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Using improv techniques in a health care setting: Episode 3: How to improve patient interactions

In episode three of this series, trainer Shana Merlin discusses how to improve patient interactions with improvisational techniques used to build rapport, help patients understand diagnoses and treatment goals, and break the “curse of knowledge” so that your communications are clear and user-friendly — no matter who you are speaking with.
 

Also available on Apple and Spotify. A transcript of this podcast is found below.

 
Additional episodes in this series:
 
Episode 1: Fundamentals of medical improv
Episode 2: Dealing with difficult patients
Episode 3 bonus: “Signposting”
Episode 4: Interprofessional medical communications
 
 
Transcript
 
Shana Merlin (preview):
“You know, oftentimes in difficult conversations, people want to know, how can I tell this? How can I say this in a way that no one gets upset? And that's not really a realistic objective for delivering bad news. And oftentimes, by overcommunicating, putting too much information, padding positives in there, it makes the message confusing.”
 
Tony Passalacqua:
Hello and welcome to this edition of TMLT's podcast, TrendsMD, Answers for health care's digital trends. I'm your host, Tony Passalacqua. This is the third episode in our series on using improv techniques to improve communication. In our previous episodes we discussed the fundamentals of improv and how to better deal with difficult patients. In this episode, we will discuss how to improve patient interactions with such improv techniques such as building rapport; the teach-back method; “chunking and checking”; breaking the “curse of knowledge; and much more.
 
We are joined this season by Shana Merlin. Shana is an improv instructor who has worked with such organizations such as the Dell Medical School at UT Austin, the Methodist Medical Center, and TMLT. She also founded her own improv school, the Merlin Works Institute for Improvisation in Austin. You can learn more about Shana and Merlin Works at www.merlin-works.com.
 
We will also be joined by Stephanie Downing, an education coordinator in TMLT’s Risk Management Department. To learn more about TMLT’s CME or to schedule any future CME activities, you may contact Stephanie at 1-800-580-8658.
 
Shana, let’s start with the natural place to start: How should a patient interaction begin?
 
Shana Merlin:
Yeah, and I bet a lot of people listening to this podcast have done thousands upon thousands of patient interactions, and everybody has their own way of, um, interacting with patients. I'm going to show, uh, an example. Stephanie's actually going to help me. I'm going to be in role as Dr. Merlin. I am not a doctor, but I'm going to, I am an actor, so I'm going to portray a doctor on this podcast, and Stephanie's going to portray a patient who's also called Stephanie.
 
We're going to show kind of maybe how a traditional patient interaction might begin and then give us some tips from this great resource from the Academy for Health Communication called “Communication Rx.”
 
It's a great book, all about different ways to communicate better, in evidence-based ways.  So, we're going to start the patient interaction with introductions and building rapport, and this is a great time to remember all the blending stuff we talked about in the previous podcast — making eye contact, getting physically, vocally, energetically, and all that kind of thing on the same page.
 
And, it doesn't have to take long, but one or two interactions that aren't directly about the health care visit before we dive into that. So, we're going, when I say “action,” we're going to get into role as doctor and patient. Here we go. “Action.” Hi, Stephanie. I'm Dr. Merlin. Nice to see you.
 
Stephanie Downing:
Hi, Dr. Merlin. How are you today?
 
Shana Merlin:
I'm good. So how have things been? Have you seen any live music lately?
 
Stephanie Downing:
Actually, I did a couple weeks ago. Um, and that was great, but lately I haven't seen any and, um, I'm kind of sad about it actually. So, um, yeah.
 
Shana Merlin:
I'm sorry to hear that. So, tell me what brings you in here?
 
Stephanie Downing:
Well, I mean, I haven't really been sleeping that well.
 
Shana Merlin:
Okay. So, you haven't been sleeping well. Um, how long has that been going on?
 
Stephanie Downing:
Oh goodness. A few months.
 
Shana Merlin:
A few months. And what, how many hours a night are you getting?
 
Stephanie Downing:
Oh, um, on a good night, maybe like three hours if I put it all together. 
 
Shana Merlin:
That’s tough. And, um, what, what seems to be the, how's your sleep hygiene? Are you on screens? Are you, um, getting a dim light?
 
Stephanie Downing:
I am kind of guilty of scrolling on my phone right before bed, but it's because I can't sleep. So, I get on my phone, and I scroll and then…
 
Shana Merlin:
Okay, we're going to pause that doctor/patient interaction. Pretty standard and pretty good, right? So, we start with introductions, building rapport, asking why the patient is there, the patient says sleep problems, and we start going through our questions to get into figuring out our diagnosis for that issue.
 
Now, the challenges here is that just because sleep issues is the first thing that Stephanie said, does not mean that's the most important thing that we need to address in this appointment. Um, so I'm going to suggest a different model because if we spend a lot of time on this first thing and I dive into it and we, and I find out about it and I make recommendations on sleep issues, then we have this danger of this and other doorknob conversation, right? I go reach for the doorknob, and then she tells me the really important thing that we need to deal with and then I'm behind schedule. I've lost time. I'm frustrated. And the patient is also frustrated because their main issue did not get addressed. And oftentimes people don't lead with the big news.
 
