequence) and then specific lessons to write and polish specific elements of your own story in this framework. The cool part is the instruction to ‘first write your own story, and then go comment on at least 5 others.’

  • I learned that it is possible, in an online-only course, to develop a sense of community and collegiality in a short 30 days.
  • I learned that it is crucial to be gentle in first contact with others online. For example, when giving feedback on others’ stories, DO NOT start right in with ‘why don’t you add more Emotion to that moment in your story?’ You’ll learn (as did I) that conversation either stops or becomes defensive. Remember that online conversations carry ZERO nonverbal: no Kind tone of voice, no Friendly posture. All you see are the words, and it is automatic to imagine them coming from a frowning critic with crossed arms, shaking his brutish head. [Pause for self-reflection amongst my blog-readers, as well as from myself…]
  • Instead, try something my theater-trained son taught me:

‘I like… I wish… What if …’

My highly emotionally intelligent son
  • Framing any response this way allows your recipient to hear something positive, then a neutrally posed concern, followed by a tentative suggestion. Having been on both sides of such a well-formed critique, I can say: it is EASY to write, doesn’t take longer, and on the receiving end FEELS COMPLETELY DIFFERENT. It FEELS like a close friend, reaching a hand over to pull you up to a higher step.
  • FOR EXAMPLE: Take one of my story-critiques of a co-participant in the story workshop, not done well on my part: “Why don’t you add more emotion to your story? It reads like a timeline, but nothing about what you felt, or how that impacted you.” I thought I was clever, to point out one of the main points of that week’s lesson. What I received was… no response. Hmm.
  • Rephrasing the reply using this framework, when I replied to a different participant’s story, sounded like this: “Hi, Joe! I liked your story, especially the unexpected part about running away from home at 16. I wish I could be there at that moment when you made the decision, everything boiling-over, and then a crucial moment. What if you paused in your story and told us what you were thinking and feeling right then? I would be riveted.” Guess what? We had a great online conversation after that, and he re-wrote his story, and I WAS RIVETED. Win-win.

CMIO’s take? Story telling: cool. Gentle, effective feedback: cooler. Don’t we all need to get better at this?

Improving Communication with Video Visits: now with shorter video!

17 minute walkthrough
1 hour seminar version with intro and Q/A

Thanks to my excellent colleagues at UCHealth, Echo Vogel, Hillary Duffy and Duane Pearson, co-conspirators to spend an hour on a Zoom webinar to review Patient Experiences with online Video Visits. We are all on a rapid learning curve. Come spend some time with us as we review what we’ve learned.

Here is a link to my original post on Video Visits, and on Patient Experience with Video Visits.

And here is my one page PDF on best practices (including communication strategies) with Video Visits.

CMIO’s take: What are YOU learning with Video Visits?

EHR v Covid-19. Nurses help families of ICU patients, from home

ICU rounds at PVH, photo credit: Lydia Baldwin

These are our healthcare heroes at work: From ICU rounds at Poudre Valley Hospital, part of UCHealth: Starting from the left standing we have Respiratory Therapy, Palliative Care PA, and Chaplain. Sitting from the left are RN, intensivist MD and Charge RN. In front of the intensivist (in green scrubs) is a telephone on the desk. The telephone is on ‘speaker’ and dialed in to a conference line. Also dialed in are: Pharmacist working remotely, Nurse Communication Liaison working remotely, Social Work.

So many great things going on here: Social distancing as much as practical (too much further and you can’t hear each other over the din of electronic alerts across the ICU), N95 masks (all day every day), reviewing data together from so many disciplines, discussing each patient in detail and taking immediate actions (placing orders, creating consensus on medical decisions, dividing tasks for rapid action).

In times of pandemic, the hospital follows infection prevention protocol and isolates very sick, very infectious patients. In this case, we have grouped and isolated all Covid-19 patients into a distinct unit, away from non-Covid patients. AND, in most cases, patients are not allowed to have visitors.

This is both good medical practice, and heartbreaking to families who cannot be present at a patient’s most desperate hour.

Out of this swirl of confusion, Julie Griffin, Nurse Manager of Care Management, thought: we have highly qualified nurses on-leave at home (orthopedic unit nurses with no post-op surgical patients; pregnant nurses for whom Covid infection would be particularly dangerous); how might they help share the burden of patient care with bedside nurses, and still minimize risk of contagion and exposure?

