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Certified coach Kathleen Muldoon discusses her article, “The cost of presence: a lesson in listening.” She recounts a poignant experience observing a health care student disengaged during a powerful presentation by a mother sharing her life as a caregiver to children with disabilities. Kathleen, who is also a medical school faculty member and mother to a child with complex health needs, reflects on the immense value of such shared stories for interprofessional students and the “cost of presence” willingly paid by these community educators. The conversation delves into the critical need for future health care professionals to cultivate presence, active listening, and empathy, even amidst academic pressures. Kathleen emphasizes that while technical skills are vital, truly seeing and hearing patients is foundational to compassionate and effective care. The key takeaway is: Medical education must actively foster an environment where students learn to honor patient narratives and engage with genuine human connection, as these qualities are as indispensable as clinical knowledge for the future of health care.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome Kathleen Muldoon. She’s a health care coach. Today’s KevinMD article is “The cost of presence, a lesson in listening.” Kathleen, welcome to the show.

Kathleen Muldoon: Thanks for having me.

Kevin Pho: All right, so just briefly share your story and then talk about the events that led you to contribute this article to KevinMD.

Kathleen Muldoon: I am an anthropologist who works in a medical school, and I initially taught basic sciences like anatomy. A lot of us anthropologists do that as experts in the human body and the evolution and development of the body. I did that for a long time. Over that journey, my own expertise was in embryology, and my middle son, my second-born son, was born with a lot of medical complexity with a congenital cytomegalovirus infection. That just changed my whole view on my role in medical education as someone who has a foot in the community and the disability space and also as an educator of future physicians. Through that, I really leaned into how we talk about things and how we frame our understanding of all sorts of the hidden curriculum, as we call it now in medical education.

That includes how we talk about disability, but also just how we model being present for each other. I would say the second time that I was forced into a reflection on my role in this was during the pandemic when suddenly we were all isolated into boxes like these. Suddenly I had a role to play in the pastoral care of our med students who were trying to do this really hard thing and navigate these really hard curricula at the same time as dealing with all the things that everyone else was dealing with: the uncertainty, the stress, and the stress of their future careers.

Through that, I was given the opportunity to develop a track of a curriculum that I call “the humanity in medicine.” It’s a course through which we practice having hard conversations. So I’m in front of the med students in lots of different ways, but this is one way. I’ve had the opportunity to partner with the students when, and I think this happens in lots of medical schools, a patient panel might be formed or a patient is invited to come and share their story.

The prompt that got me to write for KevinMD was this one incident about a month ago, where a mom, a caregiver in the disability community here in Phoenix, which is pretty small even though our city is pretty big, and then within that community, the kind of parent that would come to give this kind of talk is even smaller, right? The advocacy community. So I know this mom, and she has six children, four of whom are disabled. She came and was going to be coming over a series of weeks to present her story for one hour at a time. I was helping to navigate the people who were joining online for her talk, but most people were in person.

In this large space with all these students gathered, most of the students were paying attention. But there was one student just sitting right in front of her who was clearly just working on something else, scrolling through slides, doing something. And I just thought, what is the cost of this? To this person’s own professional identity formation, but also to this parent, right? This parent who is there to share her story. It just got me thinking about how do we teach and model presence and that very thing that gives you that authenticity and humanity in medicine that I think we’re in danger of losing.

Kevin Pho: So what happened next after this event in terms of offering feedback to this particular student?

Kathleen Muldoon: In the moment, I didn’t want to make a scene, but he was clearly in my view and he was clearly in the speaker’s view. As I said before, I’m a mom and a professor, and I did my best teacher stare at this student, just the international sign for: Stop doing what you’re doing and do better. So I drew my eyebrows down and was just staring at him, and it didn’t work. What I tried to do was intercept the student at the end of the time period, but I was barricaded by the number of students who were trying to leave the room or to say thank you to the speaker. So I didn’t have the opportunity to give the feedback.

