Tonight's talk is not your usual communication talk. We are not going to sit here and focus on the key listening skills and the key encoding skills. We'll talk about them, but we're going to go past that. We're going to really focus on what makes difficult discussions so difficult. What are the elements that do that, and how do we address those? So our objective for today is to give you three key skills to effectively deal with difficult dialogue. Now, why should you even care about this? Why are you here tonight? Well, you should care about it, of course, because of better patient care. I know you care about that. But you should also care about it because it affects you directly, personally. Tense communications has an effect on our health, on our burnout, on our ability to think clearly. And in fact, there was recently in 2017, I believe it was, a study that was done that showed that when you were dealing with a difficult individual who was really haranguing you or bothering you, that in fact, it made you more likely to make errors in patient safety. So you should care about this for a lot of reasons. And I'm sure you do, which is why you're here tonight. Why do I care about it? Why am I doing this? Well, I'm in the process of downsizing a lot right now, and I'm tearing up old photograph albums and things and tossing them away. And what you see here is a picture of me that I just found from 1978 that was in the Miami Herald. And that was the second ever communication workshop I ever ran. There were 60 people. It was being done through Florida Keys Community College. It was, you know, it was a thing. But when I sat and looked at that picture, I had a reaction to it. And that's what I really wanted to share with you is, am I still relevant? What have I learned since 1978? And I will tell you that what I have learned is that there are many ways to learn about communication. There is the theoretical, which I have to say at age 26, that was mostly what I had. I was a good listener. I was a good communicator. But it was based on theoretical knowledge and a lot of beliefs and hopes. In the years since then, the 44 years since then, I've been kind of bounced around in life, right? And I've had to have a lot of difficult conversations. And I'm including with ex-husbands and things like that. I've had to be in situations where people were threatening me with a knife. I've had to be in situations where patients were angry with me. I've had to deal with all kinds of things. And in the process of that, probably because of who I am, I have looked to philosophy. I've looked to neuroscience. I've looked to basic religions of the world. I've looked to all of these, the way people think, to find ways to understand better what happens in communication. Why does it break down? And what are the unifying elements? So I guess what I'm saying to you here tonight as I move quickly through this is there are many ways to teach communication. There is the basic, simple, theoretical, this works way. And there is what really works. And that's what we're heading for tonight. So tonight, I'm going to have four points for you to consider by the time we're done. And these are the four. And I'll bring them up again as we go through so you'll know where I am. The point one is I want you to understand that all effective communication has only four parts. And I'll go over those. But notice I use the term effective. I don't use the term good communication because there's no such thing as good and bad. There's only effective and ineffective. Effective communication is that communication which allows the message to be imparted, which allows one person to manage to get information to another person. And that person, the recipient, actually understand the essence of that meeting and that message while at the same time maintaining their self-esteem. That's effective communication. We'll talk more. Point two is that all communication breaks down in very consistent ways. And one of the things that most of us have done in our lives is we've seen communication as discrete stuff, you know. There's disclosure. There's conflict resolution. There's dealing de-escalation. And I want to tell you that although it may seem very counterintuitive, in fact, the ways that those communications break down are related to one another. So if you can get the concept of how communication breaks down, why it breaks down, then you can actually expand your efficacy to many, many more situations. So we're not focusing on just one tonight. Point three is you can learn strategies to mitigate that communication breakdown. You can learn tools and ways of approaching a situation that help you in that situation. But they're related to the consistent ways communication breaks down. And finally, difficult communication will never be easy. I want to repeat this. Difficult communication will never be easy. And in fact, if it ever gets too easy for you, please go look for another job. Because what it means is that you've lost a touch with your humanity and your fear and your human heart. So we don't want that. We want to know that we're going to have to deal with some difficult situations. But we can be effective and we can be effective with other people during those. And that's really the key to being a healthcare provider. So let's get going here. Point one, all effective communication has the same four parts. So let me tell you about them. This is a communication model. And there are several out there, but this is the one I like the most. There