And so was born: Nurse Communication Liaison. Nurses from home, helping keep families connected, and reducing the burden on bedside nurses. We haven nurses helping with med/surg units as well as ICU’s. As described by ICU nurse Molly:

7AM: My day starts at 7: I review the Epic EHR chart from home for patients in the ICU. I read the notes from the nurses and the doctors overnight in our 12 bed unit. By the way, our unit has moved to double occupancy, and we’ve expanded to be a 23 bed unit. So much has changed, we’re so much busier.

8-10AM: I start receiving calls from family members and I give them updates on their loved ones, that I can, based on what I know. I am using Epic secure chat (a HIPAA-compliant text message service) to communicate with the ICU bedside nurses, social worker, respiratory therapy to get and give updates. I LOVE secure chat because it means the bedside nurse: who is gowned, gloved, doesn’t have to scrub out to answer another nuisance phone call interruption; they can catch up with chat-messages when there’s a break in the action.

10-11AM: Daily ICU rounds (picture above), where the team discusses every patient and I’m on the conference phone. It is a complete team with everyone pitching in.

11AM-430PM: We have designated ONE main contact family member for each ICU patient. We have found it can be overwhelming to have many family members calling each day for updates. I am so happy to be able to serve as the main contact for these family members and unburden our extremely busy bedside nurses to focus on their patients.

Some great unexpected moments:

Jamie: “Bedside nurses often spend 15 minutes on the phone with family. Multiply that by 5 patients and it becomes a big part of your day. We all wish we had more time to talk to families, but we’re often too busy caring for patients. I love helping connect with families and reassuring them.”

Jamie: “One gentleman was was not doing well. He was very quiet on the phone, and would never ask for anything. I spoke with his close friend at home, who noted that he was Jewish, and might appreciate a visit from a Rabbi or the Chaplain. I was able to arrange that.”

Jamie: “Being an ortho nurse on a medical unit, I was anxious at first. But communicating with the bedside nurses by secure chat and occasionally the phone, I found that even if I couldn’t answer families’ questions, I could always find out. Families are always so appreciative of the extra communication. I love this role. It is really awesome.”

Dawn: “The difference with this role is: There’s only the person on the phone. It is quiet at my home on my end. Normally when I’m at the bedside, I’m always trying to ‘wrap up the conversation’ with family: there are so many other things needing my attention. I can really feel good about being focused, connecting with family, and freeing up the bedside nurse to do their jobs.”

Dawn: “I was on the phone with the husband of a Covid patient. I noticed he would occasionally grunt, while we were talking about his wife. I had to ask him: ‘Are you okay?’ He told me he had had a fall, and had to pull on his pant-legs to go up the stairs. I recognized the signs of a major injury. It took some convincing, but I finally got him to call his doctor. Turns out the next day he was admitted and had emergency surgery himself.” As an ortho nurse, she was probably the perfect person to help.

Davida: “Sometimes you can remind the bedside nurse by secure chat: ‘his daughter would like to see his face today. Can you get the tablet in there for a Zoom visit?'”

Davida: “I feel really useful, being able to connect with PT, social work, bedside nurse all by non-interruptive but efficient Secure Chat, and then calling to make sure the family stays informed.”

Molly: “It is completely weird not to be an ICU bedside nurse right now. I think I will be better at charting in the future. Not being able to see the patient lets me understand what families want to know, that I rarely wrote down before: how do they look? are they following commands? can they squeeze? How scary this is for the family, and although it is a tricky role for us, it feels great to be helping.”

CMIO’s take? Thank you to our amazing UCHealth nurses: Lisa Claypool, Julie Griffin, Jamie Deschler, Davida Landgraf, Molly Carrell, Dawn Velandra for their experiences and stories.

Dr. CT Lin’s Covid-19 advice for patients. KOSI 101 and Mile Hi Magazine

In the link below, it is the interview from April 12, 2020.

https://kosi101.com/mile-high-magazine-public-affairs/

I had the pleasure of being interviewed by Mile Hi Magazine last week in regards to questions about how patients can cope with Covid-19 at home.

I responded to such questions as:

  • So many people contract but recover, is this what our body is designed to do?
  • Can people determine whether they have the virus without a test on symptoms alone?
  • When contracted, quarantine is the first step. What’s next in terms for two weeks – nutrition, special foods to eat to help the immune system fight?
  • Any special foods we should be eating now to be in top immune condition should we contract?
  • Any over-the-counter medicine to take for the fever or diarrhea?
  • Should people change out bed linen during the two-three weeks period?
  • Once fever breaks, is this a key sign that its over?
  • Should people exercise while body is fighting the infection?
  • Once over, should person we wait a couple days to ensure no symptoms return?
  • If Covid-19 is a flu strain, will it mutate into another strain as flu does each season for next winter?
  • Anything else you feel is pertinent to help people feel they can get over it if infected.

