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We sit down with Kim Downey, a physical therapist, and Frances Mei Hardin, an otolaryngologist, to dive into the nuances of navigating difficult discussions in the medical field. From delivering challenging diagnoses to addressing patient concerns, we’ll uncover strategies for preparing, communicating, and fostering understanding in crucial moments. Tune in as we share insights, personal experiences, and practical tips for mastering these essential conversations.

Kim Downey is a physical therapist. Frances Mei Hardin is an otolaryngologist.

They discuss the KevinMD article, “How doctors can have successful crucial conversations.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, and get CME for this episode by clicking on the CME link in the show notes. Today we welcome Kim Downey and Frances Mei Hardin. Both have been on the podcast before. Kim is a physical therapist and a physician advocate, Frances is an otolaryngologist, and together they wrote the KevinMD article “How doctors can have successful crucial conversations.” Kim and Frances, welcome back to the show.

Kim Downey: Thank you, Kevin.

Frances Mei Hardin: Thank you so much.

Kevin Pho: So how did you find Frances, and what about her story resonated with you?

Kim Downey: Sure. So we met, actually I reached out on January 1st, just a couple of months ago, and I said to Frances that we share many mutual connections and I’m working on finding ways to make positive changes in the health care system. She responded immediately, she thanked me for connecting and said she’d love to collaborate, and she told me some of the things she’s doing with her Rethinking Residency website.

So I told her some of the things I was working on as well, and I shared the link to my latest collaborative KevinMD article, which at the time was the one with Dr. Bryce Bowers and Dr. Beus Babad about why physicians share their stories of healing through writing. And she said she loved it and she’d be happy to meet to chat. So we had a conversation two days later, and our collaborative article is one of the things that evolved from our conversation.

Kevin Pho: Excellent. And Frances, you’ve been on the show before. Just for those who didn’t get a chance to listen to your story, briefly share it again, and then go straight into your article about crucial conversations.

Frances Mei Hardin: Yeah, absolutely. So I was so happy when Kim reached out. I did want to make a plug that I think we’re kindred spirits in a sense, because I’ve been told I’m a good texter, I reply immediately, I’m pretty on top of my emails, I like an empty inbox, and Kim is absolutely on top of it. So between the two of us we are very effective and productive, because we’re always on top of our messages and everything. So it’s been a joy to work with you.

In terms of my background, I am in my second year of full-time ENT practice, but after residency I also created my brand, Rethinking Residency, which is to provide resources for physicians in training and early career physicians, medical students as well, to promote their well-being and mental health.

And so certainly Kim and I have a lot of the same long-term goals and these overlapping interests. What I loved about our article on having crucial conversations is that it’s just such a skill that helps people succeed at really any level of training. So this includes premed, medical students. Certainly resident physicians do get a crash course in having crucial conversations, and hopefully having them well and effectively. But this is just such an awesome tool for physicians, like I said, at every point in the career. I would imagine that even midcareer and beyond, people are thinking, how can I have these crucial conversations better?

Kim Downey: Well, I had had some crucial conversations with my doctors, and I’ve had a little bit of training. So the authors of the book about it describe it as a discussion characterized by high stakes, differing opinions, and strong emotions. So obviously doctors need to have crucial conversations lots of times with patients, but in my case I had to have a couple of crucial conversations with my doctors. But we all have them, all the time, with people in our lives.

Kevin Pho: And Kim, with those crucial conversations that you had with your medical team, without going into too much detail, what was that like for you?

Kim Downey: Sure. So it was scary. And one of the things that you have to do to start is you have to determine your motive, what you really want out of the conversation.

So for me, and I’ll just keep to one, I had at least a couple that are in my mind right now, but if I’m just speaking to one, I really wanted them to be able to listen to me without getting defensive. So one of the characteristics is, you start with a heart. So I started by sharing a compliment, and then I did go into the things that I needed to discuss with them, but then I tried to wrap up with a little bit of gratitude as well. So, sandwich the difficult things in between some kindness.

Kevin Pho: And Kim, again from the standpoint of a patient, when physicians undergo crucial conversations, you mentioned a little bit about this, but go into more detail. What exactly would you like to see from them when they’re approaching difficult topics?

Kim Downey: Sure. Well, to be honest is a really big thing. And what we have to think about when we’re having the crucial conversation is what the facts are.

So in my case, a complication occurred and I wasn’t offered an apology at the time, and I struggled emotionally for a long time. So in any way that the doctor can offer an apology, in a way that they’re comfortable doing so, when there’s a complication, it would make a world of difference.

And actually just this morning someone was here at my house, and I happened to say in passing that I was about to do this podcast and what it was about, and then I read her, and I’ll actually read it because it’s so important, a paragraph from Dr. Jean-Paul Brutus. So I found out about him, I read his article from your site, and he has this book, Secrets and Lies from the Operating Room, and he talks in there about what to say if there is a complication, to a patient. And I read this to the other person in my house and she started crying, and for both of us it would have made a world of difference.