are four pieces required for successful communication. And I will walk through it quickly. The first piece is called encoding. So I have things in my head tonight that I wish to share with you so that you can use them and you can think about them and you can work with them. But as long as they sit in my head and they don't come out somehow, they're just thoughts in my head. They aren't communication. So I have to figure out a way to get that to you. Tonight, I am using the English language to speak with you. If we were in Bhutan, I'd probably be using Zanka. If we were in South America, maybe I'd be using Portuguese. You know, it would depend on where we were. But words and language are not the message. They are code that I am picking to get words and information to you. So symbols are also part of encoding. When we wave our hands, yes, that's nonverbal. But it's also a form of code. The universal signs for bathroom or stop or cow crossing the street, right? Those are all code. Those are not the message. They are code for the message. Now, that code, once it's been decided, has to be transmitted somehow. Tonight, I'm talking with you and I have slides. And that's how we're transmitting it. We're doing it over the bytes and over all of the pixels. And there you go. That's transmission. And part of that transmission is my nonverbals. It's the tone of my voice, the rate of my voice, how I use my body, what you see, what I'm doing to transmit this message to you. And some of it I have no control over. And I have no control over whether you like that or not. For example, I'm a female. Some of you might think, I doubt it, but some of you might think, well, that message would better be delivered by a male. In that case, my transmission is going to be ineffective. However, I am transmitting with the best knowledge I have. So I have a message, I put it in a code, and I transmit it. I want to stop here for a minute. We write things in the electronic medical record. Have we communicated? No. We have transmitted code because we haven't gone through the rest of the communication model yet. We send an email. Dear Dr. So-and-so, I need to talk with you about your patient. Can you call me at your earliest convenience? Have we communicated? Actually, no. We've transmitted code. What turns that into communication? Communication is when that message is decoded by the recipient, so whatever it is they hear or see or think or feel, and we find out what that is they thought or saw or felt, which is why we talk so much in effective communication about listening skills. That's our opportunity to verify. Now, in traditional communications courses, we focus a lot on the encoding and on the transmission because transmission, nonverbal communication, depending on the study you read, is 65 to 95% of the message we're sending that we are transmitting in our code, right? So we've spent a lot of time working on that. What we fail to spend significant time on is understanding what goes into decoding and understanding verification. We do teach-back. We do read-back. We do all those forms of verification, and as a risk management professional, I have seen communication break down even with those efforts because of a lack of something in the decoding, which is where I'm going. So first, let's talk about how do we do the simple stuff, the encoding and transmission. Now, here's what I was saying, that there are all kinds of programs to teach communication, closed loop, TeamSTEPPS, conflict resolution, assertiveness, teach-back. They're fabulous. These programs work best with a closed group, with a group that shares the same mental model and values and are together more often than not. It's much more difficult for these to be successful when you're dealing with a variant group, with a group where you are not together all the time, perhaps you and a family that just breezes in from out of town. Those times, these are much more difficult, but these are extremely effective for teaching you encoding and listening skills, as well as nonverbal skills. So I'm going to give you two slides, actually three, on how to improve your encoding and transmission and your decoding. To improve encoding and transmission, do not assume that because a person has an education, they understand what you mean. My spouse, who is a retired psychiatrist, was recently very, very ill. And some of the physicians will come in and talk with him as if he understood cardiology or pulmonology. He went to medical school in the 60s. The whole last, everything has changed since then. Do not assume that because a person has an education, they understand what you mean. Do, imagine you're speaking to a very smart 10-year-old. You don't need to talk down to them, but you need to explain what it is you're trying to say in words that a lay person would understand. Do not assume that people can hear you physically, because many, many people, particularly from the millennials on up, including the boomers and some other people, they have very severe hearing loss and don't even know it. The literature shows that after age 55, a good 25% of people would benefit from hearing aids. How many people do you know at 55 go and get their hearing checked? Very few. So do not assume they can physically hear you. Be sure that you speak distinctly. Do not assume that people can recognize your good intentions. We believe, and I know I've done it too as a risk management professional and as a mental health professional, we believe that because we really do care and we're