I made one particular point at the end of the interview. I shared our family’s strategy for coping with the anxiety and stress during this pandemic:

  1. Exercise every day
  2. Play or make music every day
  3. Limit yourself to 30 minutes of news or social media daily
  4. Three Good Things. At dinner each of us discusses THREE THINGS we are grateful for, today. INSTEAD of our natural tendency to focus on the negative, this exercise helps us reframe our day in a positive light.

CMIO’s take? I challenge all of us to do THREE GOOD THINGS with our loved ones at dinner every night.

Viral Misinformation vs Actual Virus (Medium.com)

https://medium.com/swlh/misinformation-goes-viral-1aad951e4492

This article “Misinformation Goes Viral” from the Medium is written by a PhD in Cellular and Molecular Medicine from Johns Hopkins School of Medicine, working now in Neurobiology at the University of Utah. Worth reading, and forwarding.

I agree with his well-written article and his sound reasoning, as a Professor of Medicine at the University of Colorado School of Medicine, the Chief Medical Information Officer at UCHealth, and a General Internal Medicine doctor seeing patients (now primarily via Telehealth!) in clinic.

His article has a number of main points with detailed explanations:

  • Americans did not have Covid 19 prior to Jan 2020
  • The virus is not man-made
  • Models are not deliberately misleading people
  • Covid is NOT the flu
  • Bill Gates is not a Bond villain
  • 5G cell towers do not spread Covid
  • Healthcare workers are not paid off by big pharma
  • Herd immunity must be achieved through vaccination, not unchecked infection

CMIO’s take? Let science and rational thought triumph in these difficult times.

EHR v Covid-19. Video Visits: How to Improve the Patient Experience

The new normal? No white coat during Video Visits! (c) CT Lin

Executive Summary: We have a global pandemic, daily policy changes, we work from home, have new video tech, and we are learning to communicate and build relationships in new ways. It is easy to forget that there may be a scared patient on the other end, counting on us. How might we improve the patient experience? Some ideas:

IDEA                                                    DETAILS

Secure Chat with your MAScrub your schedule together, days ahead for patients more appropriate for telehealth vs in-person visits, med rec, troubleshooting, visit focus
Arrange your room, selfSee tipsheet in Epic “Demonstrate Professionalism.“ How is: your room, your light, your clothing?
Eye Contactand, put a sticky note on PC cam to “LOOK HERE!”Arrange the camera at eye level if possible. For some, looking down = frowning? Eye contact on video visits is EVEN MORE important. “If I look away it is because I’m looking at information in your chart”. 
Avoid running lateIf you DO, inform your MA by Epic secure chat & they can inform patient
Greet the patientI like to raise my arms in surprise when we connect: every human connection now, is amazing. Maybe thank them for connecting with you. Ask if they’re in a safe private spot (eg: advise patient NOT to be driving!)
Talk, human to humanAsk: how are you coping (aside from medical concern)? Scared? Worried?  
Reflective ListeningEven more important now in this time of anxiety. You can reflect or say back Data, Ideas, Feelings, Values. It strengthens connection: for example  DATA: “It has been 5 days of worse symptoms?”  IDEAS: “so you think it might be gout?”  FEELINGS: “you’re worried about work? Hmm.”  VALUES: “so, what’s important to you is your family.”
PEARLSSome clinicians may have taken the Excellence in Communication course. The PEARLS acronym can also be helpful. Some examples:   Partnership: “We’ll get through this together.”  Empathy: (reflective listening, as above)  Apology: “I’m really sorry that happened.” “I’m sorry for my part in it.”  Respect: “You have worked really hard on this.”  Legitimization: “Anyone in your situation would feel that way.”  Support: “My team and I are here for you. We aren’t going anywhere.”
Physical Exam creativityTeach them to take a pulse “say beep when you feel it” and YOU can count. Patients may have a BP cuff, Pulse ox, flashlight, thermometer. 
Ask for help from familyOthers may help add to history or exam findings
They may ask about YOU as a human“How are YOU doctor? Are you staying safe?” So many surprising comments from patients worried about their doc. Thank them! 
Brief LIFE adviceDuring pandemic, consider: A) Limit news/social media to 30 min/day. B) Exercise daily. C) THREE GOOD THINGS exercise: proven to reduce depression, anxiety if done consistently “What 3 things are you grateful for today?” Can become a great family habit at dinner. 
AVS,
Open Notes
From My Health Connection, they can see your AVS (after visit summary) and your Progress note (called Clinical Note) to remind them of details of your visit. Maybe at end of visit, ask: “Sometimes I don’t explain myself well. Can you tell me what you’ve heard, so we’re on the same page?”
Reassurance and Hope“We’re going to get through this!” “Stay in touch with your loved ones.”
Ending the visitConsider: a handwave OR palms together, nod OR thumbs up OR “You Got This!” Forecast next steps or if your MA will call them after.
Secure chat with your MAHandoff any items after visit for continuity (referral, next visit, lab, etc)

