Before you say a word

By Nettie Reynolds, MDiv, hospital and hospice chaplain, retired

 

Sometimes the hardest part of a challenging conversation happens before we’ve said a word. We’re walking toward a patient’s room, sitting outside a colleague’s office, or preparing to call a family member. We’re rehearsing. How do I say this? What if they become angry? What if I make things worse?

 

During my years as a hospital chaplain, I participated in difficult conversations with physicians, nurses, other healthcare professionals, patients, and families. Sometimes I was there because a patient or family was struggling with what the care team had told them. Other times, members of the clinical team were trying to work through a difficult situation themselves. The circumstances were always different, but someone usually needed to say something that wasn’t easy to say, and another person needed to be able to hear it.

 

How do we enter the conversation?

Before thinking about what we’re going to say, it can help to think about how we’re entering the conversation. Are we going in determined to convince someone? Are we already frustrated? Have we decided we know why the other person is behaving the way they are? Are we relying on our professional role to carry more authority than the relationship can support?

 

Starting as a human doesn’t mean setting aside our expertise. It means remembering that expertise is only one part of what the person across from us needs. A clinician brings knowledge and experience into the room. But a patient or family brings knowledge, too. They know their history, their relationships, what they’re afraid of, and what matters to them. When the conversation is between colleagues, each person may be seeing something the other isn’t. This is where listening becomes more than waiting for our turn to speak.

 

Say what needs to be said

Before going into a challenging conversation, it can be helpful to ask one question: What does this person need to understand when this discussion is over? It’s not everything I’ve been rehearsing in my head. Not every frustration I’ve accumulated. What needs to be said now?

 

With a colleague, that may mean talking about a specific behavior rather than making a judgment about the person. “When this happens during rounds, I’m having trouble getting the information I need,” gives someone something concrete to respond to. With a patient or family, the words will be different, “I know this isn’t what you were hoping to hear. I want to make sure we talk honestly about what happens next.”

 

Research on serious illness communication gives us good reason to take preparation for these conversations seriously. In a randomized clinical trial published in “JAMA Internal Medicine,” researchers found that preparing patients and clinicians for goals-of-care conversations substantially increased how often those conversations occurred and improved patients’ ratings of communication quality.

 

We can prepare for difficult conversations. But we don’t have to prepare every word.

 

Listen for what’s underneath the words

During my work as a chaplain, I learned that what someone says first isn’t always what they most need us to hear. Anger can have fear underneath it. A family member who seems demanding may be terrified of losing someone they love. A colleague who becomes defensive may be hearing something very different from what we intended to say.

 

Understanding that doesn’t mean excusing inappropriate behavior or abandoning our own boundaries. It means being willing to ask what else might be happening.

 

Sometimes one question can change the direction of a conversation. “What worries you most about this?” “Can you help me understand what you’re hearing me say?” “What do you need me to understand?”

 

Then comes the harder part. We have to listen to the answer. Listening doesn’t mean agreeing. It doesn’t mean giving someone what they want or changing a medical recommendation. It means making room for something we don’t yet understand.

 

Don’t let the title do the talking

Healthcare comes with hierarchy. Titles, credentials, training, and areas of responsibility matter. There are decisions that require particular expertise, and there are moments when someone has to make the call. But authority and trust aren’t the same thing. If we enter a difficult conversation believing our title should be enough to persuade the other person, we may miss what’s happening in front of us. This can matter with patients and families, but it also matters among colleagues. A nurse speaking with a physician, a resident speaking with an attending, or one member of a care team questioning another may be navigating more than the immediate disagreement. Professional expertise matters, but it can’t do all the work for us. Walking into a room as the physician, nurse, chaplain, or other healthcare professional establishes our role. But it doesn’t automatically establish trust. Sometimes the most important thing we can do before beginning a challenging conversation is to remember that we’re simply one human being talking to another.

 

Curiosity

Beginning with curiosity can open up and change the conversation. It can sound like, “I want to understand how you’re seeing this.” Or, “I think we’re looking at this differently. Can we talk about it?” Neither sentence gives away authority or expertise. It simply opens the conversation rather than closing it before it’s even started.

 

Kindness doesn’t mean avoidance

There’s a difference between being clear and being unkind. We sometimes put off difficult conversations because we don’t want to hurt someone, damage a working relationship, or make an already tense situation worse. Avoidance can feel kinder in the moment. We circle around the difficult part, hoping the other person will somehow arrive there without our having to say it. But kindness isn’t avoiding the hard thing. Sometimes kindness is saying it clearly enough that the other person doesn’t have to guess what we mean. This can be especially important when emotions are high. Simple language helps. So does silence. We don’t have to fill every quiet moment after saying something difficult. The other person may need a few seconds to understand what they’ve just heard.

 

Not every conversation has to be finished today

There are often difficult conversations that don’t end with agreement. A family may need time to absorb what they’ve heard. A colleague may initially become defensive. Someone may be too angry or overwhelmed to continue productively. We can stop. We can say, “I don’t think we’re going to resolve this right now. Can we come back to it?”

 

There are also times when another person needs to be part of the conversation. A supervisor, social worker, chaplain, patient advocate, interpreter, ethics consultant, or another member of the care team may bring something we can’t provide by ourselves. Knowing when we need help isn’t a failure of communication. It can be part of communicating well.

 

Before you walk into the room

There’s no perfect script for a difficult conversation. People are too different for that, and so are the circumstances that bring us together.

 

Here are three things I try to remember:

1. Know what needs to be said.

Before you begin, be able to tell yourself the central thing you need the other person to understand.

 

2. Begin with the human connection.

Your expertise matters, but don’t ask your title to do the work of building trust. Start with empathy and curiosity about the person across from you and what you may not yet understand.

 

3. Remember the relationship.

The goal isn’t to “win” the conversation. It ‘s to leave the other person with as much clarity and dignity as the situation allows and, when possible, a way forward.

 

Many of the important conversations we have in healthcare aren’t easy. We’re talking about things that matter deeply to people: illness, death, fear, disagreement, mistakes, trust, and the way we treat one another.

 

Finally, difficult conversation doesn’t have to end in agreement to go well. What matters is that we speak candidly, listen carefully, and remember that the person across from us deserves to be heard and treated with respect.

 

 

 

 

 

 

 

 

 

 

This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.