trying to help somebody, that they know that. Well, they don't. They're operating from their own place of fear, and so they don't always hear us. So do leave space for processing of thoughts. Also, something very important that very few providers do, I've noticed over the years, people can only remember three facts when they're upset. I want you to take a second here. Think about a time that you received shocking, sudden bad news. It could be a death. It could be, hey, honey, we're getting divorced. It could be a car wreck with somebody you love. Time slows down. You do not hear everything that's being said to you because your mind is in shock. Please remember, in difficult conversations in particular, people are only going to remember three things that you tell them. So before you go into that conversation, and this is something I always teach in conflict resolution and in disclosure in particular, be prepared in your mind with the three things that's important for that person to know. If they ask you more things, that's fine. But what are the three things you need them to know? And if the news is bad, something else to bear in mind, that we all regress at the sight of bad news. I was talking to a woman yesterday who's on the medical center PFAC with me, and this is a woman who's been sick for years and has had all kinds of things. But yesterday, she got a new diagnosis of myasthenia gravis. She said that stopped her mind completely. She does not remember anything else. And she said, I thought I was prepared to handle anything, but I wasn't. So remember, when we're giving difficult conversations, people's minds are not functioning as they would be under normal circumstances. To improve our listening, do not assume you can judge the rightness or wrongness of what somebody is saying. Because whatever they're saying is right or wrong in their mind is different than what's right or wrong in your mind. Now, I have worked in mental health for many years, and my spouse ran the lock unit for 35 years. And I said to him one day, does anybody schizophrenic or anything else with a severe mental illness, have you ever met anyone who woke up in the morning and said, I think I'm going to have all kinds of crazy thoughts today? That just seems like a good thing to do. Well, no, of course they don't. Because in the lexicon of their way of thinking, even if it's uncomfortable, it seems to make sense. It seems like it can be real. So when we're engaged in a difficult conversation with anyone, not just mentally ill people, when we're engaged, remember that whatever that person is saying to you, as crazy as it sounds to us, makes absolute sense to them. So we're not going to talk them out of it. What we have to do is give them space to have that feeling and show them that there's a possibility that other things might exist. Don't assume you know how they should feel or react. And don't assume you understand. But be curious. Ask questions to gain a perspective on the other person's perspective. Be inquisitive. Encourage them to give you more information. Ask permission. We once had a family come in when I was working in risk management. And I got a call. It was the surgical post-surgical unit. And the surgeons were all upset. And the family was upset. And the nurses were upset. Everybody was upset. So I went up to the unit to see what was going on. And it was a family who wanted to take dad home post-operatively with his NG tube. And by the way, still in restraints because he was a little bit flailing. Because they wanted to give him pulverized seaweed through his NG tube. Well, of course, the doctors and the nurses and everybody were upset. And they even called in a psych consult. And the psych consult was upset. And I walked into this big brouhaha. So I said to them, all right, let's sit quietly a minute. So I said to the woman, tell me what it is about pulverized seaweed that makes you want to give it to dad. So this woman, whether she's right or wrong, didn't matter. She told me what she believed was in pulverized seaweed that would be good for the health of her dad. My response to her wasn't, you know, you're nuts. My response to her was, you know, if I had something that was that nutritious, I'd want my father to have it too. What's in what we're giving him anyway? Well, she said before the doctor could say any more, I don't know, but it can't be much. It's clear. So in her mind, it was clear. So it was water. That's what became the reality of the situation. So we called the pharmacy and we got her a list of nutrients. And when we were done, the woman said to us all, thank you. I just needed to know that he was getting good nutrition. He can stay now. So to improve your listening, it's not a matter of convincing someone. It's a matter of being curious about what it is they're bringing to the conversation. And finally, I want to talk to you about nonverbal language before we get to the difficult affinities. Nonverbal language, it's really quite simple, folks. There are all kinds of keys about don't fold your arms and don't scratch your head and don't sit like this and sit with all kinds of things that people can tell you to do and not do. And you can drive yourself crazy. I'm going to give you a very simple formula. I once saw a painting of these two old people in rocking chairs and inside of the rocking chair was a little kid underneath inside their heart. When we break bad news of any sort, whether it's a disclosure or a bad prognosis or a behavioral thing or somebody is angry, they're