Image: This AI-generated image is Not Quite What I Wanted.
The images in this post were generated by Bing Chat Dall-E image generator to different versions of the prompt below:
Draw an impressionistic picture of a doctor and a patient; we can see the doctor’s face clearly. The upset patient is in the act of throwing with the right arm; a plastic water bottle has just struck the chest of the doctor. The doctor is surprised, the exam room is out of focus. The doctor now has to figure out how to repair this conversation.
You be judge of how
a) I am not yet a great prompt engineer
b) Bing does not yet understand staging and body postures and
c) generally, WTF?
Two decades ago, after just a few years spent seeing patients in a busy internal medicine practice in Sacramento, I had burned out. Sure, I was great at all the internal medicine stuff: diabetes, blood pressure, heart, lung, stomach problems and more. But, I was tired of the endless parade of vague symptoms and self-destructive behaviors (lack of exercise, alcohol- and cigarette-consumption) for which my skills were ineffective, and I often felt powerless.
In the late 1990’s, all the junior faculty at the University of Colorado were required to attend a four-hour communication workshop held by the Bayer Institute (now, the Institute for Healthcare Communication).
At this workshop, I found communication tools and an entirely new way of thinking about patient care, one that emphasized demonstrable caring, listening, and relationship-building. And I came away with not just theory, but practical words I could use myself.
I was excited enough that I spoke to my workshop instructor, Dr. Fred Platt after the course and asked if I could learn to teach the material as a way of understanding it better myself. To my surprise, he took me under his wing.
I traveled to West Haven, Connecticut to learn to be a facilitator of the physician-patient communications workshop. I was proud to receive this honor. I met about 30 other physicians sent by their respective organizations to learn how to teach the communications workshop. We were the chosen! We were the elite!
The next day at the training center, my puffy big head and I were not at all prepared for the intensity of the interview with my first “standardized patient” (an actor mimicking a patient scenario in a standardized way).
I was told “You are a surgeon going to see your first patient of the clinic morning.” I walked in, sat down, and said: “Good morning, Ms. Smith. How can I help you today?”
The patient screwed up her face and … and threw her plastic water bottle at my chest. She yelled: “You have f***ing ruined my life! And you DON’T EVEN CARE!”
My Best AI-generated Image: This is as close to my intent as I got (patient throwing water bottle at surprised doctor)
Eyes wide, I froze. After a few seconds of terrified silence, the coach sitting at my elbow signaled “time-out.”
“Maybe you’d like to pause here? What is going through your mind right now?”
What was going through my mind was: “OMG OMG OMG. I have to get out of here.”
Less correct image: jet-powered water bottle? No wonder the doc is surprised.
Eventually I calmed down, we debriefed the situation, and I decided I could try again.
It took several repeated attempts, and constant at-my-elbow coaching, to even start a conversation with her. Wow. Turns out, there is a LOT to be humble about, in our line of work!
In hindsight, it was a perfect example of “limbic hijacking.” The limbic system in the brain regulates emotion. Limbic hijacking describes a moment when emotions run so high that the heart-rate spikes and the reptilian “fight or flight” hindbrain takes over. In the moment she threw the water bottle at me, my poor pre-frontal cortex (PFC), where problem-solving and effective communication skills are stored, got shoved aside by my protective reptile brain, and went completely silent.
Me: ‘Hello? Pre-frontal cortex? I’m stuck! I need a rescue! What constructive words can I say here? Help!’
PFC: =petrified silence=
Hindbrain: ‘I know! Get up and run away!’
Me: ‘Great. A lot of help you both are.’
I was hijacked.
Less correct image: OK, what? That fist is also not quite right. I’d look away, disturbed, too.
Over the course of a week, we practiced many communication strategies, all the ways to build a connection between doctor and patient, until I could survive that hostile interaction, and even bring back tools for teaching others.
Excellent communication
is at the root of so many great things. One of the patient-interview frameworks we learned was E4: Engage, Empathize (of which, one crucial skill is reflective listening), Educate and Enlist. The E4 framework is a dramatic contrast to the way many physicians interview their patients, which could be called F2, or “Find It: Fix It.” In other words, focus on data. As a consequence, a physician following “F2” ends up ignoring ideas, feelings and values, which are crucial in establishing an effective therapeutic alliance between doctor and patient.
In the years since I took the course in West Haven, this material has become available in an online course through the Institute for Healthcare Communication and you can sign up for it here.
The E4 framework could be summed up in a quote from a physician colleague who told me:
“The more I listen, the more my patients learn.”
This beautiful, seemingly contradictory statement, has a lot to teach.
Less correct image: OK, this is not even close.
OBSERVATION 1: an example of reflective listening.
“Hey doc, those pills you prescribed didn’t work. I’m still gaining weight and my blood pressure is high. Maybe you should give me something that works for a meat-and-potatoes guy like me. I like my prime rib. And I hate when everyone lectures me about exercise. I just need to be able to see my daughter graduate.”