They kind of want to ease into it, right? But as health care providers under all the pressures we're under, [we] can tend to grasp on that first thing to get the conversation going and start going up the ladder of questions. So, we're going to instead …  what the, uh, “Communication Rx” book recommends — by Dr. Calvin Chu and Laura Cooley — is we're going to create a shared agenda.  So.  When she, uh, in a moment, when she tells me what her first issue is, I'm going to go, “Okay. And what else? And what else? And what else? And what else?” And it's interesting because in a TMLT training we did years ago, um, someone came up to us after the training, me and Dr. Millman, and said, “Oh, I love improv. I took improv classes. I use ‘Yes and’ all the time.” And we said, “Oh, what do you do? How do you use ‘Yes and?’”  And she said, “Oh, well, when my patients tell me what brings them in, I just say, ‘And what else?’  And what else?’ ‘And what else?’ ‘And what else?’ And she's like, ‘And they think I'm the best doctor in the universe.’”
 
And part of that is that they get heard; all their issues are heard, and they don't necessarily all get solved in that visit, but they get addressed in some form or fashion in that visit. Even if that “addressing” is saying, “Hey, let's talk about this in the next visit.” And it gives the doctor, who's the expert, a chance to prioritize what's actually important in that visit.
 
So, the patient gets heard; the doctor gets to prioritize; and we also are starting in that collaborative decision-making of sharing control of that appointment to making sure that everyone gets what they think is important done. So, let's tie back into the conversation. I'm going to ask what brings you here. And Stephanie, again, is going to say this sleep issues, but I'm going to try this different approach with, um, establishing a shared agenda. Okay. Action. 

So, Stephanie, what, what brings you in? 
 
Stephanie Downing:
Well, I haven't been sleeping very well lately.
 
Shana Merlin:
Okay. Not sleeping well. What else?
 
Stephanie Downing:
Um, I have pretty bad headaches pretty much daily.
 
Shana Merlin:
Okay. Daily headaches. Okay. What else?
 
Stephanie Downing:
Also, I'm pretty lethargic and kind of moody all the time.
 
Shana Merlin:
That would make sense with the headaches and the sleep issues. Um, what else? 
 
Stephanie Downing:
Well, I recently found out that I have really high cholesterol, and I need to change my lifestyle, I guess. And I think all of this is making me not sleep very well and making me moody. I'm not sure. I just, I kind of feel like it's all related, but...
 
Shana Merlin:
Okay, so I have here written down, um, sleep issues, headaches, moodiness, and high cholesterol. Is that, is that everything? Is there anything else to add to that list? 
 
Stephanie Downing:
No, those are the main things right now that I've kind of been dealing with.
 
Shana Merlin:
Okay. Well, take a look at this list. I think that for today's visit and the time you have, the top priority is actually going to be dealing with that cholesterol issue. So, I'm going to put that as the number one thing we want to address. And it sounds like that might be some of the cause of your stress, which might be causing some of the other issues, but we want to take the sleep issues and the headaches and the moodiness seriously. So, I'm going to have you complete a self-evaluation for mental health and see if we want to refer you to psychiatry or maybe have a schedule follow up appointment about that. Does that sound like a good plan? 
 
Stephanie Downing:
I'll, I'll try it for sure. That sounds good.
 
Shana Merlin:
Okay. So, we'll pause there so you could see in this example that she buried the lead, right? This cholesterol issue seems like it's probably the most life-threatening issue, as well as might be the source of the, some of the other problems, right? Health anxiety, maybe keeping her awake at night.
 
So, establishing that shared agenda, and you can see it doesn't take that long, we make sure that she said, ‘yeah,’ she, she says, ‘that's all I want to talk about today.’ And, and we can get a plan in place. Of course, there are going to be outliers. They're going to be people that will give you their whole life story.
 
And you've got to say, “Okay, I think that's five things. That's all I can do today. Let's start there.” But for the most part, people come to the doctor with a list in their head or a list on a piece of paper and you want to get that whole list out. And also set reasonable expectations for what can be done in this visit versus what's going to have to be done in later visits or in other ways.
 
And that also is a great way to have [a] good patient experience because they know what to expect. If they're expecting something different and the visit ends and they didn't get it, that's often when they're upset. “Hey, wait, what about this cholesterol thing? What are we going to do about my headaches? It's driving me crazy.”
 
So, uh, a really cool model for opening that patient examination with building rapport; asking what brought them there; soliciting all their concerns; shared collaboration; and creating that agenda. And then, of course, we can move into the bulk of the session, which would be working through that agenda.
 
