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- 1.Build a relationship
- 2.Open the discussion
- 3.Gather information
- 4.Understand the person’s perspective
- 5.Share information
- 6.Reach agreement on problems and plans
- 7.Provide closure
- 1.Build rapport by expressing empathy and respect, competence and expertise, honesty and openness, as well as commitment and dedication
- 2.Acknowledge uncertainty, validate concerns, and explain the processes in place to find answers
- 3.Be prepared to answer questions about safety and expectations moving forward.
With these principles in mind, let’s take a deeper dive into communication frameworks for having difficult conversations and giving bad news in the context of this pandemic.
A useful paradigm to keep in mind during these interactions is set forth by Harvard Law School Professors Douglas Stone, Bruce Patton, and Sheila Heen in their New York Times-bestselling book Difficult Conversations.
In studying a variety of conversations, they found:
An underlying structure to what’s going on, and understanding this structure, in itself, is a powerful first step in improving how we deal with these conversations. It turns out that no matter what the subject, our thoughts and feelings fall into the same three categories, or ‘conversations.’ And in each of these conversations we make predictable errors that distort our thoughts and feelings, and get us into trouble.
The three conversations can be summarized as:
1. The Facts Conversation. In discussions about COVID-19, this would encapsulate concepts like R0 or the anticipated impact of physical distancing on reducing transmission. This knowledge is critical for us as future physicians. Given our own biases as physicians-in-training (perhaps including, among other things, our personality types, coping styles, and our training), our go-to approach to uncertain or challenging situations is often to return to the facts. However, no matter how convincing the evidence, facts alone are not enough to fully connect with listeners.
Psychologist Jonathan Haidt describes this idea in his metaphor of the Elephant and the Rider. Although it may seem like the Rider, representing logic and reason, can control where the two end up, the Rider’s commands are worthless unless they’re directing the Elephant (representing our emotions). If they are in opposition, the Elephant always wins out.
2. The Feelings Conversation. More often than not, emotions are at the heart of difficult conversations and should not be excluded from the problem; if our partners’ feelings are negative or different from ours, we should not view them as barriers or as issues to resolve. Making space for and acknowledging emotions is critical to building a relationship that allows more meaningful connections.
The first step is to recognize those emotions; we can make that easier by anticipating them ahead of time. The exact emotions evoked in a given situation depend on how that situation relates to the values we hold most dear. Sometimes what sounds like a factual question is actually an expression of emotion. For example, “How can this be happening?” may not necessarily be a question about coronavirus epidemiology, but rather an expression of worry or fear.
3. The Identity Conversation. At the core of every difficult conversation is what this situation means to us. The authors explain: “We conduct an internal debate over whether this means we are competent or incompetent, a good person or bad, worthy of love or unlovable. What impact might it have on our self-image and self-esteem, our future, and our well-being?”
And all this cuts both ways: the conversation involves both your identity as well as your conversation partner’s. What does the outcome of the conversation mean to you? Taking stock of this ahead of time will prevent you from getting caught up and acting against your best judgment.
In short, focusing on facts without feelings will only make the conversation worse. To best anticipate your partner’s feelings, it helps to think about their identity and how the situation may relate to their most important values. The subsequent sections review specific communication techniques that have been proven to help clinicians provide facts about challenging situations in a way that also addresses underlying emotions.
It is equally important that you take stock of your own reactions in preparing for potentially difficult encounters with patients. Anticipating your own negative feelings may help you recognize these emotions and let them go to have more productive interactions. For example, you may find that the anxiety of patients who are not sick or are mildly ill evokes feelings of annoyance, and even anger when you are simultaneously caring for severely ill patients. These are perfectly normal reactions, but they will not lead to productive encounters. The important thing is to accept your feelings and try to let them go as you turn your attention to each particular patient.
Many conversations around the coronavirus pandemic will involve delivering difficult or serious news. Here, we can apply several frameworks to the conversations we have with patients, as well as in the community in a non-clinical setting.
SPIKES is a mnemonic developed by oncologists for delivering bad or serious news. The pandemic has obviously evoked a wide range of emotions, including denial, fear, and altruism, for which this framework is relevant.
REMAP is a mnemonic developed to guide Goals of Care discussions. As medical students, we may be asked to care for patients with COVID-19 or to talk with family members of these patients, where REMAP would be highly applicable. REMAP can also be used outside of clinical settings to guide challenging conversations when expectations between two parties do not align. Can you envision a scenario where you could apply the REMAP framework?
Regardless of the framework used, giving bad news is challenging for both the person delivering the news and the person receiving such news. Sometimes, a person receiving the news may react with anger, frustration, heightened anxiety, sadness, or another similarly intense emotion. Having a framework for your response in this moment can be helpful for demonstrating how much you care. The NURSE framework is one example; examples I provided below. Brainstorm 1-2 scenarios where you would use the NURSE framework in the context of COVID-19.