• Rob Orman

22. Mastering Communication When It Matters Most

Updated: Sep 24, 2020

"We all went into medicine to help people. Helping people is joyous."
-Loren Rauch

Who teaches doctors how to speak to patients (or each other)? It’s usually something that’s picked up as you go. Let’s be honest though, some clinicians are much better at clear and empathetic communication than others. It’s an under-taught skill that’s way more important than the attention it gets. In this episode we take a look into the mind and practices of master clinician Loren Rauch. Loren is one of the wisest clinicians we know and intentionally applies humanity to every aspect of his practice. Among the topics addressed are: the ethical imperative of the well-deserved compliment; navigating difficult conversations; communicating with trainees, nurses and new learners; and tips for dealing with patient anxiety.

Guest Bio: Loren Rauch, MD is a graduate of UCSF Medical School and holds masters degrees in both public health and health sciences from UC Berkeley. He completed his emergency medicine training at Harbor, UCLA and, in addition to decades of clinical experience in the United States, he has spent time as an instructor for first responders in the jungles of Southeast Asia.

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We discuss:

Why we should thank patients for coming in to the emergency department, regardless of their chief complaint [05:15];

  • It takes courage to seek care in the emergency department.

  • Many patients face self-doubt (as well as questioning from friends/family) about whether their symptoms warranted an emergency visit to ask for help.

  • Validating the patient’s decision benefits the patient. It also is a good way to make sure you’re not on the road to burnout.

  • “As soon as we start getting into that state of resenting people for coming in for complaints we believe are silly, you are not on the slippery slope of burnout. You ARE burnt out.”

“We all went into medicine to help people. Helping people is joyous. ‘Thank you so much for coming in. I will help you.’ That's a joyous activity.” -Loren Rauch

Using humor to reframe something you dread into something that makes you laugh [10:10];

  • “Let me introduce you to General Weakness, General Fatigue, and Major Pain.”

Tips for helping ease the anxiety many patients (especially kids) have when in the ED [11:40];

  • Reassure them that they did the right thing in coming in.

  • Let them know your plan: testing, diagnosing the problem, working with them to come up with a solution.

  • Get procedures done as quickly as possible with “ambush and attaboy”. Minimize the time from when you tell someone you're going to do something and the time that it actually happens. Follow with a proud pat on the back.

Pros and cons of wearing a white coat [19:10];

  • Loren argues that the white coat is one of the easiest ways to quickly build rapport and give patients reassurance.

Different approaches to informing patients about what tests you plan to do [22:15];

  • Loren uses general terms. “We’re going to do some blood work to check your kidneys, heart and liver. We’ll do an x-ray of your lungs. When we get this back, we’ll have a better idea of what’s going on and come up with a plan.”

  • He prefers this over a disease-specific approach, especially for patients who are anxious, sophisticated, and likely to spend their wait-time googling potential diagnoses.

How to deliver the bad news of a miscarriage [24:55];

  • For most, this is a tragic event that will have reverberations for the rest of the patient’s life. There are things you can do to help people in that moment, so they are better able to process it.

  • When a couple miscarries, Loren tells them: 1) “It’s not your fault, although you will feel like it is.” AND 2) “Most of the reasons why you have a miscarriage are completely beyond your control. Often it is due to the chromosomes not aligning correctly which prevents something like the heart from forming properly.”

Helping family members when their loved one is dying [30:30];

  • “The actual process of having your loved one die in front of you is completely overwhelming. And none of us, including medical professionals, are thinking straight.”

  • Encourage and support the family to hold their loved one’s hand and tell them they love them.

  • Sometimes the family member will collapse or scream. While this can be distracting to staff, these are normal reactions and should be expected.

“If I were to die, I would want someone holding my hand and being kind to me. I try to remember to put a hand on the patient's hand and just be aware of this as a person who is in the process of dying.”

The importance of taking a mindful pause after a patient’s death [36:50];

  • After a death, take a moment to pause and reflect on a life well lived. Thank the team for an excellent job and remind everyone that this person had people who loved them.

  • “Acknowledge the death, instead of pretending it didn't happen, burying it, or distracting yourself.’

  • Ideally, do this with the family present.

The heightened responsibility of the team leader in the ED [41:00];

  • As physicians, we have great influence over the team’s welfare and a profound ability to shift and improve the situation for everyone else.

  • If we are positive and supportive, that goes a big way to making the whole emergency department happier, more productive, and more fulfilling.

Why doctors need to have enormous sympathy for ourselves, and it is a lifetime of practice [42:00];

  • While the job of a physician carries incredible prestige and ability to help people in profound ways, many will always have something to complain about.

  • Doctors are extreme perfectionists. “We have an incredibly difficult time being happy or satisfied with anything... Whatever is going on, we'll see how it could be done better”

  • Sympathy comes from understanding this and being kind to ourselves, knowing that we are naturally going to find problems with things. “That's how we're wired and that's how we're trained.”

“Perfectionism is socially advantageous and personally expensive.”

The value of being conflict avoidant in clinical practice [46:00];

  • It is best to be conflict avoidant, yet know how to stick up for your patient or yourself when you need to.

  • Many are taught a malignant aggression in residency, and that needs to be worked out of you. Ideally, you get along with everyone.

The resentment that comes from comparing your tasks to someone else’s, and how this can suck the joy out of your work [49:15];

  • Rob and Loren caution against wasting energy worrying about whether you’ve seen more patients or done more work than your partner.

Comparison is the thief of joy. -Teddy Roosevelt

  • Loren suggests trying to do something every shift that is not otherwise your obligation (like picking up an extra patient or arriving early to work). “You're going to be surprised at how much joy that brings you and how appreciative it makes the other provider. And that appreciation is what feeds us.”

The ethical imperative of the well-deserved compliment [53;30];

  • A compliment is Loren’s secret supercharge for new learners who may be overwhelmed: “You're way ahead of where we'd expect you to be at this point in your training. You're doing a great job.” This brings enormous relief to the learner as well as personal satisfaction to the teacher.

  • Compliments are a welcome reprieve from what they’re accustomed to hearing, which is what they’re doing wrong and suggestions for improvement.

  • We don’t tell people they did the “right thing” often enough. It’s an enormously powerful statement.

“We seldom take a moment and reassure people that they’re doing great...We all need to do it more.”

Why our job isn’t to be right; our job is to be reasonable [56:20];

  • Being right is very challenging. Being perfect is nearly impossible.

  • Sometimes we have to reassure people (especially those feeling overwhelmed) that it’s ok to strive to be reasonable. “That’s all we can expect from anyone.”

And more.

Shownotes by Melissa Orman, MD

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