afraid. When we break bad news or have a difficult conversation of any kind, we are not dealing with that rational adult we might see before us. We are dealing with the child inside. So what do we do when we're dealing with children? We get on their level. We speak soothingly. We don't talk down to them, but we sit there and we're very much with them. We don't necessarily touch them, we give them their space, but we're with them and we listen to them and allow them to be themselves slowly, soothingly and on their level. That's all you got to remember. The rest of it is all dressing. This is the key element to effective nonverbal communication in a bad situation. So if I were to ask you, what's the most important skill for the message sender? What would you say? I'm going to move on. Communication breaks down in very consistent ways. So let's go with this. I want you to think for a minute. Do you agree with this statement or not? Working with a good listener inclines you to feel favorably towards the speaker and be willing to give them a second chance. Who wants to say yes? You can raise your hand if you do. Who wants to say no? Who wants to say yes? Who wants to say yes? You can raise your hand if you do. If I can see your hands, that would be wonderful. Maybe I can't the way this is set up. I'm not seeing anything here, so I guess I can't. OK, well, I would say let's keep going. Ah, good. Some people have raised their hands. Good. All right. Yes, I think it's true. But why is it true? And some of you are sitting there going, OK, Jerry, you've been going on about this. Just tell us what to do. Only if it only were that easy. I want you to think now we're getting into the nitty gritty here. I want you to think of a time when you were completely misunderstood in a communication situation. Doesn't have to be at work, can be at home, can be with your family, can be with a good friend. What was the situation? You were completely misunderstood and you were totally surprised. I hope everybody has one. I know I do. It was once when I was dealing with my daughter and I said something that I thought was totally helpful, and she started yelling at me like I was from I was trying to kill her. I was like, what? Where were you getting this? It was so off the mark. OK, when those things happen, the chances are these disconnects were caused by someone seeing the situation differently from you. Well, you might be saying, of course it is. Yeah, but it's not that easy. Now, back to our back to our little model here. We have our encoding. We have our transmission. What we never talk about in communication training is the decoding. And we never talk about what goes into the encoding. Right. How we are coding things, what we're picking and how people are hearing us and why they hear us. We always tend to think, well, if I use the right words, they'd understand me. Well, that's not necessarily true. It has to do with what's going on in their mind, what's going on for them so that they're projecting onto your answers. What does that really mean? We our own beliefs get in the way of our good communication. So we have a fear of communication and competence, and that makes us more fearful, which freezes us, which makes us more difficult for us to communicate. They're afraid of the communication and they start freezing and they start pointing fingers. We believe in a logical thinking process. Well, you know, when people are upset, they're not logical. We confuse fact with truth. And I think this is really important. I want to just say this. Facts are facts. They're things that happen. Truth is what I believe about what happens. So it may be true to me that you were rude, but the fact is. Maybe you just spoke in a tone that I tend to interpret as rude. The fact may be that the nurse came in and did ask me my name again, but the truth to me is she wasn't paying attention to who I am. So fact and truth are very different. They're a matter of perspective. Our point of view, our insidious, inherent bias comes through everything we do. When people talk to us, we hear through our insidious, inherent bias. When we talk to other people, we talk to them. I see a raised hand. I don't know if it's a question or if it's. Or if it's somebody still wanting to, is it a question, doctor, so fair, if you have a question, please ask, please unmute. No, OK. All right. Let me go back. I went too far. OK, we tend to believe that there are right answers for everything and believe in immediate answers. So I want to tell you that communication is a lot fuzzier than that, particularly when it comes to the decoding. Here's point three, you can learn strategies to mitigate that communication breakdown. So now we're starting with the what do you need to do here? Here are some unifying strategies that work in all communication situations. The first thing is you need to recognize your own personal view and that there is a difference between truth and fact. And that other people's responses are not personal to you. Now, views can be positive or negative. You know, we talk about bias like it's a bad thing. I have a bias of a pizza over spaghetti. I have a bias of of Schubert over Rachmaninoff, but that's a bias and it's not good or bad. They're just different. We also do have biases that lead us to make discriminatory choices that may not be in everyone's best interest. But they're all biases and recognizing that all of us have a view and all of us have a bias. So when I said that sentence to my daughter and she got really