I think that my article is this opportunity to share the message that I understand the demands on our time. Because we all have them, and everyone in that room had pressures on their time, and I have pressures on my time, but what are we losing if we give up that opportunity to be present and authentically and holistically present to hear each other’s stories and let that change us?

And I’ll say the meta-reflection for me is that I was angry in that moment because I was experiencing my own trauma as the mother of a child with 42 active coded diagnoses and who is very medically complex, from all the times where I have felt ignored by my son’s health care provider. So in some ways, it’s good I couldn’t intersect with him right then because I don’t know how open I would have been to hear his story.

But we’ve all met people who think differently than us, that make different choices from us. I would say my anthropology training is what informs my ability to learn from those moments, to ask those questions and stay curious because I want to know what leads you to make these decisions. And how do we—because in the long run, it’s not the kind of doctor I’m sure that this person anticipates being. So this article is my feedback to the whole community, instead of being able to reach that one particular student at that time.

Kevin Pho: Speaking from the perspective of a patient advocate, family advocate, and child advocate, tell us the impact when a clinician that you’re talking to is present in that moment. Tell us the difference that it makes during that health care intersection.

Kathleen Muldoon: It makes a world of difference, and you can tell when somebody is present to you because they’re listening to you. They’re taking your own individual circumstances into account. That makes the world of difference because you feel seen, you feel heard. Having the answers is not what a parent like me looks for because we know that not everybody is going to have the answers all the time. I don’t think that most parents expect a doctor to have all of the answers right away.

But what we want to hear is a willingness to ask the questions that center us and our experience and to take that in and truly see us. And if you don’t have the answers, say, “I don’t know right now, but we’re going to find out.” That partnership, I think, means the world of difference and makes the difference between a parent that is seen and adheres, or complies, or whatever the term we want to use, with the treatment plan, but feels like a true partner. And has that loyalty to that person because you know that they’re going to see you and center what’s best for that person or, in this case, my son in that moment. I think that that kind of trust means the world of difference.

Kevin Pho: As we know, attention is becoming a limited and scarce resource, and you have increasing amounts of distraction. Of course, you have scrolling apps, social media. You have all these digital devices that really take away from being present.

Kathleen Muldoon: There is a tension in medical education. It feels like, especially as more knowledge is gained that we want to impart to these students in the first four years of their training, which is where I specialize, we just put more and more and more in. And the problem with that is that there’s no expiratory system in medical education. So you do get distracted not only by the distractions that we all have, but by the tests in front of you and the mounting pressure. That is a very real thing.

How do you balance that against being present to your own self, in addition to the person in front of you and your own humanity? I think that that is where we’re all struggling right now. I don’t have the answer. I’m modeling this for you now: I don’t have the right answer. But what I would say is listening to yourself and knowing when you are out of balance with how you face the chores in front of you, with how you face your ability to pause and listen to your peers, your patient in front of you, your professors, whatever discussion space you’re in, is the thing that we’re not practicing enough.

I would suggest that being present, like many of the other clinical skills, is a muscle that you develop. The more that you practice just being intentional with your space—and I know, 15 minutes a visit, and just turning over, and all of the pressures and the EMR and all the things that are mounting up—having those things balanced against your ability to use those 15 minutes to be present is a real problem to look at from multiple angles. So the more that you practice, what are the ways in which I can show my presence, even in a small portion of that time? And be present to my own emotions. What comes up for me when I am present? I think those are the ways forward. When you start practicing that muscle, it’s just going to keep building and building and building.

Kevin Pho: Now, you mentioned that you teach a lot of medical students about how to navigate difficult conversations and how to be present. So what are some of the tips that you share with them during this time with all the distractions and navigating difficult conversations?

Kathleen Muldoon: I try to remind everybody that we approach these conversations from a place of curiosity. What we’re seeing, I think, nationally is that everybody wants to put another person into a box. And that is a way to distance yourself from them. But there are so many philosophies, so much research now that shows that when you can see the core value of another person across any kind of divide that might be in front of you, you can make that connection.

