Discussion with audience – what is their view of dissonance? Conflict? Can we come to a common understanding?Discomfort in ourselves? In the other? In both?Words, settings, witnessing suffering… Feelings are what define this… “Dying” “will die” “Cancer” “Spread” – how do they feel compared with “metatastasized” “treat”
Exercise on what have you done well? Seen done well? Delivery of news, etc. Diads – dialogues. Experiencing counsel.
Describe types of encounters… Like the discus thrower, the cake eater… (Kelly’s patient), the patient who wanted to go home.
Click clip from DVD player first if possible video clip 4
What would have happened if it were just the last stanza? Without the dissonance?
This time, turn back to the diad – tell a different story. This time, share a story of a tough incident: witnessed or experienced. Something you feel ok sharing here, now. Remember, listener, your role: to hold these words in complete confidence, to listen, to watch. Don’t touch. Try not to give too many non-verbal cues. Simply watch. Notice what comes up inside of you and in the person before you. Be aware. Be present. When done speaking, simply say, “I have spoken.” After, listener, respond with, “I have heard.” Then change the role.
Nurse who feared the morphine…Physician who feared stopping the IV antibiotics…Clinician who changed the goals of care… confusing all…
Dissonance in healthcare
Space between two notes:Dissonance in healthcare encounters Suzana Makowski, MD MMM FACP Assistant Professor of Medicine Palliative CareUMass Medical School, UMass Memorial Healthcare
My life is not this steeply sloping hourIn which you see me hurrying.Much stands behind me; I stand before it like a tree;(and you look like a tree there, for a moment)I stand before it like a tree;I am only one of my many mouths,and at that, the one that would be still the soonest.(By this time the person you ran into is backingoff down the corridor. Then you follow them, and you say,)I am the rest between two notes,which are somehow always in discordbecause Deaths note wants to climb over—but in the dark interval, reconciled,they stay there, trembling, And the song goes on, beautiful.(from Selected Poems of Rainer Maria Rilke (Translated by Robert Bly)
DissonanceLet me explain dissonance. Dissonance can be described as notes whose frequencies are less than "harmonious” to our ears.For instance, playing notes that are one half-step apart (open first-string E played with the fourth fret of the second string, a D#) is considered dissonant by most people. Playing notes that are a major seventh interval apart, 11 frets, is also considered to be quite dissonant; for instance, play the open second string (B) together with the 6th fret of the first string (A#).However, dissonance is a requisite part of most music that we hear, providing it with "tension" that leads to "release. "Without it, we end up with music that tends to command little attention.- Mark Hanson
How are we taught?• Official teachings• Unofficial teachings• Patient encounters• Colleagues• Interdisciplinary interactions
The physician-patient encounterBad News in the ERThe serious young doctor started the story at the beginning.“Your son was at a concert when he collapsed.”Can I see him? “An ambulance was called. EMTs started CPR.”Where is he? “They tried to revive him, but got no response.”Please... “They brought him here. We worked a long time.”Oh God. “We didn’t want to give up. He was so young.”I searched the doctor for sorrow found a stoic earnestness. He ended with an apology.“I’m so sorry,” he said, as if he’d hurt my feelings, as if I could forgive him.Alchemy of Grief – Emily FerraraFirst published in Family Medicine
Difficult encounters• The meaning of distress is as important as the symptoms themselves. – Eric Cassell• Curiosity: – with where this is coming from, – how despair will manifest, and – how/whether resolve will follow.“There is only one way to understand the other person’sstory, and that is by being curious. Instead of askingyourself, ‘How can they think that?!’ ask yourself, “I wonder whatinformation they have that I don’t?’… Certainty locks us out oftheir story, curiosity leads us in.”(page 37 – Difficult Conversations)
Lessons from Mahler and Brahms• Brahms meditation
Dissonance - Resolution• Reflection on listening to Dr. O’Reilly speak of Mahler and when you listened to Brahm’s: – Act of listening – What happened in the piece? – What did you experience?“Something about Music directly links us to the Eternal, the Divine, theSpiritual. […] It’s the sense of awe that is awakened in us at momentsin life when something helps us get in touch with the fact that thematerial world is just the smallest part of the wonder of it all.So I think healing has to do with slowing down, coming into thepresent, listening, accepting, forgiving, entering into community with,and healing is prevented by the opposites of those things.”- Balfour Mount, MD
“Good listening requires an open and honest curiosity about the otherperson, and a willingness and ability to keep the spotlight on them.Buried emotions draw the spotlight back to us...Our listening abilityoften increases remarkably once we have expressed our own strongfeelings.” (page 90 - Difficult Conversations)
Outside the patient’s room…Other physicians,Nurses, social workers,Administrators…How do theseprinciples apply?