angry, it was her bias that came through in her response. People say things and we get upset. It's our bias and our bias may be as simple as I like to be treated with respect or our bias may be as simple as parents shouldn't do that. Our bias could be anything, but recognize that we have a view. And when we're listening to people, we aren't listening clearly either, which means they aren't listening clearly. So we have to remember there's a difference between the truth of what they think is going on and what we think is going on and the fact and the responses of others are absolutely not personal to you. So let me talk about that view. I call it view. It's the basis for decoding and interpreting. It's the third part of the communication model. We all have a view. Everyone's view is different. No two people live in the same world. If we did, we had the opportunity to do an exercise here. We would find out if we had the ability to do it here, that everyone sees the world completely differently, even though we might be in the same field of work, even though we might come from the same part of town. No matter what we see differently, no two people live in the same world. It's the lens through which we judge the world. And it's related. It's related, but it isn't. It's based on learned beliefs filtered through our nervous system. So as you look at this picture of the girl with the turquoise hair in those chairs, some of you are going cool chairs. Some of you are going 1960s chairs. Get out of here. Some of you are looking at her hair and going, hey, that's pretty neat. Some of you are going, I would never let my daughter wear her hair that way. That's nothing right or wrong in any of that. That's all simply view. View is based on a sympathetic nervous system, our beliefs and our assumptions. So let's talk about that. First of all, we all know about our amygdala, right? The brain, the thing that tells us when we're afraid or scared that triggers before anything else, we go into a situation and we have a tendency. I'm sorry, my cat fell over. He's on. I think he's OK. OK, we have a tendency to to judge a situation before we know what's going on in it. We see a wound up cord and we think it's a snake until we go over and realize that it's a rope that just happens. Right. We also have beliefs about people. Maybe you believe people should always be kind or should always know what to do or should know what's expected of them. Those are shoulds. We should on ourself all the time. And also we make assumptions. They're out to get me. If I don't make a fuss, nothing will get done. These are the things we tell ourselves. So our beliefs and our assumptions are things that we have learned. And just take a second here. Think about what some of your beliefs. I could tell you mine. What are some of your beliefs and assumptions about people? They're not right or wrong. They just are. Well, I hope you've come up with a few, because those are your view. And beliefs and assumptions are not facts, they're learned, and they're often unproven. Now, here's where they come from. They come from groups we belong to. The organization in which you work has its own culture, therefore, you have a certain number of beliefs and assumptions based on that. Where you grew up. I grew up in a Cuban community in Tampa, and I grew up thinking about the roles of men and women that way. It wasn't until I later tested those roles that I changed my mind, but that was part of my view. The religion of our childhood teaches us many things about our health, about the relationships of people. Our gender is a culture. Men and women think differently, linguists will teach us that, right? It's not men are for Mars, women are for, not that, it's we think differently because of our culture. Our age is a culture. Our physical traits create ways in which we perceive the world. I'm four foot 10. If it isn't on the first or the front of the second shelf, it doesn't exist, right? And I noticed things that happened when I'm in public, that happened when I was young, and now that I'm older, that didn't happen in my middle age. Ways that people treat me because of, they see me and they have beliefs about little people, right? Education, not how much education, but what kind of education you get affects the way you see the world. We think we choose our careers, our careers choose us, because we see the world in a certain way, we're drawn to certain kinds of education. And then all of our temporary conditions, illness, fatigue, medication, COVID, how hot it is, how cold it is, all of these things will affect what you hear in a conversation and how you react. Have you ever noticed that there are times that you just run a short fuse, you can't stand it, you're going to react? Well, yeah, and so do the other people. So the point of all of this is, we see things as we are. We see things as we are, as scientific as we believe we are. As academic as we believe we are. We see things as we are, not as they are. We see the truth from our perspective. We don't necessarily see the fact. Not good, not bad, only indifferent, only the thing that gets in the way in communication. Often when we think we're listening, we're judging through our view, which stops the communication from progressing and relaxing and allowing the other person to feel like they're being heard. The way to make a person feel heard is to recognize that I see things through my view and you see things through your view. Let me listen to your view, even if I don't agree with it. Most