Tony Passalacqua:
Shana, I know just before we started doing this recording, we were talking about the “curse of knowledge.” We were also discussing some ways of potentially breaking that curse of knowledge. Could you go into a little bit of detail for our listeners on that?
 
Shana Merlin:
Yeah, so it, the curse of knowledge is kind of counterintuitive because knowledge should be a great thing, right? And it is. And that's why medical professionals have extra schooling to get all this knowledge and expertise. But it is a curse in terms of communicating to people outside of your area of expertise. We tend to, as people, not just as medical professionals, but all people, tend to overestimate how well and how much other people understand of what they're saying. I have extra work to do to communicate what's my expertise inside my brain into your brain.
 
So, if we have this doctor's visit about cholesterol, and I keep talking about cholesterol. Stephanie may or may not know what cholesterol is. But I tell you what, she's probably not going to ask. Most people don't feel comfortable. They feel foolish asking all those things. So, instead we want to make sure that we break the curse of knowledge.
 
So, we can do that in a few ways. One, we ask questions to find common ground and understand where to start. So, if I'm in role as the doctor, I might say something like, “Let's talk about your cholesterol. What do you know about cholesterol in this test that you just got?”
 
Stephanie Downing:
I know that it has to do with my diet, and it's probably not the best diet.
 
Shana Merlin:
Okay.
 
Stephanie Downing:
My age too, because I'm getting older. That's what I hear. I'm not really sure.
 
Shana Merlin:
Okay, great And so I can tell as a professional that she didn't say what cholesterol was, or what are the dangers that can have. So, I want to make sure that I explain. Now, again, I'm not a medical professional. So, I don't want to go into explaining what cholesterol is because I don't know if I’ll do a good job. But I would then, as if I was the doctor, explain in a very simple way what cholesterol is and what are the risks or dangers and how it does relate to uh, your health and lifestyle. Now, if she said, “Well, I've been researching cholesterol and I know X, Y, and Z about it; A, B, and C about it,” then I don't need to do all that. I'll get right into a higher-level conversation around it.
 
So, this is why it's great to ask questions about what people understand before you start explaining, because you often lose people because you're starting too basic, and they already know it or you're starting too advanced and they're not going to ask basic questions. So, knowing where to start is really important and you know where to start by asking questions.
 
The second thing, uh, that we can do to break the curse of knowledge is we're going to start with the headline, the main idea. I might say something like, “We want to get your cholesterol under control, so you don't have a stroke or a heart attack. Now, let me talk about what that means.”  So, I'm giving the headline, the main idea, and if I felt like she didn't know what a stroke or heart attack was, maybe I'd start with those, “so you can live a long and healthy life, right?”
 
But I'm going to give that headline so that she knows why I'm talking about this and what's important to listen for. A lot of times, uh, scientists and health professionals want to start with the details. “Well, when we measure cholesterol, we're measuring this, and this is the range we need, and as it gets above this range, we start to get alerts, and that's when we start to need different medication, da da da da,” and you haven't said the headline, the why. What’s the main idea? Because they're listening for all those details, and they're getting lost and confused, because they don't know what the big idea is. So, we need that context, that shared context, and for you as a health care provider, you're like, “This is so obvious I wouldn't even think to say, to prevent heart attack or stroke,” but that's exactly what we need to say is that headline.
 
So, we have to ask questions where to start, start with the headline. And lastly, we want to use simple everyday language. We want to avoid jargon. So, I know I'm going to get in the weeds when I say something like, “Well, your LDLs and your HDLs and your arteries and your coronary, ….” That's all great now if I'm talking to another health care provider, of course, use the terminology, use the acronyms.
 
But if I'm talking to someone outside of that area of expertise. I might say ‘good cholesterol’ and ‘bad cholesterol,’ or I might say ‘heart,’ or I might say, um, and as I'm getting into talking about, ‘I want to recommend statins.’ Like, I need to explain what those [are, instead], ‘I want to recommend a medication I think that can help with this, and those are called statins.’
 
So, using common everyday language can really help simplify and make sure that the patient is on the same page.
 
Tony Passalacqua:
How do you know if you have broken the curse of knowledge? 
 
Shana Merlin:
That's a great question. How do I know that what is in my brain is in your brain, right?
 
There’s a great metaphor, uh, in the “Communication Rx” book about this, which is talking about don't give them the whole pineapple, slice it up into chunks and feed it to them a bit at a time. So, they talk about ‘chunk and check,’ right? So, this chunk and check is going to be a way that we make sure that we're really communicating successfully.
 
So, chunk, meaning after I give one nugget, one piece of information, checking for understanding and making sure we're on the same page and ready to move to the next thing. One of the things I have noticed since I worked with health care professionals is they like to talk fast. And there's good reason they talk fast.
 
They have a lot to do, a lot to communicate quickly. But when it's time for checking for understanding, it's a good time to pause. Chunk and check. So, I'm going to, we're going to go back to that patient experience. I'm going to give Stephanie a chunk of information about cholesterol and then I'm going to check for understanding.
 