Ladder of Inference– Peter SengeFifth Discipline Fieldbook, 1994“We all have different storiesabout the world because weeach take in differentinformation and then interpretthis information in our ownunique ways.In difficult conversations, toooften we trade only conclusionsback and forth, without steppingdown to where most of the realaction is: the information andinterpretations that lead each ofus to see the world as we do.”(page 31 Difficult Conversations)
Dissonance and Empathy• What is our role? – To be honest – To lend strength and alleviate suffering• How do we not burn out? – Exquisite empathy – Self-awareness practice – SolitudeKearney MK, Weininger RB, Vachon ML, Harrison RL, Mount BM. Self-care of physicians caring for patients at the end of life: "Being connected... a key to my survival". JAMA 2009 Mar 18;301(11):1155-64, E1.
The Prerequisite to Practice: It’s more than “self-care”• Mindfulness practices/compassion practice: meditation, music…• Story-telling• Narratives• Medical Humanities• Solitude, reflectionStudy (Lutz, Davidson) showed that long-term meditators on compassion’s response to vicarious suffering surprising.
On Breaking Bad News By Emily Ferrara – used by permission.after William Carlos Williams Not in print.Nourish the subtle body between“I” doctor, and “Thou” patient.Tend not to the news—for lackof what is found there (men dieevery day)—but to what is foundbetween. The unarticulatedfear, sadness palpable in the deepeningdark, broken by touch, eyes brimminghollyhocks, double-blossomed whiteand multiple magentas take breathgive life, subtle body, what is foundis nourished, is all we have. Lean in.
Some Resources• http://www.upaya.org/bwd/• http://litmed.med.nyu.edu/Main?action=new• http://www.umassmed.edu/Content.aspx?id=41252• http://pallimed.org• Cassell EJ. AAHPM annual meeting 2009. http://www.aahpm.org/education/09conf/09highlights.html#nature• Ferrara E. The alchemy of grief : alchimia del dolore, traduzione di sabine pascarelli. 1st ed. New York, NY: Bordighera Press; 2007.• Goleman D. Emotional intelligence. Bantam 10th anniversary hardcover ed. New York: Bantam Books; 2006.• Kearney MK, Weininger RB, Vachon ML, Harrison RL, Mount BM. Self-care of physicians caring for patients at the end of life: "Being connected... a key to my survival". JAMA2009 Mar 18;301(11):1155-64, E1.• Lutz A, et al. Regulation of the Neural Circuitry of Emotion by Compassion Meditation: Effects of Meditative Expertise. PLoS ONE; 2008. http://psyphz.psych.wisc.edu/web/pubs/2008/LutzRegulationPLoSONE.pdf• Martensen RL. A life worth living : a doctors reflections on illness in a high-tech era. 1st ed. New York: Farrar, Straus and Giroux; 2008.• Nepo M. The exquisite risk : daring to live an authentic life. 1st ed. New York: Harmony Books; 2005.• Stone D, Patton B, Heen S. Difficult conversations : how to discuss what matters most. New York, N.Y.: Viking; 1999.• Drazen RY. A Wayfarers Journey: Listening to Mahler (movie)