people want to be listened to. Most people want to be listened to. Here's a summary acronym, and I didn't make it up, and I wish I knew where I saw it and where it came from. I have looked it up. It's called Q-Tip. Quit taking it personally. Now, one of the things I've learned over years of working with angry patients and patient relations and stuff is that most of us and most people do what I call projectile projecting on everybody. When I say to you, I'm going to pick on Brian because he's been my host and worked with me and he's a delightful man. When I say to you, I love Brian, I'm actually not saying anything about Brian at all. I'm saying that when I talk to Brian, I feel uplifted, I feel accepted, I feel good about myself, I feel good about what we're doing. One of you out there, I don't know who it might be, might say, I can't stand Brian. Well, that's not about Brian either. What you're saying, maybe I wish Brian sent out more memos and emails. I wish Brian did this or that or sent us a schedule three months in advance. It's about you, not about Brian. My statement is about me, not about Brian. There's a whole philosophy that talks about when we say things, none of us are really talking about that situation. We're talking about ourselves. That family member who says, I hate you because you aren't treating mom right, what they're really saying to you when you listen to it, isn't about you. They're saying, I am so frustrated, I am so scared, I feel so darn helpless, and you happen to be the object of it. It's not about you, it's about them. What happens to most of us is that we take it personally. We think they're talking about me. How dare they talk about me like that? It gets easy to get trapped in our reactions. When we do that, we give the entire conversation away to the other person. They've got all the power now because we're so busy defending ourselves internally. What does this have to do with difficult conversations, you're asking? It has everything to do with difficult conversations because the key to difficult conversations is to give the other person space. Now, I'm not talking about when you're in physical trouble, guy with a gun pointing it at you, that's not what I'm talking about here. I'm talking about people who are giving you a hard time. I'm talking about people who don't want to comply and adhere to our medical treatment plan. I'm talking about people who yell at you about how mom is doing. That's who I'm talking about here. And when we give them the control, we actually have bought into the difficult discussion, making it more difficult. So let me give you another analogy. Someone starts yelling at you. When you start thinking, it's about me, how dare they talk to me that way? You've been caught in their trap. You're their little fish. Now they got the power. They got you. And not only do they got you, you're throwing fuel on their fire so they got more, don't talk to me that way. What do you mean don't talk to you that way? I can talk to you that. It's your fault. Mom isn't out of the hospital yet. What do you mean it's my fault? She hasn't been doing with me and you haven't come in when you were, but no, you just make it up. You can see how that goes. Right? You've been in those conversations. I know I have. What happens when you don't get caught, when you realize it's a projection is that you're able to say, yeah, I know it's frustrating. I wish it were different. It's not. How are we going to work on this problem together? What are we going to do to change this? We got a problem. What do you think should happen? Well, I think you should be fired and well, that would be one solution. I'm not sure that would help us with this problem, but you notice how, when you stop to, and if we had more time, I would do role plays with you, but you notice how, when you don't get caught, it gives you more strength to be able to move around and to deal with the conversation, to be able to talk with them about other things that are possible. We can never assume we're understood, never assume it, never assume that we understand. We have to start from the premise that a person with whom we're communicating is operating through a completely different lens. They're wearing yellow sunglasses and we're wearing brown ones. It's up to us as the communicators to ensure that we are listening and we're giving the space and we see the projecting that's going on and don't buy into it. Step back from the projections, create space. We can't assume they understand our message, we have to ask them questions. How does this affect you? What do you think you're going to do about this? How do we deal with this in our family? We have the responsibility to be as neutral as we can be. That is how we control this conversation. So if you're in a conflict, there's another point here, which is get on the same side of the bus. And then some specific tactics. So let me get on that. There was a study done in the 1950s with small boys, about 11 years old. And the psychological researchers took these two groups of boys and they made them enemies at camp. Literally, they made them enemies. They were like, oh, those boys have cooties. Oh, these boys can't do anything right. They're horrible. You don't want anything to do with them. So they made them into enemies. Right. And one day the researchers said to the boys, of course, they didn't know they were researchers, said, we're going to go to the movies. Well, only one thing bad, you got to ride on the same bus. Oh, no, don't run a ride