Monday, March 27, 2017

irresistible communication


If you’re interested in storytelling as a diagnostic and therapeutic tool, you should get a copy of the book, “Irresistible Communication” by King, Novik and Citrenbaum. (It’s out of print but still available “used.”)
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In this book, the authors discuss subtle communication techniques that encourage and facilitate storytelling in the clinical setting, for example, when delving into a patient’s medical history. These techniques operate on a subconscious level to engage the patient/client in ways that relax him, and affirm the fact that he is being heard and understood. They enable the clinician to read the patient’s body language and to understand how the patient accesses and processes information—whether he is a visual, auditory or kinesthetic learner—and how this affects memory, receptivity and comprehension.
“Seek first to understand,
then to be understood.”
~Stephen Covey~
Some of this is accomplished by simply mirroring the patient’s posture, respiratory rate, eye movements and positional changes. If the patient is anxious and breathing rapidly, the clinician can begin by matching the patient’s respiratory rate and then gradually slowing and deepening his own breathing. When the patient is engaged, his breathing will begin to slow and deepen, enabling him to relax. His anxiety will then lessen.

Observing the patient’s eye movements can tell a lot about how the patient processes information. Whether his gaze is directed upward to the right, upward to the left, or to one side or the other suggests the predominate sensory pathway by which he accesses memory.
Let’s say the patient was involved in a car crash. You can get a good idea of how he remembers it by the direction of his gaze and the language he uses to describe the scene. For example, he may say, “I heard the tires squeal right before the truck slammed into my car,” while gazing sideways and to the right, where the impact occurred. He is processing the accident according to what he remembers hearing. If you ask him, then, “What color was the truck?” this will take him out of his story. His memory will blur and important information may be lost, whereas if you ask him, “What else did you hear?” he may recall the sound of crumpling metal, broken glass, the voices of people coming to help, the sirens…all in accurate detail. He may never remember the color of the truck if he doesn’t process memory visually.

A visual person might recall the way the blood splattered on the windshield or way the lights were flashing in the ambulance. His gaze may be directed up and to the left or right as he recalls the details.

A kinesthetic learner might describe the shards of glass striking his face, or the sharp pain in his neck at the moment of impact.
The same traumatic experience can be recalled differently according to the patient’s predominant sensory processing pathway.

“To effectively communicate,
we must realize that we are all different
in the way we perceive the world and
use this understanding as a guide
to our communication with others.”
~Tony Robbins~
Interestingly, the clinician can put this information to use when treating the patient. The visual learner may benefit from written instructions or diagrams. The auditory learner may do better with a CD or audiotape. The tactile learner may constantly want to touch the injured area. Ask the visual learner, “Do you see what I’m saying?” Ask the auditory learner, “How does that sound to you?” Ask the kinesthetic learner, “How do you feel about that?”

Repeating or rephrasing what the patient says is another way to improve effective communication. Asking the patient to repeat instructions is also useful. How many times has a patient gone home with written instructions when he can’t read…
This, of course, is an oversimplification of a complex and intriguing approach to communication techniques. Since “Irresistible Communication” was published almost 35 years ago, a vast amount of research into the neurophysiology of sensory processing pathways has been published.

It reminds us that a lot more goes into narrative than telling a story, and listening involves a lot more than just hearing.
"I know that you believe you understood
what you think I said,
but I am not sure you realize
that what you heard is not what I meant.”
~Robert McCloskey~

Thursday, March 23, 2017

memories are made of this


As a retired physician, I am bursting with memories. Some are biggies…like the five-hour ambulance ride it took to transport a fragile premie from a rural upstate hospital to the medical center where I was a resident. Lights and sirens the whole way. Or running a clinic out of a tent in the African bush without electricity or running water. Or prepping a patient who was sent to the OR by the emergency room doc for an appendectomy in the middle of the night…when my pre-op exam revealed a leaking aortic aneurysm instead. That got things moving!
On the other hand, some memories are brief, isolated moments that punctuate the middle of a busy day…a dousing with pee during a newborn exam, a spontaneous embrace or word of gratitude from an appreciative patient, a smile or a grimace or a groan.
“We don’t remember days.
We remember moments.”
~Cesare Pavese~

Monumental or trivial, happy or sad, memories stick with us. When you consider the number of patients we see every day over the course of our careers, all the details we tend to, all the information we process, it’s amazing we remember any of it.