And a great thing to do is to kind of at the end say, ‘I know I threw a lot of information out at you there. Can you tell me what your takeaways for this appointment to make sure, I want to make sure I did a good job. Can you tell me like what do you think is the big ideas here? What are your action items? What do you need to do?’ And that's to make sure. It gives me an opportunity to make sure she understood and correct any misunderstandings before she's out the door. Okay, so I'm going to action in on the appointment. 
 
“Okay. So yes, I'm looking at your cholesterol test and it is high, and we're worried about cholesterol because we want to make sure you don't have a heart attack or a stroke. So, we need to get this cholesterol number down. And to do that, we're probably going to need to start using some lifestyle changes, some medications. Does that make sense?”
 
Stephanie Downing:
Yes. 
 
Shana Merlin:
“Okay, so we're going to want to make sure you have a low cholesterol diet as well as adding in these new medications of statins and I'm going to explain what statins are to you in a little bit. Does that sound good? “
 
Stephanie Downing:
Sure.
 
Shana Merlin:
“Okay. And then I'm going to want you to fill that prescription and take those as directed and we're going to follow up in a couple of months to see if that's changed your cholesterol levels. Okay? “
 
Stephanie Downing:
Okay.
 
Shana Merlin:
“So, I know I just threw a lot out at you about a really important diagnosis. So, can you kind of repeat back to me what you heard? I want to make sure that you caught everything.”
 
Stephanie Downing:
“Sure. I need to eat healthier. And I'll need to take some medication to help get my cholesterol numbers down. So then when we meet up the next time, hopefully I'll have it under control.”
 
Shana Merlin:
“Yeah, that sounds good. And I'll put some resources in your, my chart about what, um, what diets I recommend and lifestyle changes. “
 
Stephanie Downing:
That sounds good.
 
Shana Merlin:
Okay. All right. We'll pause that. So, this is this idea of “chunking and checking.” As we know, a great question to ask is, ‘What questions do you have?’ as opposed to ‘Do you have any questions?’ Because we want to ask that nice open-ended question. So, if I say, ‘Do you have any questions?’ she's going to say…
 
Stephanie Downing:
“No.”
 
Shana Merlin:
 That's right. If I say, ‘What questions do you have?’ that changes the default to, I should have a question. Let me think about what that could be. So, what questions do you have? She might say…
 
Stephanie Downing:
Um, I would love some resources on better foods to eat. Yeah. Because I love to eat at McDonald's every day. 
 
Shana Merlin:
Uh, great. I'll help you send something about great options at fast food places. That might be a better choice for you.
 
Stephanie Downing:
Oh, that sounds awesome.
 
Shana Merlin:
Cause we don't want to get rid of McDonald's, a hundred percent.
 
Stephanie Downing:
And I don't like my grapes cut in half. 
 
Shana Merlin:
So, another way to think about this is called the teach back method. Making sure you can teach this back to me is, is how I know you have heard me. And I know I love to give my parenting metaphors, but I do this with my kids all the time.
 
If they have instructions, if I'm telling them what the schedule is, I say, ‘Okay, tell me, tell me what the plan is tonight, so make sure you understand.’ And that way it gives [me] a chance to make sure they've got it and [for] me to clarify any misunderstandings. And it’s important to do with humility. ‘So, I was like, I threw a lot at you. I want to know if I did a good job. Can you tell me what you heard?’ As opposed to, ‘Can you tell me if you understand any of that?’ Right? We don't want to use that sassy attitude. So, a great way, that teach back method, chunk and check, to make sure that you've really closed that communication loop and completed it.
 
Tony Passalacqua:
Stephanie has been really good about answering a lot of these different questions. But it doesn't always seem to work that way when you have a patient with you. How do you get someone to open up if they're having a hard time giving you those details that you're looking for?
 
Shana Merlin:
Yeah, I think a great way to ask better questions, get to the most juicy information, is to use a technique called “Listen to go deep.”
 
And this is actually from "The Art of Change." And I'm going to do an activity to kind of help demonstrate this. And Stephanie's going to participate with me. So, what I'm going to do is I'm going to share a three-word summary of a true story, something that happened to me in my life. And then Stephanie, I'm going to invite you to ask questions to see if you can find out what the story is. Okay?  So, my three-word summary of my personal story is “minor celebrity nightmare.” 
 
So, there's a few steps to this listen to go deep. The first step is when, uh, I'm speaking, after I speak, you're going to give me some vocal attention. You're going to make a sound to let me know you are listening and interested.
 
So, tell, give me a sound that lets me know you're listening and interested.
 
Stephanie Downing:
Yay. 
 
Shana Merlin:
That's like a cheerleader. Yeah. Woohoo.  So, it might be like, mm. Uh huh. Uh huh.
This is another way, like we were talking about earlier in building rapport, is giving people cues that you are paying attention and listening. That's the first way to help them open up.
 
