- Email: [email protected]
The Standoff
SEE ONE, DO ONE, WRITE ONE
The Standoff Stephen D. Brown, MD For 16 years, I have kept taped to my desk a passage taken from a book written by an inspiring young woman with cystic fibrosis. Published posthumously, the book details the complex interplay of her medical, social, and emotional life [1]. In one chapter, she writes: “Saw good ol’ dr. brown (he’s done all of my interventional radiology stuff) in the cafeteria and he stopped by to hear the latest news. I like docs that keep up even when they aren’t currently involved.” I had met the patient 2 years previously, in 2001, early in my career as a pediatric interventional radiologist. One evening, she developed severe hemoptysis requiring emergent bronchial artery embolization. Her mother, who as a parent probably had as much experience in hospitals as I had as a physician, insisted on remaining in the interventional suite during the procedure. This was an unusual and unnerving request. We sometimes invited parents in for simple procedures, but never for complex procedures that required sedation in fragile patients. On one level, I believed that the patient’s interests would not be well served by granting her mother’s request. Her presence in the room would add unfair stress to the team and an unknown variable to an already unstable clinical situation. I could not predict how events might unfold if an adverse event occurred. These seemed reasonable objections. But, there was another level as well. Even though I had excellent training, I had done few embolizations on my own, and I
remained insecure about my skills. I was afraid that she would see my inexperience, or worse, incompetence. Apprehensive and stressed, I, like she, was anxious to exert control. It was a classic difficult conversation. How much of my rationale should I explain? How could I discuss my concerns without offending her, or worse, frightening her more than she might already have been? Now, 16 years later, I might counsel my own trainees to sit with the mother to talk gently about her concerns and to listen empathetically first before expressing their own concerns. I might urge my trainees to validate the mother’s disquiet and to admit to similar feelings if their own loved ones were in comparable circumstances. We might explore together whether to acknowledge openly to her the stress already in the room, the need to maximize variables that were controllable, and the desire to not introduce unknowns into an already tenuous circumstance. Ultimately, I might advise my trainees to create a comfortable space where the mother could voice her concerns freely, and where they could hopefully establish a mutual respect, rapport, and trust. I might even later create a vignette around this conversation that my trainees could re-enact with actors in a controlled simulated environment with opportunities for constructive feedback from actors, mentors, and peers. However, at the time of this interaction, no such opportunities existed for training in communication
ª 2016 Published by Elsevier Inc. on behalf of American College of Radiology 1546-1440/17/$36.00 n http://dx.doi.org/10.1016/j.jacr.2016.12.022
skills. I found myself in an exceptionally difficult conversation with nothing but observation and previous personal experience from which to prepare. After a tense exchange, I declined her request, and she accepted the decision. The procedure went well, as it should have given the meticulous technical training my team and I had (despite my insecurity). What about the communication? Had I done that well? Certainly my training for speaking to the patient and parent stood in stark comparison to the training I had for performing the procedure itself. The situation transported me back 10 years previously, when, as a junior neurosurgery resident in California, I found myself leading a team meeting with a family whose son had been neurologically devastated after a motor vehicle accident. The time had come to consider withdrawing mechanical ventilation. I was the only physician in the room. The other participants included the patient’s nurse, a priest, and a Spanish translator. The meeting accomplished its objective: the family agreed to discontinue life support. Afterward, I had a burning need to know how I had done. What could I have said better or differently? I asked the priest if I had done a good job. “Yeah, fine,” he answered. He walked quickly away, leaving me uneasy. After 25 years, I still recall that meeting and wonder if the family remembers that conversation. My enduring sense is that they deserved better, and so did I.
