Monday, March 2, 2015

Atul Gawande's Gifts to Palliative Care and Rethinking How to Teach with Tact

by Lyle Fettig, MD

Let me tell you about a palliative care colleague.  His office is next to mine.  If both of our doors are open, I can hear his phone conversations.  Occasionally, I'll recognize when he's having a challenging conversation.  My ears especially perk up when the challenging conversation is with a physician colleague.  I cannot detect it by the volume, pitch, or tone of his voice.  He varies all of those features as he would in normal conversation even though the topic is more tense.

Here's what I notice as I listen:

  • He uses more open ended questions than usual, aiming to clarify the other doctor's position and concerns.
  • He uses more silence.  I can hear him patiently listening and never interrupting.
  • I hear statements of appreciation for the role the other physician is playing in the patient's care and/or the relationship the physician has with the patient.
  • When there are areas of disagreement, he makes clear statements of the intention which underlies his position.  The intentions are almost uniformly statements that represent interests of the patient.  
  • When he makes suggestions, he doesn't represent them as a matter of doctrine. 
I learn from listening to him.  He turns the conversation into a "learning conversation."  Does this approach always resolve the issue to his satisfaction?  No. But it frequently does.  And in the process, he's building relationships with colleagues who might otherwise be skeptical.  If we talk about these challenging conversations, he always seems to give the other person the benefit of the doubt regarding their intentions. He doesn't just take this approach with challenging colleagues though.  Whether it's our interdisciplinary team, our fellows, or a junior medical student, he consistently brings these ingredients.  

Humble and Curious

The first adjective which comes to mind when I think of Atul Gawande is eloquent.  The masterfully written Being Mortal would not have been possible without his eloquence.  After reading the book, watching the Frontline episode, and now hearing him at the AAHPM Annual Assembly, humble and curious also rise to the forefront. Gawande recognized he could improve his own skill in approaching conversations with seriously ill patients.  He sought out those who have expertise, namely his palliative care colleagues at Dana-Farber/Brigham and Women's Cancer Center.  And he exercised his curiosity to learn.

During the Q/A at his plenary session, Gawande was asked:
"Do you ever get ANGRY at physicians who torture their dying patients? Sure they weren't "trained" in communication, but they are human."
Gawande answered by reflecting on his own imperfection.  (People in glass houses shouldn't throw stones.)  He then framed the challenge that is before our field of hospice and palliative care:
"The most interesting problems are those in which good people do bad things."*
Those physicians who do this poorly ARE only human, after all.  Most (or should I say all?) grew up in a culture where death is the enemy, it's hard to talk about, and then went to medical schools where they were exposed to a hidden curriculum which reduced their capacity for empathy.  We may feel angry when things go poorly and we can't fix it, but it's also important to make sure we're pointing our finger at the right problems.  The "torturing physician" likely has inadequate skill or capacity to approach the situation fruitfully, and may lack the  systematic infrastructure to make up for the inadequacy.  We only see the end result of a culture and healthcare system not designed for proficiency in this area.  The physician isn't a bad person- more likely quite the opposite.

Commandment #8 of the Ten Commandments for Effective Consultation is "Teach with Tact."  When describing this commandment, the oft-cited original article mostly focuses on how to leave recommendations. The authors give solid advice about providing references of evidence to the primary physician in a timely manner. "The patient may quote the article to the primary physician....few physicians enjoy expanding their horizons in this matter."  Part of our humanity is the desire to always fulfill our physician role as expert, even when we aren't always the expert.

We can hope that other physicians will naturally follow Gawande's lead and use their capacity for humility and curiosity to learn from our field.  Make a list of those surgeons, oncologists, critical care specialists, hospitalists and others who exhibit these capacities.  You may be surprised how long the list already is.

What about those that don't exude humility and curiosity?  What about those times when we feel angry?

Bob Arnold provides the following wise advice:
"The learning point is how to listen respectfully, assume they know something about the patient, and be humble in my suggestions,” Arnold says. “We need to be as kind to our primary clients, the referring physicians, when they don’t do what we think they should, as we are toward patients and families who make different choices than we would. If I can ask myself why a smart, hard-working doctor would want to do things differently than I would, I can be a better advocate for the patient and help the doctor provide better care for that patient."  
We need to carefully consider how to teach with tact.  We need to skillfully teach with humility and curiosity, gently guiding rather than brashly imparting.   Remember what Chester Elton said during his Thursday plenary session as he quoted his father, "You be nice to everybody, because everybody is having a tough day."  Empathy isn't just for our patients.  Horizons won't expand through lambast and lecture.

My palliative care colleague probably sounds familiar to you.  You hopefully have colleagues who exhibit the same humility, curiosity, and equanimity.  And not just them.  You too.

Look for opportunities to combine your expertise in palliative care, your desire to help others do better and humility that you can always learn new ways to teach others tactfully.  My colleague recognizes this and has signed up for a VitalTalk Faculty Development course this spring.  I've done this in the past and highly recommend it.  The facilitation methods are grounded in humility and curiosity. Also, keep your eyes out for the work being done by Gawande, Susan Block, and others at Ariadne labs.  It's exciting stuff.

I recently taught a communication course with a group of cardiology fellows using VitalTalk facilitation methods.  One of the very skilled fellows in my group came up to me a the end of the course yearning for even more feedback than what she received throughout the two day course. 

Atul Gawande's eloquence may not be matched by many but he is not the only one who is humble and curious.  This brings me hope.  

HT to Patrick Clary for helping me get this quote right via his Tweet. 

Photo: The 2014 PHS Philadelphia Flower show courtesy of 

Lyle Fettig (@lfettig) is a palliative care doctor in Indianapolis where he lives with his wife and two boys, both who love Funky Bones at the IMA 100 Acre Park. He proudly declares that he is a member of the VitalTalk Community which he considers an alignment of interests rather than a conflict.

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