So, you're going to nod and you're going to, and you're getting exactly. So, when you're nodding and go, uh huh, that makes me want to tell you more. Okay. That's the first step. The second step, and this one is hard, just like our first letter, last letter game. The second step is you are going to have to repeat a word that I said. We call this backtracking.
 
Stephanie Downing:
One word.
 
Shana Merlin:
A word or a phrase. Okay. And you're going to repeat it back as if you know what it is. So, if I said minor celebrity nightmare, you might go, Oh, so less minor. Yeah. Oh, celebrity. Hmm. Nightmare. That's it. Okay. And then the third step is you're going to ask an open ended, “who, where, what, when, how” kind of question.
 
And that helps us get data and information. Don't ask a “why” question from the start, cause that's going to be more opinion and editorial, right? So, you're going to not, grunt, you're going to repeat a word, hmm, hmm, “Nightmare. What kind of nightmare?” Okay.
 
Now, if you have no idea what to ask. What I said is confusing, you don't know where to start. Here is your go to question. And this one's a great gem on its own, but great in listening to go deep. You're just going to go, “Hmm…nightmare. Tell me more.” Okay. “Tell me more” is going to invite me to talk and give, let me lead in the direction that I want to talk in. I do this a lot when people say things that are confusing, offensive, uh, unexpected. I just go, “Ah, tell me more about that.” Right? And oftentimes, it'll become clearer without me making an assumption and jumping in with a question based on that assumption. Lastly, if I say something unexpected, you have one more option of our question. You can say, “What does X have to do with Y? What does this have to do with that?”
 
So, our brains naturally want to connect unrelated ideas, and that's a lot where the guessing comes from. But instead, you want to make me connect those ideas. So, you're going to say, “Well, what does this have to do? You said this and you said that. What does this have to do with that? And let me make that clear.” Helping me break my curse of knowledge, because I think it's obvious, right? Okay. I just threw a lot of instructions out at you. So, let's make sure you understand by teaching back to me. So, um, we're going to go back to “minor celebrity nightmare,” and I'm going to invite you to do all three of those steps.
 
I will warn you. I'm going to be very strict. Okay. You got to do all three. Are you ready?  Minor celebrity nightmare. 
 
Stephanie Downing:
Celebrity. Well, what kind of celebrity were they? 
 
Shana Merlin:
A voice actor.
 
Stephanie Downing:
Voice actor. Where did this happen?
 
Shana Merlin:
This happened at RTXFest.
 
Stephanie Downing:
RTXFest. What is RTXFest?
 
Shana Merlin:
RTXFest, uh, was a fan conference for the creators at Rooster Teeth.
 
Stephanie Downing:
Okay. Fan conference. Rooster Teeth. It was a voice actor.
 
Shana Merlin:
Okay. I'm going to pause for a second. Do you, are you familiar with Rooster Teeth?
 
Stephanie Downing:
Yeah. I remember them from way back.
 
Shana Merlin:

Okay, great. Cause some people might be like, that's something unexpected, right? They made, um, games and animation, funny videos, and that kind of thing.
 
Do you see how even now, just do, you've already gotten so much more information by using this listen to go deep technique. Okay, so maybe I time back into the game and I say, um, well the thing is I hate my handwriting And I'm giving you something unexpected.
 
Stephanie Downing:
So that's when you can use that. What does that have to do with voiceover actor nightmare?
 
Shana Merlin:
Perfect. Right. So it goes, uh, uh, handwriting. What does handwriting have to do with voiceover nightmare? Well, the thing is, is that I hate my handwriting. And I was there at RTX Fest signing autographs for my character that I do voiceover work with. But I felt like I was just taking a sharpie to everybody's fan art and ruining it with my disgusting signature. So, it was a “minor celebrity nightmare.” So, um, that's just me trying to brag and work in my voiceover career, my very limited voiceover career,
 
But it's also a good demonstration of how effective this listen to go deep technique is by asking open ended questions, giving signals that you are listening and interested. You can get a lot of information quickly.
 
Now, I don't recommend, don't do a whole conversation like that. Like this was an example. This was a demonstration. You wouldn't want to, I mean, that'd be kind of annoying if you were like that the whole time. But oftentimes just doing one or two of those things can really help unlock and open somebody up.
 
And I'm so used to working this way. It's become such a way of being. You might've noticed when I was pretending to be the, the doctor, I was like, “Oh, headaches.” 
 
Stephanie Downing:
You did, yeah!
 
Shana Merlin:
I can't help it!  That's how I listen now. But it's also helping me make sure I'm really tuned in to the last thing you said. In improv, we say your scene partner is like your life preserver. They're the ones that are in the moment. So, clinging on to whatever you say or do and repeating that is really going to help me stay in the moment with you. And it's also going to make sure that I'm catching key information. So, if I say, “Oh, headaches,” and you go, “No, no, actually it's migraines.” “Okay, migraine,” that's, you're also hearing your own information and getting a chance to adjust and correct and clarify. So, a super powerful tool to pull out when, um, when things are unclear, when someone is hesitant to give you the full story, when they have a hard time organizing their own thoughts, um, this can be a really helpful tool of listening to go deep.
 