with the guys with cooties. How terrible that would be. So the kids all come, but they want to go to the movies, they get on the two sides of the bus. Lo and behold, the bus won't start. The bus doesn't start, right? So the bus driver who's in on this says, I think we're going to need people to push the bus. But it's going to take all of you. You're going to have to work together to figure out how to push this bus and make it work. No, I don't want to work with that. But the kids got out, figured out what they needed to do, because going to the movies was more important than pushing a bus with a guy with cooties. And they figured it all out. And the boys pushed the bus. Interestingly, the result of the study was that when the boys got back on the bus, they didn't sit divided anymore, that the communication barriers had started to break down. They had a common enemy, the bus, a broken bus. Now that was a, it's not a Shaggy Dwarf Dog story, it's a real study that was done. The point of that study, however, has been brought forth many times in much more traditional studies, which is when you want to bring people together, give them a common enemy. Give them a common enemy. The key to effective conflict resolution is to not say you and I have a problem, because then you and I are enemies, but you and I together want what's best for mom. We have different point of views. How are we going to work on this together and pose that to the other person to bring them out, to bring them forth to you, so that together you can work on a problem? Trust me, this works. I can't tell you how many times I had families coming in demanding huge amounts of money for something that wasn't worthy of huge amounts of money, but they felt it was, that was their point of view as, you know, they came to the risk manager, they had a claim. And before they left, maybe not the first conversation, but by the time we were done, we ended up, I can't tell you how many benches with rose bushes and library books we got that would honor the parent or the family member even better than giving them money. So be aware, make a common enemy, work with them. That's a facilitation skill. So how do you manage the angry patient? You shift from, you have a problem with me and I, with you, to together, we have a problem about, and then second point is agree on stuff, anything, even if all you can agree on is we both want what's best for mom. Can we agree on that? Yes. Okay. So now let's talk about what I can do and what I can't do. What is it? And let's work together to figure this out. You may not do it in one conversation, but you can shift the tone of an angry patient conversation. And again, I have to say, trust me, it can be done. Now physically remain at arm's length away. You don't know if a person's going to like, lose it, maintain calm, but don't be condescending. Don't put anything between you and the door, keep safety, reinforce that you want to solve this problem and reinforce that they are not the problem, but the situation is the problem. I hope by now what you're getting from all of these unifying things is the way to have a difficult conversation is to depersonalize it, to make the problem, the situation, and you're there to help with the situation and keep it out of the range of you and me. And that's the key. Final one is to use some specific tools to stay present. So let me go through some of these. I'm going to give you some quick techniques and I have used them all and they work. And you have these in your handouts, so you can look at them again and decide which ones work for you. But when I go into a situation where I get triggered with anger, or I have to pick up that phone call with that person I do not want to talk with, or I feel like something is about to happen, I stop. And by the way, you can do this anywhere. You can do this in a chair. I have done it in an airport. You can do it in the middle of a meeting because nobody knows what you're doing. Take a normal breath and pay attention to it. Take a second breath, slightly slower and slightly deeper. And then take a third breath, consciously aware of trying to slow your heart rate and your body. Wait a few seconds and repeat that. Now, I tend to call this stealth meditation because you can do it anywhere and it helps you slow down your blood pressure. It really does work. It's part of what's taught to people with high blood pressure to help them. And it helps me and it helps other people that have used it. So that's one stealth technique you can use in a tight situation. Nobody has to know you're doing it and it helps you stay centered so that you can do the other things like not taking things personally. Another technique, and I use this all the time as well, what else might this be? I call it. You feel something, you hear something that feels outrageous, maybe it hurts your feelings or you're just like, that's crazy. Recognize you're triggered. Take a breath. Ask yourself, what else can be going on? What is the backstory here? Carry on your active listening and give the other person the benefit of the doubt. See what you can learn that changes your reaction. The reason I say this is we often hear something, we get triggered and we believe what we think it is. That woman is a lousy mother. That person really just doesn't care. That person just wants to live in the hospital. We think all kinds of things based on our history, our emotions, what we've heard before, but what else can it be? Why might that patient not be adhering to the treatment