Some conversations are difficult – really difficult. We know we need to have them; explore options, weigh up risks and benefits, talk about how the end of life may be. Wouldn’t it be so much easier if there was just a standard script – one that everyone already knew; those on both sides of the conversation. But maybe if there was a script there wouldn’t be a need for these difficult conversations as everyone would already know the beginning, and the middle, and the ending. The story already written.
As a clinician I have had some ‘training’ on how best to conduct these difficult conversations. There was the occasional seminar at medical school, the preparation for final year OSCEs and later practice for specialty exams. Everyone in the exam room had the same script; clinicians versed and rehearsed, patient actors briefed. Tick boxes on an A4 sheet of paper, pass mark already decided.
I think awareness of the importance of ‘teaching’ clinicians to have these conversations has increased exponentially over the last few years. But life isn’t like an exam room, and non-exam difficult conversations rarely follow the same pattern. I attended all these seminars and passed my exams, yet I still felt, and in fact often still feel, totally unprepared as I walk in to that room to have one of those conversations. We are not robots, and neither are our patients.
As I think back, I can recall instances where I have been on both sides of these conversations; the giver and the receiver of bad news. The one needing to guide the decision making and the one affected by the decision making. When I recall these conversations I can remember both those I felt went well and those I felt went really badly. I sometimes wonder why there can be such a stark contrast in how these conversations can feel; and this is why I believe that it is not really possible to ‘teach’ someone how to conduct a difficult conversation; it is something an individual just has to learn. Yes, having a structure helps, but the tick box guideline from the exam OSCE cannot begin to encompass the dynamics of interpreting body language, employing silence and touch, the ability of just being.
Dr. Robot was a news story I’m ashamed to say initially passed me by. There has been much written about this over the last month, since the original story went viral at the beginning of March 2019. Very few editorials and comments, if any, have been positive. The thought of a patient being told via a ‘robot’ that they are going to die cut to the core of many people’s values. Disbelief was rife; here was a story that caught media attention and spread like wildfire via social media.
I wonder how many other difficult conversations happened the same day that the Dr. Robot conversation occurred? How many of these conversations resulted in those involved feeling content that the discussion went as well as could be expected? And how many left those involved wishing things had been communicated a little differently; the wrong choice of words, a mistaken interpretation of body language. What lessons were learnt by those involved and how can we ensure that this learning can occur rather than leaving those involved with feeling of regret and inadequacy?
I often say to my colleagues – doctors in training who I am mentoring and supervising, that learning how to conduct difficult conversations takes time, and practice; that they will make mistakes, and most likely beat themselves up about them from time to time. It is really important to learn from each and every experience. I describe how I learnt, and still learn, so much from watching and listening to other clinicians having difficult conversations; picking up the aspects that I felt went well, and mentally noting aspects that didn’t, formulating my own style from the menagerie of clinicians I have worked with.
Dr. Robot hit the headlines, but isn’t it a shame that one of the thousands of conversations that went well that very same day didn’t receive the same media attention? Celebrating the good, learning from excellence, recognising that the human side of medicine is still very much alive and thriving. How many patients and families will remember that day because of the kindness and genuine empathy of the healthcare professionals they met? Treasured encounters and conversations. Time to just be, acknowledge and share. Maybe a hug or held hand, a shared tear or the occasional laugh. Human beings united. Moments that re-humanise us in the technical and, at times, robot driven world in which we live. Let us remember that we need to embrace both; technology in the form of telemedicine and tele-consulatation most definitely has its place, essential especially for those living in remote communities or for the provision of super-specialised services. But those difficult conversations will always need the human touch.