And what he says is, I’m very sorry this has happened to you. This is not the outcome that any of us wanted for you. I’m disappointed that you have had to go through this. I know that you are feeling very upset, frustrated, and angry, and I would be feeling the same way. All I can do is say I’m sorry that you’re in this situation, and we’re going to do everything we can to understand the events leading up to this so that we can avoid it happening again. In the meantime, I want you to know that I am here for you if there is anything I can do.

Kevin Pho: Frances, in your world of otolaryngology, tell us about some of the crucial conversations that you have with patients.

Frances Mei Hardin: Yeah, absolutely. So from my standpoint, I definitely understand where Kim is coming from, and we really connected over some of her medical experiences in the past.

I do want to shout out Kim again, because something that she did so well, that really touched me in learning her story, and that I think all physicians benefit from hearing, is truly the level of preparation that she brought into those conversations. Because she does talk about, I mean, she read Crucial Conversations, she visualized how those conversations could go, she played out different ways to really thoughtfully come into them, like she said, in a way that doesn’t make the physician defensive, or tries to avoid that type of outcome for the conversation. I just think she did so much to prepare, and that really inspires me, on the surgeon side certainly, to do all that level of preparation to improve my practice and improve the way that I communicate with patients as well. Of course it’s awesome how you did that, and it leads to you being such a phenomenal patient advocate for yourself. But we should all be bringing our best selves to these crucial conversations.

In my daily life, really in my practice, I’m at a rural community hospital, I’m in solo practice, and I have a lot of really locally and systemically advanced head and neck cancer come into my clinic. Certainly even outside head and neck cancer, a lot of young people with lymphoma. And so I would say that where I get to practice these skills, and where I do really try to bring my absolute best level of communication and empathy, is with breaking the news of these new cancer diagnoses, because that’s typically one of the big cruxes that I myself and my clinic work on with these patients.

Kevin Pho: And Frances, when you have to give patients cancer diagnoses, or difficult news in general, tell us some of the challenges that you face from the physician side.

Frances Mei Hardin: Well, I think it’s just so important, as a physician, I can probably predict the first one to five questions that they’re going to have. They’re going to be questions about, well, what does treatment look like, in a very real sense, and also they start asking about survival numbers.

And so, like I said, at the point that I’m seeing them, I am that really first step. They are coming to me with an unknown etiology three or four centimeter large neck mass. And what I tell them is, I will of course scope them, let’s say I find a lingual lesion and I’m thinking this is a larynx cancer and it went to the neck and they now have a large neck mass. What I tell them is, I show them all the scope images, we have the technology, we show them the images and the videos in clinic, and I don’t hold any punches about saying I’m concerned that this is a malignancy. I say, this is suspicious for being a more sinister type of process. Of course, nothing’s settled until we have the biopsy and we’ve proven it, but it is my job to worry about you, and it’s my job to treat things like they could be cancer until we’ve proven that they aren’t.

And so I really show it to them, and I say, OK, we’re not going to panic either way, because I also need them to get through the workup with me, which is imaging and tissue diagnosis. And so that means I’m ordering a lot of CT scans, and then we come up with the biopsy plan, whether that is an FNA or tissue from the operating room, or however we need to get pieces of this.

But I feel like I come at it in a way where I do say, we are a team in this, I have to get you a couple more answers before we get you down that treatment pathway. Typically when they come back post-biopsy, that’s when we really get into treatment. But broadly, if I can see that this is a head and neck primary, or let’s say it’s an HPV tonsil cancer and I can see that it’s a cystic neck mass, it’s a classic presentation, I will start talking to them about broad categories of treatment, things like primary surgery versus primary radiation.

Kevin Pho: Kim, the article mentions the concept of psychological safety during crucial conversations. So talk more about that and why that’s so important.

Kim Downey: Sure. That would open up the person to really being able to listen to what you’re going to say. Because if you just go in there and start yelling or complaining or accusing, they’re going to shut down and they’re going to get defensive and just think of how to respond.

Whereas if you can start, again, we call it start with a heart, and come from a place of true good intention of trying to explain how you feel, and using the I statements instead of the you did this or you did that, or accusing the other person. And again, because I planned, I just went over it over and over and over in my head, probably more than I had to, but I wanted to make sure that they would feel safe to listen to me. And the way I presented it, they did.

And so Frances and I had this conversation, and that’s how we ended up writing the article. She does such a great job, I want to give Frances a plug for her Rethinking Residency and all of the things she’s doing for residents, and the things that they need to learn, and the way she wants to support them. And after our conversation she thought they could benefit from knowing this and from learning this, and that’s why she asked me to write about it.

Kevin Pho: So Kim, when you think back to some of the positive interactions that you had with your medical team, which ones particularly stood out to you, and what exactly did they do right during these crucial conversations?

Kim Downey: Well, the doctor that I have in mind at the moment, it was a year later, it was a year after my surgery, and I just wanted to talk to her about it, and she didn’t know why we were having the meeting. But the way I presented it, she really did listen to me, and I could tell that she was, and she actually apologized a few times during the conversation. And I could tell, in a few things that I thought could have, should have been done differently, she really seemed to take that to heart, and that she would try to do things differently in the future. So I think that was really just the most important thing.