What we practice is when, especially when an emotion comes up for you because you disagree with somebody or somebody’s not being compliant or they’re challenging you, stay curious about why this person is acting this way. What I see is that core value. We even do exercises through a course I teach using improvisational theater techniques. For example: “This is my friend so-and-so, and they are somebody who values time efficiency, or money, or whatever it is that the challenge is that’s coming up or being seen in medicine.”

Then you can respond from a place of, “Well, I’m also somebody who values those things. So how do we move forward in this conversation?” It’s a way of saying that you identify with a person, not necessarily their idea or their behavior, but the core value, because we have so much more in common than we might suspect from the way that things have become so polarized and divided.

Kevin Pho: You mentioned polarization and division, and that’s all the more important because in the current political climate, there is an increased distrust in medical experts. So I think some of the advice that you share here is actually salient, not just from the medical education standpoint, but in medical settings in general.

Kathleen Muldoon: Yes, and then within medical education, within the larger climate, we’re in a situation right now where I think we are training future doctors to be brave in multitudinous ways. And so practicing that skill of courageous conversation, of moving things forward and being present to the person in front of you, I think is ever more important right now.

Kevin Pho: Now, is there a success story that you could share? It doesn’t have to be in the paradigm of medical education. It could be through your coaching practice where you implemented some of these techniques in an individual and it really moved the needle in terms of how they better stayed present and better communicated with patients.

Kathleen Muldoon: I mean, I think I’ve had the joy of having several. The course that I teach on courageous conversation is a mandatory course in the first-year curriculum at my medical school. There are some people, as you probably know, that sometimes can create a divide between what’s a hard science and what’s typically considered part of medical training—biochemistry, anatomy, physiology—versus the softer side, the more clinical skills. So there are sometimes students that are openly hostile against taking this course or these trainings.

Kevin Pho: What does that look like when they’re openly hostile?

Kathleen Muldoon: It looks like disengaging from the conversation. It looks like phoning in their responses to the discussion. I implement a reflective writing practice, both to practice the skill and to process my own emotions from this conversation, which has been demonstrated to decrease burnout the longer you’re in training. It looks like sometimes putting an armor on, from which you are not seeing the person in front of you. Sometimes that is previous experience. A lot of med students come into school now with work as a scribe or an EMT or previous experience and think, “I know how medical systems work; this is how it is,” and are unwilling to hear a different side of the experience, especially from a more minoritized person in the system. Sometimes it looks like putting your faith on as an armor. That’s what disengagement can look like.

One success story is that I did have a student who was very much like that this year and was, for lack of a better word, forced to be in community with me about these issues. The more that I could engage with this person and see through to them that, “You are my friend and we share this core value, that medicine is worth the hard parts and worth looking at all the underside in order to make it better and move it forward; we just have different opinions on how to do that,” the more that we practiced it, he is now one of the biggest proponents of this course. He takes some of the group roles for our discussion and the practices that we’ve implemented in order to see everybody in front of him in a different way.

It’s not necessarily about shifting anybody’s position, because we need that diversity of thought, but about being open to the invitation to the discussion, and then also the invitation within yourself to say, “What’s coming up for me in this conversation? Why am I finding it hard?” I’m just so proud of this student for meeting that invitation and taking on the challenge because it isn’t easy for anyone to do that. It is easier to distance a problem than to engage with it. So, I consider that one of my greatest partnerships.

Kevin Pho: We’re talking to Kathleen Muldoon. She’s a health care coach. Today’s KevinMD article is “The cost of presence: a lesson in listening.” Kathleen, let’s end with some take-home messages that you want to leave with the KevinMD audience.

Kathleen Muldoon: My take-home message is: what are we giving up if we give up that willingness to be present to each other even when we have distractions and other demands on our time? My call to the community is that we make each other and our systems stronger by being present to each other, even in discomfort, and to lean into that. It will always be worth it.

Kevin Pho: Kathleen, thank you so much for sharing your perspective and insight. Thanks again for coming on the show.

Kathleen Muldoon: Thank you so much.