Link to PDF of this document.

And, here is how our Medical Office looks now, deconstructed. One part is in my basement …

The deconstructed doctor’s office (c) CT Lin

And here’s Medical Assistant Becky, hard at work keeping both the patient and the doctor on track at her home. That virus has got no chance against us.

CMIO’s take? Hang in there! You Got This!

Thanks to all my colleagues for letting me “borrow” their ideas for this post.

“What Matters to You?” instead of “What’s the Matter with You?” -guest post, Heather Coats, PhD, APRN-BC

Is the integration of an individual’s narrative into the Electronic Health Record FEASIBLE to Improve Person-Centered Care? (CT Lin: I’m excited to welcome Guest Blogger: Heather Coats PhD)

Person-Centered Care, a buzz word to refocus our Western (US) healthcare system on the user of the system, the person who has a health need.  We as clinicians, use the word “patient” but they are a human, just like us the clinician. We all have past, present and future stories that make up “who we are” However, this whole self sometimes is seen as parts in our western medicine culture…the cancer patient in room 202, instead of Jon, the person…who is a grandpa, a dad, and businessman whose illness is impacting his ability to be all of these things.

In recent years, the shift in Western Medicine to incorporate the person’s experience has been moving upstream. The IHI (Institute for Health Improvement) “Person- and Family-Centered Care” domain–Putting the patient and the family at the heart of every decision and empowering them to be genuine partners in their care, goal is to develop “partnerships between clinicians and individuals where the values, needs, and preferences of the individual are honored; the best evidence is applied; and the shared goal is optimal functional health and quality of life”  http://www.ihi.org/Topics/PFCC/Pages/default.aspx

Since 2015, the IHI helped share the practice of asking the individual receiving health care:  a simple question…“What matters to you?” in addition to “What’s the matter?” This reframing of the clinician-person interaction orients the care being provided more to the whole person, to give a much different light to a plan of care that opens the door for opportunities to involve the person’s whole self. http://www.ihi.org/about/Documents/IHI_Timeline_2018.pdf.

Now, I do not want to diminish the physiological as an important component in the delivery of care. As clinicians, our expertise (life experiences, training) are grounded in knowledge of the physiological, but I would dare to ask, we are not the experts in the whole person who is sitting across from us. Second, when a person is facing an illness…cure of the illness may not be a reality, but healing of the self is still possible.

A recent NPR Morning Edition aired on their Morning Edition program (June 8, 2019): “Storytelling Helps Hospital Staff Discover the person within the Patient aired on June 8, 2019 on Morning Edition on National Public Radio.

https://www.npr.org/sections/health-shots/2019/06/08/729351842/storytelling-helps-hospital-staff-discover-the-person-within-the-patient

Person-centered narratives are one proposed way to have dedicated tools to shift to more person-centered care.  

An exemplar of this narrative shift, is the MyLife/MyStory program at the William S. Middleton Memorial Veterans Hospital in Madison, WI. https://www.youtube.com/watch?v=_Wy1aMXQCTk. This program has included over 2,000 person centered co-created narratives into the electronic health record since 2013. Their program has trained an additional 50 sites to implement programs similar to theirs. 

This is where my “story” comes in,  I had the pleasure to attend MyLife/MyStory  training back in 2015, which allowed me to think about this type of program could be implemented outside the VA, and have a program of research that tested person centered narratives interventions to improve communication between clinician and persons receiving healthcare. My NIH/NINR funded research focuses on the implementation of a person centered narrative intervention that co-creates a first person narrative that is approved by the person, then uploaded into the person’s electronic health record for their healthcare team to learn more about “What matters to them?”  The first phase of the program did prove to be feasible and acceptable by the individual- the person hospitalized for serious illness, their family, and their clinicians. Through this work, perhaps, there is just one more way to help shift Western healthcare to “truly” be person and family centered.

