Unfortunately, they are avoided in the most costly of situations.
Few environments lend themselves to crucial conversations more than healthcare. As a physical therapist, I have crucial conversations on a daily basis. Often they are with patients, but they occur with colleagues as well.
Health misinformation is pervasive and costly. It will not improve unless clinicians hold each other accountable. It is disturbing to see frequent use of nocebo and fear to drive people to improper medical care.
This is unacceptable.
Why do clinicians fail to hold each other accountable? Sometimes it is a lack of knowing the research themselves. But often it is a fear of the confrontation.
Experts clinicians are blinded by their fallacies.
I would venture a guess that most, if not all, clinicians have been on either the receiving or giving end of at least one difficult or crucial conversation. The issue is they may not be aware of it.
Often, clinicians are in an authoritarian position and are on one end of a large information asymmetry. Patients are commonly in the dark — or relying on information from Dr. Google and their friends and family — while clinicians have years of training and experience. This creates a dynamic of one person telling the other what to do.
This is a problem.
Let’s start with the fact that clinicians are not infallible. We fall victim to cognitive fallacies and biases with regularity. If we fail to adhere to recent and high-quality research, the fallacies become costly.
No one is exempt from errors. Regardless of someone's credentials, their beliefs should be questioned and doubted. This does not mean we never make decisions and education is worthless. Instead, we need to create environments and develop mindsets that any assertion is open for discussion.
“Scientific knowledge is a body of statements of varying degrees of certainty — some most unsure, some nearly sure, but none absolutely certain.” — Richard Feynman
Shame is never the answer.
Why are crucial conversations uncomfortable? To answer this, I will turn to Brené Brown, author of Daring Greatly (Amazon) and Dare to Lead (Amazon).
Brown’s research is primarily focused on vulnerability and shame. These are typically the primary reason for a clinician failing to hold colleagues accountable. If a conversation does occur, it is often poorly conducted. Brown defines vulnerability as uncertainty, risk, and emotional exposure. Experiencing vulnerability is not a choice, but we are able to decide how we respond to it.
“Perceived vulnerability, meaning the ability to acknowledge our risks and exposure, greatly increases our chances of adhering to some kind of positive health regimen. The critical issue is not about our actual level of vulnerability but the level at which we acknowledge our vulnerabilities around certain illness or threat.”
To facilitate a successful crucial conversation, it is vital to establish trust. A primary way to build trust is to listen and be patient. Trust grows over time and it strengthens when we feel heard and valued. This in turn allows both parties to freely give and receive advice without fear of judgment. When judgment enters the equation, our perception of self-worth comes along for the ride.
When someone feels their self-worth is on the line, they are far less likely to open up.
This is when we reach the proverbial fork in the road. As tempting as it may be to take the advice of the wise New York Yankees legend Yogi Berra and “take the fork”, we need to decide whether we will take a step back and focus on continuing to build trust or push forward and force the conversation.
The danger of pushing forward is the likelihood of shame entering the equation. There is not a shred of evidence that supports the use of shame to obtain a positive outcome. Shame is far more likely to lead someone towards destructive and harmful behaviors. Additionally, the feeling of shame (“I am bad”), rather than guilt (“I did something bad”) often leads to blame-shifting and excuses.
I have had many crucial conversations with colleagues and residents I mentor. Shame is never a “strategy” to convey a message. I will question decisions, but in a manner that invites collegial conversations, not Twitter “debate” style.
The key part is making sure it is a conversation.
Listen to seek understanding.
Former US Secretary of State Dean Risk stated, “One of the best ways to persuade others is with your ears — by listening to them.” This is the foundation of conducting a crucial conversation.
Start by developing a shared pool of meaning. This is effectively accomplished with open-ended questions and listening (i.e. motivational interviewing). The goal of the conversation is not to “win” but to create a safe, healthy dialogue that leads to progress.
Prior to starting the conversation, gather as many facts as you can, without making negative assumptions. We then fill in any gaps through questions. Often, patients may assume that dialogue is decision-making. Unfortunately, this may have been a prior experience. Instead, it should be a process for gathering all relevant information. We can demonstrate our seriousness for dialogue by asking someone to share their stories. We can share ours as well to facilitate a feeling of safety.
A quick but important point to make. These conversations about misinformation are not exclusively clinician to clinician. They are patient to clinician as well.
Patients should question clinicians — from physical therapists and world-renown surgeons — every time treatments are being proposed. Every article posted, tweet sent, and podcast interview conducted by a clinician should be questioned by non-clinicians. No-one is exempt.
Holding each other accountable.
Whether it is a colleague or patient initiating crucial conversations and questioning clinical decisions, it is easy for a clinician to feel their autonomy is being challenged. This can result in the clinician developing a thick set of emotional armor to protect themselves from shame and emotional discomfort. The answer is not to avoid the conversation or to attempt hammering though the armor, as these will only lead to disappointment, frustration, pain, and distrust for the patient.
Instead, we must listen to create a safe environment that leads to a willingness to discuss.
We are all responsible for our words and actions, including the words unspoken and the actions we fail to take.
Failure to challenge misinformation is only a piece of the solution to eliminate it. There are many drivers, mostly financial, of the creation and maintenance of misinformation. Crucial conversations are the foundation for addressing the issues. We must all be willing to challenge current beliefs and approaches to healthcare.
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