Imagine, though, what it must be like for your patient. You may already have seen twenty patients that day. It’s all a blur. Each patient, on the other hand sees one physician or provider that day—you—and will be totally focused on this particular encounter. Years later, he may still recall the fear or dread that tempted him to cancel his appointment. The smell of cigarette smoke on your clothing. The impatient sigh that escaped when you glanced at your watch. How cold your hands were, or how warm. How hurried you were, or how kind…
“…You will never know the value 
Of a moment
Until it becomes a memory.”
~ Dr. Suess~

 …when you don’t remember the patient at all.
Whether you’re a provider or a patient, if you’re interested in narrative medicine, you have to tap into those memories. Relive those moments. Reflect on your experience. And share what you have learned.
“One day you will be just a memory
For some people.
Do your best to be a good one.”

Monday, March 13, 2017

it's not too late...yet

If you are interested in, or simply curious about the concept of narrative as an instrument of healing, you should run right out and pick-up a copy of “What Patients Say, What Doctors Hear” by Danielle Ofri, MD.
In this book, the author explores the doctor-patient relationship and tackles the issues of communication and miscommunication and how they affect medical outcomes. If you harbor any cynicism about the relevance of narrative medicine as a healing practice, you should read this book. If you want to learn more about it, you should read this book. Then lend it to a friend. Or two. Or three…
Among the issues she tackles are:
·       Obstacles to effective communication that suck the best of us dry—time constraints, over-booked schedules, exhaustion, and burdensome mandates and initiatives that have nothing to do with improving patient care

·       The importance of listening skills when obtaining the patient’s medical history, and how our body language, attention and response can intimidate or discourage the patient from sharing important parts of his story

·       The importance of our personal backstory, and how it affects our expectations and interactions with patients

·        How the use of jargon reflects our attitudes about patients, for example, referring to the disease rather than the person who has a disease (the diabetic, the epileptic, the asthmatic) or labelling the patient who “failed” treatment, the “poor historian”, or the “noncompliant” patient

·        The effect of gender, race, culture, socioeconomics, and religion on communication

·        How to break bad news to the patient and his family

·        The correlation between poor communication and malpractice claims, and the pros and cons of disclosing medical errors

·        How effective communication influences the perception of pain, and how this has been likened to a placebo effect

…none of which we learned about in medical school.
Thankfully, it’s not too late for us. Narrative medicine is all about communication as a healing practice. If it interests you, I recommend Ofri’s book. And…if you missed the debut conference on Narrative Medicine at Kripalu Center last summer, the good news is that they are running it again this year and registration is now open. You can find a link to this summer's conference here
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Among other leaders in the field, Rita Charon will be speaking.
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Rita Charon
Rita Charon, MD, PhD, is professor of medicine and executive director of the program in Narrative Medicine at the College of Physicians and Surgeons of Columbia University. She completed her MD at Harvard Medical School and her doctorate in English at Columbia. A general internist, Rita took her PhD when she realized how central the telling and listening to stories is in the work of doctors and patients. She teaches literary theory, narratology, and creative writing to students and faculty at the medical center and in the graduate Narrative Medicine program. Rita is author of Narrative Medicine: Honoring the Stories of Illness, coeditor of Psychoanalysis and Narrative Medicine and Stories Matter: The Role of Narrative in Medical Ethics, and coauthor of the forthcoming Principles and Practice of Narrative Medicine.
Also attending again this summer will be Nancy Slonim Aronie (my fav).

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Nancy Slonim Aronie

Nancy Slonim Aronie is the author of Writing from the Heart. She has been a commentator for National Public Radio’s All Things Considered, was a visiting writer at Trinity College in Hartford, Connecticut, wrote a monthly column in McCall’s magazine, and was the recipient of the Eye of The Beholder Artist in Residence award at the Isabella Stewart Gardner Museum in Boston. Nancy won teacher of the year award for all three years she taught at Harvard University for Robert Coles.

If you are interested…and you should be…check out I’d love to meet you there.