1
When formal opportunities to learn relational proficiencies are unavailable and communication skills are not taught, learning still occurs, sometimes actively and sometimes passively. The processing is commonly subconscious, but the lessons penetrate nonetheless. Past conversations that we witness between physicians and patients during our early training experiences lay dormant until they surface in the present. Once, as a medical student back in 1988, I passed a patient’s room and overheard a neurology resident yelling to an elderly stroke patient: “YOU’VE GOT BLOOD IN YOUR BRAIN.” “What a buffoon,” I thought to myself as I walked by. “What an insensitive dork!” Three years later, as a neurosurgery resident, I heard myself repeating these same words when called to the emergency room one night to evaluate a man who had suffered a pontine hemorrhage. His wife and I stood across from him as he lay unconscious and intubated on the gurney. She was noticeably pregnant. “He’s got blood in his brain,” I explained. It was all I could think of. About 2 years later, I walked into a café where a woman and small child were seated. She recognized me and came over. It was the wife of the patient with the pontine hemorrhage. He had survived after a prolonged hospitalization. She told me that my words at that first encounter were her most vivid memory of the entire experience: “He’s got blood in his brain.” Such is the power of informal relational learning in medicine that a conversation overheard outside a hospital room in Philadelphia in 1988 would hold such enduring impact for a completely unrelated individual in Palo Alto in
1993. Once again, I was struck with an overwhelming sense: the patient’s wife deserved better, and so did I. By the time of that encounter in the café, I had left neurosurgery with plans to begin a diagnostic radiology residency in Massachusetts. The specialties were as different as the Pacific and Atlantic Oceans, with one notable exception: The only opportunities to learn about communicating with patients were random observation and real-time practice. As I rotated through ultrasound, fluoroscopy, interventional radiology, pediatric radiology, and obstetric imaging, I realized that such opportunities were abundant and that the exchanges could be intense: informing a woman of a miscarriage, performing a palliative paracentesis on a woman with advanced ovarian cancer, obtaining consent from a patient for a high-risk biopsy, apologizing to another for having to repeat a botched study, explaining to the parent of a child with cerebral palsy that I had broken his child’s severely demineralized leg while maneuvering him during fluoroscopy. Over time, it has been gratifying to see emerging awareness of the need for formal communication and relational skills training in radiology. Overall, however, such curricula remain scarce. Even as CT and MRI revolutionized medicine, speech recognition software became commonplace, and teleradiology broke traditional market barriers, we still tend to learn communication skills the old-fashioned way: “See one, do one.” My skills gradually improved as I observed others, gained clinical experience, and grew more confident. But there was much room to grow, as I learned during the evening standoff
with an apprehensive parent who wished to be present for her child’s procedure. My only gauge of success regarding that conversation was that I managed it without burning bridges that grew more important over time, because this patient required multiple additional procedures. Indeed, over the next 2 years, I came to know this delightful young woman and her parents well, to the point of periodically visiting her in the hospital just to say hello and catch up. Certainly, the door to these small interactions would not have been open if the procedures had not gone reasonably well. However, I also believe that door would not have been open had the communication failed. The relationship with this patient with cystic fibrosis and her family took me into a world that enriched me indelibly. I met a circle of family and care providers who showed me the dignity achievable in sickness and in death. I learned how my small gestures of caring as a radiologist could be deeply appreciated. Just as acquiring a new language introduces one to new, previously inaccessible experiences and people, so too does the ability to communicate well with patients, even in radiology. It is a marvel, really, that allows us to join meaningfully with patients in their journey and to connect with them in mutually enriching ways. As the old learning paradigm hopefully yields to newer models for teaching relational skills, radiologists will find more avenues to such relationships. The patients deserve this, and so ultimately do we.
REFERENCE 1. Rothenberg L. Breathing for a living: a memoir. New York, NY: Hyperion; 2003.
The author has no conflicts of interest related to the material discussed in this article. Stephen D. Brown, MD: Associate Professor of Radiology, Boston Children’s Hospital and Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115; e-mail: [email protected].
2
Journal of the American College of Radiology Volume - n Number - n - 2017
The Standoff Stephen D. Brown, MD For 16 years, I have kept taped to my desk a passage taken from a book written by an inspiring young woman with cystic fibrosis. Published posthumously, the book details the complex interplay of her medical, social, and emotional life [1]. In one chapter, she writes: “Saw good ol’ dr. brown (he’s done all of my interventional radiology stuff) in the cafeteria and he stopped by to hear the latest news. I like docs that keep up even when they aren’t currently involved.” I had met the patient 2 years previously, in 2001, early in my career as a pediatric interventional radiologist. One evening, she developed severe hemoptysis requiring emergent bronchial artery embolization. Her mother, who as a parent probably had as much experience in hospitals as I had as a physician, insisted on remaining in the interventional suite during the procedure. This was an unusual and unnerving request. We sometimes invited parents in for simple procedures, but never for complex procedures that required sedation in fragile patients. On one level, I believed that the patient’s interests would not be well served by granting her mother’s request. Her presence in the room would add unfair stress to the team and an unknown variable to an already unstable clinical situation. I could not predict how events might unfold if an adverse event occurred. These seemed reasonable objections. But, there was another level as well. Even though I had excellent training, I had done few embolizations on my own, and I
remained insecure about my skills. I was afraid that she would see my inexperience, or worse, incompetence. Apprehensive and stressed, I, like she, was anxious to exert control. It was a classic difficult conversation. How much of my rationale should I explain? How could I discuss my concerns without offending her, or worse, frightening her more than she might already have been? Now, 16 years later, I might counsel my own trainees to sit with the mother to talk gently about her concerns and to listen empathetically first before expressing their own concerns. I might urge my trainees to validate the mother’s disquiet and to admit to similar feelings if their own loved ones were in comparable circumstances. We might explore together whether to acknowledge openly to her the stress already in the room, the need to maximize variables that were controllable, and the desire to not introduce unknowns into an already tenuous circumstance. Ultimately, I might advise my trainees to create a comfortable space where the mother could voice her concerns freely, and where they could hopefully establish a mutual respect, rapport, and trust. I might even later create a vignette around this conversation that my trainees could re-enact with actors in a controlled simulated environment with opportunities for constructive feedback from actors, mentors, and peers. However, at the time of this interaction, no such opportunities existed for training in communication
ª 2016 Published by Elsevier Inc. on behalf of American College of Radiology 1546-1440/17/$36.00 n http://dx.doi.org/10.1016/j.jacr.2016.12.022
skills. I found myself in an exceptionally difficult conversation with nothing but observation and previous personal experience from which to prepare. After a tense exchange, I declined her request, and she accepted the decision. The procedure went well, as it should have given the meticulous technical training my team and I had (despite my insecurity). What about the communication? Had I done that well? Certainly my training for speaking to the patient and parent stood in stark comparison to the training I had for performing the procedure itself. The situation transported me back 10 years previously, when, as a junior neurosurgery resident in California, I found myself leading a team meeting with a family whose son had been neurologically devastated after a motor vehicle accident. The time had come to consider withdrawing mechanical ventilation. I was the only physician in the room. The other participants included the patient’s nurse, a priest, and a Spanish translator. The meeting accomplished its objective: the family agreed to discontinue life support. Afterward, I had a burning need to know how I had done. What could I have said better or differently? I asked the priest if I had done a good job. “Yeah, fine,” he answered. He walked quickly away, leaving me uneasy. After 25 years, I still recall that meeting and wonder if the family remembers that conversation. My enduring sense is that they deserved better, and so did I.
