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Why words matter so much in critical doctor-patient conversations

New research by Stanford Medicine clinicians and scientists aims to ensure that doctors know the right words to use in critical conversations.

When Loren Sacks, MD, said I could test a virtual reality training simulation for doctors on managing difficult conversations in critical care, I knew it would be tough.

I met Sacks, a doctor in the cardiovascular intensive care unit at Lucile Packard Children's Hospital Stanford, when I interviewed him for a story about the challenges in health care of getting such conversations right, and the ways those conversations could go awry.

The development of the VR module is among several initiatives by Stanford clinicians and researchers who understand that when clinicians aren't skilled in end-of-life care, patients and their families could end up not fully grasping the severity of their -- or family members' -- illnesses or care options.

For the simulation, I had to tell an avatar father it was time to disconnect an artificial heart pump that was keeping his son alive.

As an editor my work depends on finding appropriate words, especially in sensitive situations, so I figured I'd do OK. Also, I've felt the helplessness and grief when loved ones had devastating health problems, or died either unexpectedly or after long illnesses. So I don't shy away from talking with other people going through the same things.

But neither my professional nor my personal experiences left me well prepared. During the simulation, prompts and suggested language streamed across the screen: Tell the father there are difficult things you need to discuss together; ask open-ended questions ("Tell me how you think your baby is doing?"); explain why the heart pump is no longer helping his son and suggest that he talk things over with his wife; tell him the care team will support them through the next steps.

Still, I stumbled, struggling with what to say, as the father slumped in his chair, cried, then stood up and started pacing, demanding to know why something else couldn't be tried.

I came away frustrated at things I'd uncharacteristically done wrong: I put up a wall of "professionalism" that prevented me from showing empathy. And I didn't know if it was acceptable to say I was sorry, so I didn't -- Sacks later said I could have. I kept repeating pat phrases and couldn't find words of comfort.

For the next few days I was sad, thinking about the devastation that parents who lose a child experience.

David Magnus and Jason Neil Batten are studying why common words physicians use often mean different things to patients.

I can't imagine being a doctor who's charged with giving someone that news. But Sacks and others I interviewed for the story understand the importance of using the right words, tone and emotion in those situations, and they see it as a privilege to be in a position to help families through the worst times of their lives.

"That is, to me, as powerful as anything else we do, because this is an event, a time in this patient's life, that's going to be remembered forever," said Marcos Mills, MD, a pediatric cardiology fellow who works with Sacks.

Still, even people who have are practiced at having those conversations sometimes look a back and wish they had handled one or another differently.

"It's really hard emotionally and psychologically. It's hard to do, and it's really hard to do it well," said David Magnus, PhD, whose team is using linguistic theory to examine the root causes of doctor-patient miscues, and to understand why common words physicians use to explain challenging medical concepts -- such as "treatable" or "comfort care" -- often mean different things to patients than they do to doctors.

"Our research shows that even when physicians seem to be doing a good job, there is the potential for miscommunication."

That's why he and others are working to increase awareness and training options, especially because opportunities to learn this skill are traditionally limited.

"The vast majority of what people learn is from watching an attending or a supervisor do it, or being pushed to just do it themselves and figure it out," Sacks said.

New tools like virtual reality might give these doctors a chance to flub their delivery before an avatar, gaining the skills they need to share awful news with real people as compassionately as possible.

Illustration by Jeffrey Decoster; photo by Steve Fisch

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