Teaching Crucial Conversations: The Curse of Knowledge & the ASK Problem

4 09 2012

One of the most interesting conversations that I had recently was at the ABIM Foundation Summer Forum Open Space Sessions.  The ABIM Foundation Summer Forum is a summit of thought leaders and experts representing healthcare organizations, policymakers, patients, payers, doctors, and trainees who come together to tackle a major problem in healthcare.  The topic of this year’s forum was in keeping with the launch of the new ABIM Choosing Wisely Campaign and aptly named “Choosing Wisely in an Era of Limited Resources.”

The Forum has a unique format, employing a mix of routine panel discussions, but also “Open Space” conversations where participants actually drive the agenda, deciding what they want to work on.  One of the Open Space topics that I ended up joining was on how to train physicians to have crucial conversations with patients.   After forming this group, there were some immediate questions raised– why only physicians?  What about other members of the care team, including the patient?  Moreover, individuals in our group each had a different definition of what  “crucial conversations” were.  One clear theme was around end-of-life conversations with patients, but that was not the only one.  For example, how to talk to a patient who is asking for a medical test that is not indicated?

As I returned home, I reread some of the literature I have become acquainted with on why we (humans) don’t communicate as well as we should.  Using this framework, it’s worth considering why doctors and patients may not communicate as well as they should.  Drawing from the knowledge communication literature when an ‘expert’ is communicating to a ‘decision maker’, two distinct problems can arise:

  • Curse of Knowledge– The curse of knowledge, otherwise known as the paradox of expertise, represents the difficulty of experts to use commonplace jargon to communicate their ideas to those that are not experts.  Because experts tend to surround themselves with other experts, it can be very difficult for an expert not to use technical jargon when communicating with people who not experts.  This is easily evident in a variety of scenarios – most notably in the first few seconds of the trailer for the movie Contagion when doctors try to tell Matt Damon that his wife, played by index case Gwyneth Paltrow, is dead.  The doctor starts by saying “I am sorry…she failed to respond”.  On cue, Matt Damon responds, “OK can I go talk to her?” clearly missing the meaning of what the doctor has just tried to communicate.  Likewise, one of the patient advocates at our table shared the story of how she came to know she had cancer – “It’s malignant” …so she deduced from “Mal” and all the words that start with “mal” are bad (malice, malpractice…to name a few) so she thought “Mal … bad”.
  • ASK Problem – the ASK Problem stands for the Anomalous State of Knowledge.  This is a problem that arises when the decision maker does not have the knowledge that it takes to ask questions, since asking questions often relies on having intimate knowledge of the subject at hand.   This is particularly salient since we have major campaigns that often are directed at patients to “ask more questions” of their doctor.  However, it may be very hard for a nonexpert to ask a question of an expert if they don’t have a set of common knowledge to go on.  Asking questions is so difficult that our work shows its rare for even physicians to ask other physicians questions, and instead they opt for what is known as “back-channeling” or saying “Uh-huh” to indicate their agreement.  The only problem with this is that back-channeling is that it can be exhibited by demented patients so it is not necessarily a confirmation of comprehension or understanding.  To make matters worse, a recent study shows that patients may not ask questions for fear of being labeled “difficult”.

How can we get around these problems? Well, improving a conversation requires training on all sides. Patients can also be coached to take a more active role in their care. However, healthcare personnel also need to be prepared so that their newly empowered patients are not an unwelcome surprise. Physicians and other healthcare personnel need to be trained in how to speak to patients about difficult decisions in a sensitive way.   One model curriculum we can learn from has been developed by oncology fellowship directors and is called OncoTalk.  One of the key tenants is the principle of NURSE, which describes how to respond to patient emotions during complex decision-making.

  • Naming the emotion “It sounds like you are afraid of X”
  • Understanding the emotion  “I can understand the fear that goes along with X.”
  • Respecting  “You are asking the right questions…”
  • Supporting  “I am here to support you through this decision…”
  • Exploring  “What are you thinking about now?”

Of course, the age-old question is can you teach empathy? Well, according to one recent study, empathy wanes throughout medical school.   So we should, at the very least, try to at least preserve it.

Vineet Arora MD





Help Debunk A Medical Myth About Patients Leaving AMA

11 07 2011

This week at FutureDocs, we are working with our friend and colleague Glass Hospital as well as one of our medical students and a recent residency graduate to bring to light a medical myth about hospitalized patients who leave against medical advice.  Here is an excerpt from his post about our work which includes a new Squidoo page created by Gabe Schaefer MS3 on what to do when patients leave AMA and the video vignette below.  Let us know what you think and please share this with anyone who you think may benefit!

Excerpt from this week at GlassHospital:

Like Mikey, the Life cereal kid who died from mixing Pop Rocks and Coke, or the spider eggs in Bubble Yum that help make it so soft and chewy, Medicine has its share of urban legends.  Did you know, for example, that if you’re hospitalized and decide that you want to leave “Against Medical Advice” [AMA], that your insurer won’t pay for the hospitalization?

Bunk.

Apparently, this canard is pervasively believed amongst doctors and passed from generation to generation of trainees just like the nonsense about cute ol’ Mikey.  A few years ago, a medical student came to me with a case of moral distress. She had seen the doctor-in-training with whom she was working become upset at a patient for declining an invasive heart procedure.