Heather Coats, PhD, APRN-BC
Assistant Professor of Research
Office of Research and Scholarship
University of Colorado, College of Nursing
Nurse Practitioner, University of Colorado Hospital Palliative Care Consult Service (PCCS), Department of Medicine, Division of General Internal Medicine, University of Colorado, School of Medicine

Giving Advice? How to do it right (NYTimes)

I love this: giving advice is often not giving advice.

This Zen statement is not about Zen.

Our physician informatics credo emphasizes relationships .

“We improve physician and team wellness and effectiveness by building extraordinary relationships and innovative tools.”

Extraordinary Relationships come from excellent communication.

Excellent communication comes from listening well.

Listening well comes from a position of empathic understanding.

Empathy is what we all crave. We should all learn the skills to exhibit empathy to others; this is the only way we might receive some in return. This article is a start.

Making slides for a talk? How to make them more memorable (advanced tips)

Powerpoint deck on how to give a good powerpoint talk linked here: https://www.dropbox.com/s/pmzloklxmmr5132/2019-0513%20How%20to%20give%20an%20effective%20presentation%20-%20advanced%20-%20CTLin.pptx?dl=0

I’ve been thinking about giving talks backed by powerpoints. Leaving aside the many talks on “Death by Powerpoint”, the lifeblood of the industry is on slides-man-ship in presenting new ideas to our own organization’s leadership, and at national meetings.

And then you see these lovely presentations by TED speakers who are inspiring, tell great stories, but DO NOT have to provide detailed scientific rigor underneath their high-flying narratives.

We, in informatics, have to contend with both parts of this conundrum: how to tell a compelling story well enough to capture imaginations, and more importantly, purse-strings, and yet back it with enough data and science to be compelling to our very picky bean-counters and scientists.

Further complicating this fact is that often, our powerpoints get distributed by email and have to STAND ALONE to convince others, sometimes. Therefore, the whole TED TALK, with IMAGES ONLY and NO DATA become useless in this context; now we have to figure out EITHER how to write an entire white paper (1-4 page brief that can be read quickly) to supplement any slides we give, or to modify these slides so that they CAN stand alone. Ideally, we can write a powerpoint slide deck that includes enough detail to satisfy data-hounds, and yet engaging enough, with a minimum of words, to create a compelling narrative.

CMIO’s take? Only you can judge if I’ve achieved my goals (see link). This is a summarization of more than a decade of my ‘doing it wrong’ and set of guiding principles that I’ve used to continually improve my own talks. I already presume that you know how to build a Powerpoint deck, and that you’ve read other articles on How-To in powerpoint, maybe Garr Reynolds’ Presentation Zen, or Dan Roam’s Show and Tell. There’s lots out there. But this is my take.

“Thinned-out interactions made empathy harder to access.” News: Scientific American

Scientific American, article by Jamil Zaki

https://www.scientificamerican.com/article/the-technology-of-kindness/https://www.scientificamerican.com/article/the-technology-of-kindness/

I’ve been saying this for awhile. Important communications are best had in-person. Meetings 1:1, meetings with groups IN PERSON. What percent of emotional communications occur through BODY LANGUAGE versus TONE OF VOICE versus THE ACTUAL WORDS?

  • Body Language: 50%
  • Tone of Voice: 40%
  • Actual Words: 10%

Sure, you can dispute the evidence, as some have, but I find the ratio to be about right. In my medical practice, and also in our Informatics work with the Electronic Health Record, that if we consider in-person conversations the gold standard, that telephone conversations (where the body language disappears) are a risky way to have an effective conversation and to diagnose the patient (leaving aside the inability to do a physical exam).

Worse yet, having patients use MyChart, or at UCHealth “My Health Connection” online patient portal, drives use to communicate using ACTUAL WORDS, without the benefit of Tone of Voice or of Body Language. And, as you can see from the percentages above, this allows much greater opportunity for misunderstanding. For example, can you imagine how the following statement might be misunderstood?

I’m sorry that your father passed away.

I’m “sorry” that your father passed away.

I’m sorry that YOUR father passed away.

I’M SORRY that your father passed away.

Tone of voice and body language USED TO BE how we communicated such difficult emotion. Now, we are only left with words. And, if we are NOT SKILLED with the wordcraft (as many of us are not, were never trained, some of us can’t even really manage a keyboard effectively), what chance do we have of being understood?

CMIO’s take? I love the quote above, will say it again.

Thinned out interactions make empathy harder to access.

Jamil Zaki

It is so true. What am I going to do about this? What are YOU going to do about this?