Tony Passalacqua:
Shana, are there any other ways to break the curse of knowledge? 
 
Shana Merlin:
Yeah, there's lots of ways to break the curse of knowledge. We've already talked about starting with the headline, um, asking questions to know where to start and reducing jargon, but another really powerful tool in medicine is imagery and metaphor.
 
It's a way for us to talk to people without using, um, a lot of specialized knowledge. So, some great metaphors that health care providers use are about cars, houses, uh, those kinds of things. Those are great things to steal and borrow from anyone you hear because they're, they're really useful.
 
So, if we go back to this example in our doctor patient visit around cholesterol, okay? I might say, “What do you know about cholesterol and how that works,” right? To find out where to start. And Stephanie might say something like….
 
Stephanie Downing:
I know that it has to do with my heart and how it pumps my blood. 
 
Shana Merlin:
“Great. You're exactly right. It does have to do with your heart and how it pumps your blood. So, we have these things, these kinds of tubes coming off our heart that we call arteries, and we can think about them like plumbing. Okay? Like pipes in your house. Have you ever had a clogged drain or clogged pipe in your house?”
 
Stephanie Downing:
“Of course.”
 
Shana Merlin:
“Of course, yeah. Something gets built up. Maybe it's hair in the bottom of your shower. Maybe it's when there's, you pour bacon grease down the drain, and it becomes solid and that's actually kind of what cholesterol is. It's fats that become solid in the tubes that go to your heart and once you have too much built up there, what happens?”
 
Stephanie Downing:
“It clogs the drain, clogs the artery.”
 
Shana Merlin:
“It clogs the artery, and that blood can't go to your heart. And that's what we would consider a heart attack. So, we want to make sure that your pipes don't get clogged. And that's what this medicine helps us do.”
 
Now I always want to say, um, I am not a doctor. So please do not take this as medical advice. I am a comedian, but, uh, I think we get close to something accurate there.
 
Stephanie Downing:
I get it. I can picture it. I, I understand better now.
 
Shana Merlin:
Yeah. So, the metaphor that a doctor used explained to me, so I have a lot of food allergies, and I had many more, I've grown out of many of them, but when I was a kid, it's like, sometimes I would have food allergy, I would have allergic reactions and sometimes I wouldn't to the same thing. And it was very mysterious. And I remember when I was a kid, again, this medicine might be outdated, but when I was a kid, what was explained to me when I was a kid was by this doctor, this allergist said, think of your, there's like a bucket inside of you and every time you have an allergic reaction, more gets filled into that bucket, that bucket gets filled up with every allergen that you eat.
 
And then at some point it gets so close to being full that you could eat something very little, just a small trigger, but that's going to make the whole bucket overflow, and you have a big reaction to something that maybe you'd had before and had a little reaction to. And that helped me really understand, obviously it stuck with me for forty years, um, it stuck with me for a long time, this metaphor of how allergic reactions work and why they can be confounding sometimes.
 
Tony Passalacqua:
All right, Shana, so we can't have a discussion about better patient conversations if we don't cover delivering bad news. Do you have any sort of advice or tips and tricks for our physicians on how to deliver that?
 
Shana Merlin:
Yeah, I mean, obviously that's hard and important work to deliver bad news. Um, and some of my recommendations are going to be pretty standard things to expect. So, one thing we want to do is we want to have a, they call it a shot off the bow. So, we want to give kind of a warning, a heads up that we're about to have a serious conversation. So that might be sound like something like, “I want to talk to you about this latest test and what it means.”
 
Okay? Or “Please have a seat. We need to have a conversation about. our plan, something like that.” So, you're giving a heads up, giving that person just a moment or two to brace themselves for a serious conversation, giving them a seat, making sure you have their attention, and they're prepared for that. The second tip I would give is to be clear and direct.
 
There's often, you know, oftentimes in difficult conversations, people want to know, how can I tell this? How can I say this in a way that no one gets upset? And that's not really a realistic objective for delivering bad news. And oftentimes, by over communicating, putting too much information, padding positives in there, it makes the message confusing.
 
So, if I, uh, say we have a diagnosis of cancer, the pathology reports come back as cancer. So, what I don't want to do is I don't want to go, “The reports came back, and we looked for X, Y, and Z in the report. And the good news is that we did see X. And that's a good sign. And the other good thing is that you're really healthy and you're really strong and you're in a good place. Unfortunately, we also did detect cancer.”
 
So, that kind of sandwiching is confusing. Um, because all that person wants to know is, what?
 
Stephanie Downing:
Do I have cancer?
 
Shana Merlin:
Do I have cancer? And whatever else you say sounds like this, “blah, blah, blah, blah, blah, blah, blah,” right? So, we want to answer the question that's at the top of the patient's mind.
 