Rather than reason with the patient and convince her that the test was indeed indicated and would be of greater benefit than possible harm, the resident doctor in question quickly informed the patient that if she refused the procedure and signed out AMA, she’d be financially responsible for the entire cost of the hospitalization, as her insurer would decline to pay.

This left our student wondering if this was true, and if there were ethical safeguards against this.   Her moral distress led to a research project that debunks this notion [we hope] once and for all.

I can’t give you the specifics (an article on our findings is under review at a medical journal) just yet, but GlassHospital and FutureDocs are happy to share with you the educational fruits of our findings to date. You can click over here to learn more in true interactive fashion, or if you prefer, watch only the cameo-encrusted video tour-de-force right below. [Who is that guy playing angry Mr. Smith? He looks familiar. And who, for heaven's sake, does his wardrobe?]

Let us know your thoughts! On the video, the website, the urban legend. What other medical urban legends would you like to see debunked?





Can We Trust Medical Trainees with Social Media and Other Digital Dilemmas

18 04 2011

Last weekend, I was on a panel for internal medicine residents at the American College of Physicians Council of Associates forum in San Diego.  I was invited by Erin Dunnigan and Baligh Yehia, the Co-Chairs of the Council, a position that I have also held earlier in my career.  The topic – was about the debate on social media use among medical trainees and whether it was professional.  Fortunately, I was lucky enough to do it with my rock star colleague Darilyn Moyer, the program director at Temple, who also moderated last years panel on Mean Girls in Medicine with me.

The Temple chief resident, Brooke Worster, started us off by asking the much debated anathema in medical education – what is professionalism – and if it is in the digital domain, it’s even harder to describe.  Then she proceeded to show some videos of medical students that you could say exercise some creativity – from the harmlessly funny to incredibly poor taste and ranging from schools such as UT Southwestern to my own alma mater Washington University in St. Louis.

The questions from the residents were spot on and here were some of the Q&A that followed:

Medical trainees are people too – shouldn’t they able to express themselves in ways  using colorful medical humor either in a show or their profile?

The objection is not for class shows and parodies – those have existed since the very first class medical show that took place at the University of Michigan and called the Galen’s Smoker (this year’s name- “Spleen Girls”).  The issue is more complicated with public consumption of materials never meant to be seen by a public audience.  Then, when a video is seen by a patient, an employer, or another interested stakeholder, alumni, philanthropists, those that donate their body to science (to name a few), the meaning of the video is not clear and those individuals often lose faith in the medical system.  There have been cases where patients have refused care by a residency trainee after seeing their Facebook profile with images that don’t seem suitable for their doctor.  So, while medical trainees deserve the right to blow off some steam and exercise creativity, it should not compromise their ability to see patients or work in the future.

Shouldn’t we just trust students and residents to police themselves on social media?

The answer here is that while most students are capable of policing themselves, a breach of professionalism on the internet is like a NEVER event – especially if it relates to patient information or trainee information that could result in harm.  So, opting for a putting out fires approach will not be effective and it’s important for medical educators to teach students and residents about responsible use of social media.  The good news is that the more one uses social media, the more likely they are to be able to draw that line in the sand.  Our research shows that superusers, or more frequent users, are more likely to oppose regulation but are also more likely to believe that they are responsible for portraying a professional image.  So, by teaching people to use it appropriately, we may actually prevent violations and breaches.

Should schools screen social media as part of its application process?

Interestingly, some students and faculty in the audience advocated for ‘second chances’ and redemption if a student had a inappropriate picture posted since Facebook privacy settings are initially confusing and a student could be misguided initially. But, let’s face it… screening applications for admission to medical school or residency is hard and takes time.  People are looking for ANY red flag to set downgrade your application compared to others.  Don’t give them a reason.  Medicine is not unlike any other industry in which candidates are interviewed to see if they can get the job done and also represent that organization appropriately.  If a video is posted that showcases a student in a tasteless parody with your school logo or name in the background, a hospital or residency is not going to want to take that risk with you.

What can medical schools do to protect themselves?

Well, for starters, schools can have a social media policy that highlight that do’s and don’ts in this area.  Unfortunately, in a recent study by @kind4kids and @MotherinMedicine, most schools do not so we have room for improvement.   The second thing is that schools can also deliver education, not only on the negatives – or how NOT to use social media, but they can also encourage and role model proper use of social media through disseminating course materials, student press, recruitment and admissions, or communicating with their students.  A recent post on a new student blog actually has a Poll this week asking students if they would want to receive information via social media and the majority say yes.

What can students do to ensure that their digital image is safe?

This question actually came from a student that has the same problem as me – a person with another name who happens to be garnering attention for the wrong reasons – in my case, it’s someone with my same name who is an ophthalmologist and has been accused of blinding patients and has many negative patient testimonials.  So, what can I do – well I initially started on LinkedIn to try to distinguish myself from this person and I also took control of my own digital footprint using a Google Profile to highlight who I am and the links on the web that I want people to see.  (You’ll notice my Facebook profile is NOT on my Google Profile).

The same old adage about Vegas applies here- whatever happens on social media stays on social media.  Therefore, just like the national dialogue on health information technology, its important for medical educators and trainees to engage in a constructive dialogue and establish policies that both set standards and teach others how to meaningfully use social media.

–Vineet Arora, MD








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