From the E4 framework, the second skill: empathize, includes reflective listening, which is active listening, non-verbal eye-contact and head-nodding, and saying back not only medical data, but also ideas, feelings and values, so that the patient can feel that their concerns are truly heard.
Less correct image: OK, what is even happening? Offering water to a combustible patient? Good idea on those gloves.
Potentially useful reflective statements:
“It sounds like your blood pressure is still high.” (Data)
“It sounds like you are a meat-and-potatoes guy.” (An idea)
“It sounds like you HATE getting the exercise lecture.” (A feeling)
“It sounds like you really want to be able to see your daughter’s graduation.” (A value)
In a medical interview, many things are happening; a patient is telling a story, a doctor is listening for medical clues. And now, the doctor also has to pay attention to these ideas and build a relationship. It seems like too much. However, with practice, it becomes easier.
Once you say these statements out loud, they become part of the conversation. The patient feels heard, and there is less of an argument over numbers and a resistance to behavior change. Instead, the two of you are having a conversation about the patient’s motivations, struggles and goals.
Before, I thought these statements were just “fluff” and not part of being a medical doctor. I ignored them and focused on symptoms and data like the blood pressure and weight.
Finally, I realized that patient care wasn’t just about book learning and medical knowledge, but also about caring for the human being across from me. Of course, I already knew that. But did I really?
After learning 10,000 new medical terms and studying dozens of textbooks and meeting thousands of patients over 11 years of training, this new framework was a revelation. The exam room interview was so much more complex and interesting than I had previously understood. It was not only a logical search for symptoms and signs of disease, but the more complicated task of building a human connection.
Huh!
With this revelation, I felt recharged! I could enjoy patient care again.
Image: I did not mean that the doctor would CATCH the water bottle…
LESSON 1: Reflective listening improves interviews.
Reflective listening works well with patients. Communications training makes an enormous difference in reducing physician/APP burnout AND ALSO increases patient satisfaction and adherence to therapy. What’s not to like?
Try this yourself: With patients, see if you can restrict yourself to speaking less than 50% of the time. Focus on reflective listening and asking to hear more. Then summarize the medical data, as well as the ideas, feelings, and values. This is difficult at first, but it is also increasingly rewarding for both patient and doctor or provider. Done well, it does not take more time.
Less correct image: Lego version of my story
OBSERVATION 2: Reflective listening improves meetings.
In the years since West Haven, I have found many other places to apply these communications skills. In fact, we move so fast in our worlds that in meetings, you regularly see people talking past each other, trying to get their own points across, and not listening.
Have you heard THESE phrases in meetings?
- “Like I said before …”
- “Again …”
- “I don’t see why …”
- “You don’t get it …”
Every one of these sentences illustrates a mindset of trying to convince others and NOT a mindset of listening or seeking first to understand.
There are terrific books on this subject:
- Getting to Yes
- Crucial Conversations
- Seven Habits of Highly Effective People
Here’s an idea:
In your next conversation or meeting, actively suppress your urge to jump in and make your own point. Instead, listen to truly understand, and then summarize before contributing to the conversation.
“Seek first to understand, then to be understood.” — Stephen Covey
In a meeting, I am often silent for the first part,
listening to all the voices, encouraging the less vocal participants to speak up, and hearing as many viewpoints as possible. I listen for participants talking past each other, repeating themselves, and not listening to others’ positions.
Importantly, participants rarely summarize the positions or statements of others, especially those with whom they disagree. Consequently, no one feels heard. As a result, people start repeating themselves.
Usually the meeting is about half over when I speak up and make a brief summary. I call this my “buckets” summary. I say something like: “I have heard three different threads in this discussion so far.”
Then I summarize: “Bucket 1 is …. Bucket 2 is … Bucket 3 is …”
If I can, I also try to give the discussion a new direction. “Can we agree that for Bucket 1, we don’t have the right participants, and also that this is less crucial, so we can defer? Then, for Bucket 2, we can grant that participant A has a useful idea that seems straightforward. I did not hear any disagreement. The big discussion, then, is Bucket 3, where … Do we agree on this as our priority? If so, may I propose we try X? What do we think of this?”
I find that after a statement like this, if all the parties feel like they were heard, then I did a good enough job listening and summarizing. Then, we can use the remaining minutes to focus on actual problem solving.
“If you want to go fast, go alone. If you want to go far, go together.” —African Proverb
Image: I don’t understand what is happening here, but it is so entertaining. The more you look, the less sense it makes. Is she cold? Why is that one finger on the bottle so long? Is that a bed or a desk? What happened to the bottom of the glass door? Who threw the bottle? What is he pointing at? Is it a magic trick?
LESSON 2: to improve meetings? Be a listener first.
Try this yourself: In meetings, see if you can listen hard enough to serve as a summarizer, an organizer and a clarifier. Or, listen for someone who does this well, and practice listening and summarizing like they do.
To borrow my colleague’s quote:
“The more I listen, the more effective my meetings are.”
Like this:
Like Loading...