And I talk about this in my TEDx talk with the story of my son, Max, who failed his newborn hearing screening. And when I, we got the results back from his pediatric ENT, she was talking to me about enlarged vestibular aqueducts and moderate sensorineural hearing loss. And I was just like drowning. I could not make sense because what did I want to know?
 
Stephanie Downing:
Can he hear?
 
Shana Merlin:
Can he hear? Yeah. And, and she was trying to, she was a good doctor and trying to give me good information, but I couldn't, I couldn't understand it. So, when we went to the second pediatric ENT, which you do for a serious diagnosis, he brought us in there, he sat us down, and he goes, “Here's what you need to know,” signposting, “Max can hear, and he'll always be able to hear.”
 
Now he had some hearing loss, and we could get into the details of what hearing he did have and what he was missing and how he could make up for it and, you know, what interventions were needed. But until I got that top question answered, I couldn't really take anything else in. So that could be, you know, “The reports came in. I want to talk to you about this, but what you need to know is you're going to get through this. But it did come back as cancer.” So, you know, whatever, if you want that headline to be, depending on what the cancer is, which many are survivable and treatable now, if it's stage one, stage two, that kind of thing.
 
So, we want to make sure we deliver that bad news clearly, not too much, clearly and concisely. Third thing is that power of silence. Giving it that moment to land. I've been trained as a teacher and facilitator, anytime you ask a question that's a thinker, something somebody doesn't already know, hasn't already figured out, you want to wait till a count of eight seconds before you say anything else.
 
So that can be something, to just give that information. “The test came back,” and again, I'm not going to go, “the test came back positive” cause that's jargon and the person might think, “Oh, positive. That's good news.” No, I want to make it clear. Simple everyday language. “Test came back. You have cancer.” One…two…three. And I’m going to count. It's going to feel like an eternity, but it's going to feel like a moment — it could feel like a moment to them. Time does weird stuff when big news happens, right? And then you might give people some options. Different people process things differently. So, you might say, some people want to know all the information. Give me all the details. Some people don't want to know any of that. They want to know what's the next, what's the next thing I'm supposed to do. Some people just need time and space and that kind of thing.
 
So, any of those options you can offer. You can. This is a great time to do that blending where you have, you can have that shared expression on your face, the shared tone.
 
And you could say, “Would you like me to talk more about what this means? Do you want to get into what the treatment plan is? Would you like some time and space to talk to your loved ones and let them have a little shared control in navigating that experience?”
 
So, those are some, some top tips around delivering bad news, giving them that warning, being clear and concise, delivering the message, using that pause, and then offering some options.
 
Because if you start to do that download and they're not ready for it, it's just wasting everybody's time.
 
Tony Passalacqua:
So, delivering bad news, one of the things that always comes to my mind is not only what is said, but how things are said. Do you have any sort of advice on how to make sure that message is conveyed in a way that some sort of emotion is tied to it and not just words?
 
Shana Merlin:
Right. Um, and we've talked kind of from the beginning of the series about the importance of compassion and how it makes things better for the provider, for the patient and for the whole practice. And I want to share some. really clear, specific strategies for how to express compassion and understanding.
 
These are great for patient experience, but they're also great for all kinds of moments in our lives where we need to express that compassion, delivering bad news and or just, you know, “Honey, I forgot to take out the trash,” right? There’re all kinds of times to do that. So, let's go back to this health care interaction we're having where Stephanie is complaining about the, the headaches and the, and the sleeplessness and the, and the moodiness or something like that.
 
Something I may not be able to, the health care provider may not be able to address in this visit, but can still express, uh, compassion for. And we're going to go through this acronym called PEARLS, which is from that “Communication Rx “book. And it's six different ways to communicate empathy or compassion in a health care setting.
 
“So, um, tell me about what brought you here today.”
 
Stephanie Downing:
“Well, I have not been sleeping very well and, um, so I'm just constantly tired and moody and I just, I just never feel good and all I want to do is sleep, but I can't sleep. Cause I'm stressed out.”
 
Shana Merlin:
Okay. Pause. Good. So, the first letter in PEARLS is P, which is about partnering with the patient.
 
So now I'm going to give an example of how I might express that the patient is not alone. I am on their team and we're going to work with this through this together. So, I might say something like, “I want you to know that I'm going to help you work through this. And we're going to work together to solve this moodiness, these headaches, this lethargy, this sleeplessness, we're going to work through this together. Okay?”
 
Stephanie Downing:
“Okay.”
 
Shana Merlin:
That's a great reassurance that that person's not on their own. They have a partner. The E is for emotion naming. So, she didn't say an emotion, but I'm gathering emotion. What would, what would you call it? What emotion do you think your person might be feeling?
 
Stephanie Downing:
Um, kind of sad and hopeless. 
 
