Difficult conversations

A few days ago, I came across a tweet about training for ‘difficult conversations’. It piqued my interest for two reasons. First, I was wondering what a difficult conversation is, second, I actually wondered how a healthcare professional should communicate in a ‘difficult conversation’.

When I was wondering what would a ‘difficult conversation’ be, I immediately hit a stumbling block. Difficult for whom? Is the conversation difficult for me or is the conversation difficult for the person I will be talking to, or perhaps for both of us? Quite obviously, what’s difficult for me, doesn’t have to be difficult for you and vice versa. My own experience is that my expectations of a difficult conversation were often unfounded, while conversations that I thought would be easy, turned out to be very difficult, sometimes for me, sometimes for my interlocutor, sometimes for both. And I could not find an easy pattern.

The second problem I had was that I couldn’t think of an easy way of defining a difficult conversation through its theme. Yes, I can see that talking about illness, death, pain etc. can be very difficult, yet, I am very certain that a simple assumption that it would be difficult is misguided. In the same way, my own experience suggests that some of the most difficult conversations I had in my life were not about stereotypically difficult topics. In other words, in a given context, a conversation about love can be way more difficult than a conversation about hate.

So, with much doubt and uncertainty, I went to see what is understood by ‘difficult conversation’ and here is what I have found out. First, it seems that a difficult conversation is about breaking bad news. Time and again, difficult conversations are constructed in terms of about bad news. And even though there are papers (here is one of the frequently referred to) which introduce difficult conversations as being “around diagnosis, deterioration of health, and advance care planning”, still the communication starts with “principles of breaking bad news”. It really does seem that you are unlikely to have a ‘difficult conversation’ unless you tell someone something negative (here is an exception, though).

And I thought that painted an interesting picture of difficult conversations and communication in medicine. If the difficulty lies in breaking the news, the rest must be simply easy going. Or let me put it differently. Difficult conversations are those in which the only role a healthcare professional has is to break the bad news. Then the patient is left to their own devices.

I find this construction of ‘difficult conversation’ fairly bizarre, I also find it fairly counter-intuitive. Difficult communication is predicated on what’s difficult for the medic/nurse, and not for me. I would imagine that telling me the bad news is fairly difficult for you – I might cry, I might despair. Indeed, the literature on difficult conversations, from what I have been able to gather, is awash with references to patient-centeredness and all the nice and fluffy things. But I’d suggest that it is actually the subsequent conversations that are really difficult for me. These are the conversations in which I need to come to terms with what you told me. But you have done your bit, haven’t you? And you’re not really trained to talk to me then, are you?

So, having had this disappointment, I went to find out about, as the abovementioned article put it, principles of breaking bad news. Alas, the disappointment was to continue.

There seem to be two main models of breaking bad news: SCARS and SPIKES (having read these acronyms I started wondering about creating the “Setting Honesty Intent Target” model…..). SCARS is short for:

  • Setting
  • Communicate with kindness
  • Ask
  • Reflect and Respond
  • Summarise and Plan

SPIKES on the other hand is for:

  • STEP 1: SETTING UP the Interview
  • STEP 2: Assessing the Patient’s PERCEPTION
  • STEP 3: Obtaining the Patient’s INVITATION
  • STEP 4: Giving KNOWLEDGE and Information to the Patient
  • STEP 5: Addressing the Patient’s EMOTIONS with empathic responses
  • STEP 6: Strategy and Summary

Unfortunately, information on how exactly you communicate with SCARS was difficult to obtain (the abovementioned paper was fairly careful in not revealing the important information), I had considerably more luck with the SPIKES model; and I applaud for it! I’m taking the information on SPIKES from the CETL website and I complement with advice for nurses.

Here is some advice on how to communicate:

  • The Warning Shot e.g. “Well, the situation does appear to be more serious than that
  • Give information in small chunks
  • English not Medspeak
  • Check Reception Often and Clarify e.g.
    • “Am I making sense?”
    • “This might be a bit bewildering, do you follow roughly what I’m saying?”
  • Reinforce Information Often & Clarify e.g.
    • Could you just tell me the general drift of what I have been saying, to check I’ve explained it clearly?”
  • Repeat Important Points – patients who are upset or shocked don’t hear or remember well. Check your level – try to simplify without being patronising

First, we start with the formulaic, then we patronise by assuming that medical terminology is beyond the patient’s capacity to understand, kicking the patient further by assuming they can only follow ‘roughly’, and then, for good measure, positioning the patient as a little pupil who will repeat what the master said. When I repeat, you also ‘check your level’, after all, you must be sooooo above me. You obviously must check it, it’s difficult to get it right at the levels you don’t operate. Bloody hell, this is really so awful that I’d better move to the nurses.

The nurses have largely removed the patronising bits, they prefer to patronise the other nurses:

  • Sit down, as sitting down will help relax the parents/carers and try not to have barriers between you and the parents like a large table or irrelevant information around like magazines.

I would hope that your average nurse knows this, but who am I to assume? So, here is some of the communication advice:

  • Explore what is known by the parents already.
  • Give information honestly, but with sensitivity.
  • Try to use simple language and avoid medical jargon where possible.
  • Break the news using small chunks or bite size pieces of information with regular checks of understanding and try not to overload parents with information; more than one meeting will usually be required.
  • Answer questions honestly and in the best interests of the child.

What strikes me about this advice, just as in most of the advice of the sort, is how completely unclear it is. I really would like to know what ‘simple language’ is, I actually would like to know what ‘medical jargon’ is. What is a ‘small chunk’ or ‘bite size pieces of information’ (who’s going to do the biting, I wonder).  What does it mean to communicate honestly but with sensitivity – the conjunction ‘but’ suggests that one might exclude the other, so which is it?

Is that useful advice? No, it’s not, it’s banal mixed with unclear. So, what do we do? After all, I would not like this blogpost to be seen as making light of situations in which a medic or a nurse speak to those who might be at the edge of their experience. But here is the problem. The extremeness of the situation makes it impossible to simply fit formulaic communication into it. So, what do you do?

As I try to come up with a good conclusion, I recall sitting at an interview. The interviewee was an experienced psychologist working with patients at the terminal stages of their cancer. I asked her what she does with them. She looked at me with some surprise, and said something like:

  • What can I possibly do? I just sit with them.

I thought it was a brilliant answer. Sometimes, you simply shut up and be there.  And that’s the linguist’s advice.

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