protocol? What might be getting in their way that we don't know about? That's another technique. Third technique is what might they be afraid of? One of the things that's true is in the American society, and it's becoming more true as I'm sure many of you realize, it is not cool to be afraid that is considered weak. It's just plain out not cool. When people get afraid, what happens is they behave aggressively. Dogs and cats, when they're afraid, they're in the corner. What do they do? They hiss, they bark, they bite, they growl. They're afraid. They act aggressively. Human beings, when they are afraid, act aggressively. It is not okay to be afraid. It is okay in our society to be angry. By the way, anger and fear are actually the same emotion. They're both triggered by the amygdala. They're the flip side of the same feeling. When we get angry, if you ask yourself, what am I actually afraid of? You might surprise yourself to learn that you're afraid of something. Anger is fear turned outward. Fear turned inward often becomes depression. That's what that really is. It's the same sympathetic nervous system reactions. It's the same hormones. They are the exact same emotion. Someone triggers you, take a moment to recognize your fear and anxiety, admit it. Notice the desire to fire back or to counter and breathe. Ask yourself what might be to be afraid of that spawning this reaction, and then respond to their fear, not their words. I don't know if you remember Antoinette Tuff. She was the school secretary down in Georgia, I believe it was, who talked the gunman out of shooting and, in fact, into giving himself up. I've listened to that tape, I can't tell you how many times. She was amazing because all she did was stick with him and say, it's okay, honey. I know you're scared. I know you're mad. How are we going to get out of this? I've been scared and mad, too. If you ever get a chance, look up the YouTube of the tape of Antoinette Tuff, T-U-F-F, talking to him. Finally, if all else fails, walk away. If something you're said and done that makes you blind with anger, you do not trust yourself. State I cannot process what's going on at this time, I'll come back when I cool off and walk away, but ensure your physical safety. That is better than making the situation worse. Finally, and I said finally before, but admit a lack of understanding or confusion. It's okay to say, I don't know, I am confused, can we start again? So where does this leave us, besides at 8.53 my time? Leaves us at point four, which is difficult communication will never be easy, but you can be effective. And what do I mean by that? Well, first of all, if it ever gets too easy, like I said in the beginning, you've hardened yourself and maybe you need to take a break. And I say that with love and respect. Be willing to let go of the notion that you can see everything clearly, because none of us can. Fish can't see water. We can't see what we're in the middle of. There's a wonderful book of the, in the Garden of the Beast, which is about World War Two. And people, the guy who was the, it's by Eric Larson, for those of you who like Eric Larson. It's about the guy who was the ambassador to Germany, right? As World War Two was starting and how the people really couldn't see exactly what was going on. And I think about that, when I think about we're in the middle of a situation, we can't always see the best we can do is be clear and keep ourselves calm. Be willing to let go of the idea that there's only one way to see it. Be willing to question what else can be going on here that I don't know or haven't thought about. Be willing to accept the other person's not hearing what you intend and what you see and believe and listen with an open mind. In that way, you can be effective to work with them. Even if you can't get them to your point of view, you can be more effective with them. And that's the goal of having a difficult conversation. Remember, our view is the lens through which we judge the world based upon our learned beliefs, filtered through our nervous system. And we must use our view with compassion to listen. That's what's missing in traditional discussion, communication discussions. We rarely talk about the impact of our view on our ability to listen. We need to learn from one another and stand up for one another. And I'm going to say thank you. And I am open to questions. I'm going to stop sharing. I hope you had some new ideas here today that changed something for you. Brian, do you want to help take questions? Yes, that was great. Thank you for your time. As it was mentioned, we have a couple more minutes. So I think we have Dr. Clemens, you're more than welcome to come on screen. Or unmute yourself to ask any questions you may have. Hi, I don't have a question, but that was just amazing. That was so good and very helpful. And I've been working on my communication too. And I learned some new things tonight. So I just want to say thank you. Thank you, Dr. Clemens. I so appreciate that. Thank you. And thank you for speaking up. You're welcome. Thank you. A note in the chat. Thank you. Any questions or things that I can do to make things clearer for people? It looks like people are starting to sign off. I just want to tell you thank you for the opportunity to talk with you tonight. I really enjoyed it.

effective communication skills

difficult dialogue

patient care impact

communication breakdown

depersonalizing conversations

active listening

asking questions

managing anger

compassionate listening