And then another doctor thanked me for telling him, and I thanked him for listening. And then I could tell, by the rest of our conversation, because I was really scared, and because having a relationship still with this physician was very important to me, but the way we continued our discussion, I could just tell that it didn’t have a negative impact on our relationship. And if anything, I think it increased our respect.

Kevin Pho: Frances, when having these difficult conversations with patients, these crucial conversations, what are some things that you did to get better? And for those physicians listening, what kind of tips do you recommend for them so they can get better in these conversations?

Frances Mei Hardin: Yeah, I think one thing that made me better was, one, anticipating questions, because there’s always a pattern to how these play out, giving a new cancer diagnosis. And then two, having this real understanding of how significant that news is. That has led me to really distill things down.

Like I said, at that visit I find a lesion on scope, they already are coming in with this neck mass and it’s metastases to the neck, and what I’ve done is I just say, this is a two-step process. Number one, imaging. Number two, tissue diagnosis. And then you will see me. And sometimes I’ll write it down if I can see that the family needs it. But that’s something where at least even their loved one who’s with them, and ideally even the patient, they can find that palatable.

Because the very real reality, and for those of us who have experienced a cancer diagnosis for a loved one or anything like that, health care worker or not, we’re aware of the tunnel vision that can occur. I mean, just total ringing in the ears, not getting the information. So I think distilling it down to these very bite-sized smaller pieces.

And I always have close follow-up with those patients. I’m talking, come back in a week. In these early days we do do that, to make sure that the family has all the resources and support that they need. Because of course they sometimes have nutritional needs, where our hospital or our clinic nurses can help coordinate all of that, or there has been an insurance hiccup or something like that, or a financial aid packet didn’t go through.

And so I think that one way where we are thankfully able to provide better care is by keeping a pretty close eye on these patients at all the steps of their workup. Of course, by the time that the patient is already mapped out for radiation and they’re set up with their oncologist, that’s awesome, then I say, see me in four months, you’re going to focus on your treatment now. But I do think that providing that extra level of care, and of course we’re lucky to have a team in clinic where the nurses do care and spend a lot of their time dedicated to families, that’s one important piece of it.

Kevin Pho: Frances, I like how you mentioned the importance of follow-up. It’s not like you just have a single conversation and then that’s it. It’s so important to have that ongoing follow-up, because this is a journey, right?

Frances Mei Hardin: Absolutely. And there are things that really set in a lot better when we discuss them just one week later, because now, especially for our older patients, they bring some of their adult children to the follow-up, and we welcome that. I think that that’s awesome. And I mean, sometimes I do have those conversations with family over the phone, where they call them in clinic. But giving them every opportunity to get people here face to face and asking me the questions in person, I’m all for that, and we promote it.

Kevin Pho: We’re talking to Kim Downey and Frances Mei Hardin. Kim is a physical therapist and physician advocate, Frances is an otolaryngologist, and together they co-wrote the KevinMD article “How doctors can have successful crucial conversations.” Now I’m going to end with each of you just sharing some of your take-home messages to the KevinMD audience. Kim, why don’t you go first?

Kim Downey: Sure. So we ended our article with a quote from Dr. Sarah Wittry: “Healing is in speaking our truth, validating our experiences and those of others.” And I added that that rings true for doctors and patients.

And to the doctors first, give yourself some grace. There are going to be complications sometimes, even when you’re doing your best. And one thing you can do ahead of time is, whether you’re prescribing for a patient a new medication, test, or procedure, make sure they have true informed consent. Have them repeat back their understanding. This is really critical, so that they aren’t totally blindsided if a complication occurs.

And if a complication does occur, be honest, in whatever way feels safe for you to do so, including being honest and telling the patient what they can expect as a result of the complication. And do not minimize it, that just leads to false hope and confusion.

And lastly, being a doctor is really hard. We need doctors, so thank you. You’re both doctors, I appreciate you, and take good care of yourselves.

Kevin Pho: And Frances, we’ll end off with you, your take-home messages.

Frances Mei Hardin: Yeah, so I definitely echo your sentiment. I think that all of this, including Kim sharing her story in this whole conversation, and what we’ve depicted in the article, it is a reminder that these are crucial conversations.

I think that as physicians do get burned out, or maybe more experienced, more jaded about their experience, they may not be looking at this as a crucial conversation. When I look at my clinic schedule, this is legitimately like 25 crucial conversations really in a row. Maybe one of them’s an ear cleaning and that was less so a crucial conversation, but 20 plus crucial conversations.

And it’s such an important reminder, patients often, this is extraordinarily significant and meaningful to them. It affects their health directly. They have often prepared themselves for this visit. And so I do think that we have an obligation on our end to also prepare ourselves, really try to bring our best selves to the visit.

There are some people where, no matter how the information is presented to them, they might feel the need to get defensive. But that’s work on our own part that any physician can do, to premeditate on these things, to visualize, and just be prepared to approach it in an open manner where we don’t shut down or close up.

Kevin Pho: Well, thank you both again for sharing your stories, time, and insight, and thanks again for coming back on the show.

Frances Mei Hardin: Thank you, Kevin, very much.