Shana Merlin:
Great. Just naming the emotion that you're seeing and naming it. While still giving some cushion and room for them for that not to be accurate is useful. “So, it sounds like you're really exhausted and hopeless with months of sleeplessness. Does that sound right?”
 
Stephanie Downing:
“It sure does. That's how I feel.”
 
Shana Merlin:
“Great.” So, uh, the next option in PEARLS is A: appreciating patient strength or character or apologizing for the situation. And remember, you can apologize without being accountable for the situation. So, it's not my fault that she's not sleeping, but I can still be sorry that that is happening. So, I might say something like, “I'm so sorry that you haven't been sleeping. It’s so essential to making life function.”
 
Um, or I might appreciate the work she's already putting in. “Wow. Just that you've been struggling with that and making it through getting, still getting to work and taking care of your kids while dealing with all of that. That's a lot.”  Okay? So that's an, uh, appreciating the patient's strength or character.
 
I might get into R:  voicing respect for the patient's courage and persistence. So, this is a great way to acknowledge that the patient is not just a passive victim in all this; they've been making efforts and doing things. So, I might say something like, “I'm really impressed that you've figured out how to make this appointment. You've been working. You talked about the things you've already been doing to help yourself get better sleep. And so, I want to just acknowledge the work you've already put in to dealing with this.”
 
Stephanie Downing:
“Thanks.”
 
Shana Merlin:
 And we're going to talk about L: legitimizing understandable feelings. This is a great, uh, phrase that you can use in almost any, in any situation, which is, “Anyone who's not sleeping and is feeling moody and headaches would feel hopeless. Anyone going through this would have that response. Any, anyone who's going through this would want a pill to take it away.” Like, acknowledging the normalcy of that experience, um, and how valid and legitimate it is. And lastly, offering ongoing support with S (PEARLS). “So, it sounds like you've got a lot going on and we're going to keep having appointments until this gets better, until we can resolve some of this.”
 
Okay. So that sense of ongoing, not only am I on your team, but I, you know, I'm interested in this, and I'm going to do some research and follow up with you about what might be the best next step on this situation, because I'm not an expert in it yet. Right? So that's saying I'm making some, I'm offering ongoing support.
 
So those are the PEARLS: Partnering with the patient, Emotion naming, Appreciating or Apologizing, voicing Respect, Legitimizing, and offering ongoing Support. And this is such a great checklist that you can use a lot of times in your life when someone is struggling. And none of these are, solve it. dismiss it, fix it, uh, any of those things, right?
 
There are ways to kind of, um, express compassion and help, help be on the same team moving forward.
 
Tony Passalacqua:
Shana, do you have any, um, anything that you'd like our listeners to leave with? 
 
Shana Merlin:
Well, Tony, uh, we, we've covered a lot here today, and I think I'm going to throw it back to you and say, you know, what, what are you going to take away from this conversation? I want to make sure I've done a good job communicating.
 
Tony Passalacqua:
Well, that is a great question. And, you know, I really enjoyed everything that you've brought up. And one of the things that I still think is probably, in my opinion, one of the greatest things is that value of silence. I know that a lot of people, when we start hearing silence, it becomes very uncomfortable.
 
And so, it's very easy for us to jump in and start to fill that silence with just anything. Just, just a mindless chatter. But I think it's important to understand that sometimes that silence exists there in order for us to be able to process that information that we're receiving, you know, regardless if it's good or bad news.
 
Shana Merlin:
Yeah, I think you're exactly right. When I teach regular improv and when people are nervous, they start talking and they fill and fill and fill. And it's funny because it's actually a very bad strategy. Because if you don't know what to say, talking more and faster is not a good strategy, right?
 
So, if you don't know what to say, let there be silence. It is, it can be uncomfortable, but it's something you can practice and get used to and silence is not nothingness, right? There’re other things that are happening. Like you saying, processing, connecting, emoting, breathing. These are all things that happen when we're silent.
 
Tony Passalacqua:
And I would like to go ahead and flip this over to Stephanie now. Stephanie, is there anything that you found that was really valuable on this podcast?
 
Stephanie Downing:
Yes. I do love the PEARLS. Because you can use it in every relationship, every conversation. Where just, being a team member and showing your support and empathy and all that. It's, it's really, really valuable. And I would love if all my health care providers show those PEARLS while, you know, talking to them and they can sit and be in the moment and really pay attention and work as a team together. I really love pearls.
 
Shana Merlin: 
I love them too. And I think it's a great tool for creating safety in a relationship. A lot of times when someone wants to be strong, uh, they often want to solve things. But another way to be strong is to, say, create safety. “I'm with you. I'm like, we're going to figure this out.” I see, I'm acknowledging how strong you already are and all the work you've already done. And those can be great, powerful techniques in so many relationships in our life. To be able to lead and create safety without trying to control.
 
Tony Passalacqua:
Thank you, Shana. In our next episode, we will conclude the season with a discussion on how to improve interprofessional communication through improv. Please join us!
 
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