1
When formal opportunities to learn relational proficiencies are unavailable and communication skills are not taught, learning still occurs, sometimes actively and sometimes passively. The processing is commonly subconscious, but the lessons penetrate nonetheless. Past conversations that we witness between physicians and patients during our early training experiences lay dormant until they surface in the present. Once, as a medical student back in 1988, I passed a patient’s room and overheard a neurology resident yelling to an elderly stroke patient: “YOU’VE GOT BLOOD IN YOUR BRAIN.” “What a buffoon,” I thought to myself as I walked by. “What an insensitive dork!” Three years later, as a neurosurgery resident, I heard myself repeating these same words when called to the emergency room one night to evaluate a man who had suffered a pontine hemorrhage. His wife and I stood across from him as he lay unconscious and intubated on the gurney. She was noticeably pregnant. “He’s got blood in his brain,” I explained. It was all I could think of. About 2 years later, I walked into a café where a woman and small child were seated. She recognized me and came over. It was the wife of the patient with the pontine hemorrhage. He had survived after a prolonged hospitalization. She told me that my words at that first encounter were her most vivid memory of the entire experience: “He’s got blood in his brain.” Such is the power of informal relational learning in medicine that a conversation overheard outside a hospital room in Philadelphia in 1988 would hold such enduring impact for a completely unrelated individual in Palo Alto in
1993. Once again, I was struck with an overwhelming sense: the patient’s wife deserved better, and so did I. By the time of that encounter in the café, I had left neurosurgery with plans to begin a diagnostic radiology residency in Massachusetts. The specialties were as different as the Pacific and Atlantic Oceans, with one notable exception: The only opportunities to learn about communicating with patients were random observation and real-time practice. As I rotated through ultrasound, fluoroscopy, interventional radiology, pediatric radiology, and obstetric imaging, I realized that such opportunities were abundant and that the exchanges could be intense: informing a woman of a miscarriage, performing a palliative paracentesis on a woman with advanced ovarian cancer, obtaining consent from a patient for a high-risk biopsy, apologizing to another for having to repeat a botched study, explaining to the parent of a child with cerebral palsy that I had broken his child’s severely demineralized leg while maneuvering him during fluoroscopy. Over time, it has been gratifying to see emerging awareness of the need for formal communication and relational skills training in radiology. Overall, however, such curricula remain scarce. Even as CT and MRI revolutionized medicine, speech recognition software became commonplace, and teleradiology broke traditional market barriers, we still tend to learn communication skills the old-fashioned way: “See one, do one.” My skills gradually improved as I observed others, gained clinical experience, and grew more confident. But there was much room to grow, as I learned during the evening standoff
with an apprehensive parent who wished to be present for her child’s procedure. My only gauge of success regarding that conversation was that I managed it without burning bridges that grew more important over time, because this patient required multiple additional procedures. Indeed, over the next 2 years, I came to know this delightful young woman and her parents well, to the point of periodically visiting her in the hospital just to say hello and catch up. Certainly, the door to these small interactions would not have been open if the procedures had not gone reasonably well. However, I also believe that door would not have been open had the communication failed. The relationship with this patient with cystic fibrosis and her family took me into a world that enriched me indelibly. I met a circle of family and care providers who showed me the dignity achievable in sickness and in death. I learned how my small gestures of caring as a radiologist could be deeply appreciated. Just as acquiring a new language introduces one to new, previously inaccessible experiences and people, so too does the ability to communicate well with patients, even in radiology. It is a marvel, really, that allows us to join meaningfully with patients in their journey and to connect with them in mutually enriching ways. As the old learning paradigm hopefully yields to newer models for teaching relational skills, radiologists will find more avenues to such relationships. The patients deserve this, and so ultimately do we.
REFERENCE 1. Rothenberg L. Breathing for a living: a memoir. New York, NY: Hyperion; 2003.
The author has no conflicts of interest related to the material discussed in this article. Stephen D. Brown, MD: Associate Professor of Radiology, Boston Children’s Hospital and Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115; e-mail: [email protected].
2
Journal of the American College of Radiology Volume - n Number - n - 2017