KAREN GILLILAND: Welcome on behalf of the Mayo Clinic School of Continuous Professional Development I'd like to welcome you to Mayo Clinic COVID-19 webinar series. My name is Karen Gilliland and I will be your host for today's webinar on challenging conversations.

This webinar is accredited by the AMA for one credit. There are no relevant disclosures for today's discussion. And we'd like to thank Pfizer for their support of this educational activity. Before we get started we'll cover a few points. The first is how to claim credit. If you'd like to claim credit after the webinar, please visit ce.mayo.edu/covid1118. You'll need to log into the site.

If it's your first time visiting you may need to create an account. After you've done this and logged in, you'll see an access code box. You'll want to type in today's code, which is COVID1118. This will allow you to access the course, complete a short evaluation and then you'll have the ability to download or save your certificate. This link and code will be dropped into the chat box throughout today's webinar.

The second item is how we'll facilitate questions. You'll see at the bottom of your screen the chat and Q&A function. If you have any questions during this webinar for today's presenters, it's important that you drop them into the Q&A channel rather than the chat box. This will help to ensure the panel can see your questions. There is a helpful upvote button, so be sure to upvote the questions you would like to see answered. The panel may pause for discussion during certain segments of the webinar, so be sure to submit your questions that are relevant to that topic. If you are experiencing any technical issues during this webinar, please use the chat feature to share so our support team can assist.

Today's learning objectives include; one, determine best practices in discussing COVID-19 guidelines, two, identify communication challenges with the COVID-19 pandemic, three, utilize effective empathic communication techniques when communicating. Today we'd like to introduce our panel moderator Heather Preston, Senior Advisor, Patient Experience Training, Education and Coaching.

HEATHER PRESTON: Good morning, everyone and thank you for being here. I'm excited to introduce our panel today. Our team of colleagues here on today's webinar are from the office of Mayo Clinic, Experience Training, Education and Coaching team. Our team's focus is to help employees across the organization to have more effective conversations. Specifically around challenging conversations with patients, their families and with each other as colleagues. I myself have a strong partnership with the Department of Nursing here at Mayo Clinic. I train and coach providers on communication and health care and facilitate leadership training and coaching.

I'd like to introduce my colleague Ben Houge. He leads our production of our digital products and supervises Mayo Clinic patient and visitor conduct program. Jennifer Packard, is a certified coach and educator and focuses attention on developing communication skills of desk, scheduling and administrative staff at Mayo Clinic. She has a particular interest in ensuring that our written communications, the letters we send to our patients, the portal messages we send to our patients and our social media posts, express empathy and reflect the patient's point of view.

Sheila Stevens is our quality administrator, so she partners with Dr. Siddiqui to provide oversight and strategic direction to our Experience Training, Education, and Coaching team. And Dr. Siddiqui is the Enterprise Medical Director of our group. He provides medical leadership alongside of Sheila in communicating training, education and coaching. Dr. Siddiqui is also a hematologist, oncologist, specialized in the treatment of blood cancers.

So this has certainly been a tough year with COVID and everything that has come along with it and it's required health care organizations across the country to have to shift quickly. Given the stress that comes with rapid change, our team in patient experience training, education and coaching, has worked with our practice, our colleagues in their practice to ensure that we don't lose sight of the most important thing, which is human connection. I'm now going to turn it over to my colleague, Ben Houge, who will share more about this. Ben go ahead.

BENJAMIN HOUGE: Thank you, Heather. Thanks, everybody, for joining us today. I'm excited to spend just a few minutes with you prior to our Q&A session talking about challenging conversations we've had around COVID-19 and continue to have. As we move forward, I want to emphasize the Q&A feature again and say as I'm talking through some of the things that we're doing at Mayo Clinic, I challenge you to use that Q&A and get those questions entered so that when we get to the Q&A session we can answer them promptly. All right, next slide, please.

So before we get into what we've done at Mayo Clinic around communication around COVID-19, I want to remind everybody of the types of questions that we'll be answering, this panel here. We'll be talking about how to communicate about COVID-19, we won't be discussing specific COVID-19 guidelines or offering medical advice related to COVID-19. If you have questions about those guidelines or you're seeking medical advice, please go to mayoclinic.org for safe care and visitor guidelines, as well as trusted coronavirus information. Next slide, please.

Like many health care institutions across the world, we've experienced significant uncertainty and challenges here at Mayo Clinic from our patients, our visitors and our staff as well as the communities that we go home to every night. We're all feeling the fatigue around restrictions, the difficulty that we're having around the questions that we have about coronavirus and when this will end.

So all these emotions are piling up and creating some communication challenges here at Mayo Clinic around restrictions and the fatigue that we're all experiencing. We're having to deliver bad news from a distance. We're having to re-communicate masking and distancing guidelines to our patients, our visitors and our staff. We're also having to invest in webside manner as our telehealth infrastructure is being scaled up.

Additionally, we're seeing misinformation and having to grapple with that as we're communicating with patients. We're seeing our patients are better educated than ever before coming to us with information that is often accurate but sometimes not as accurate. And it's important that we honor their beliefs at the same time that we also share with them our evidence based approaches to managing this pandemic. Next slide, please.

So an important component that you'll hear over and over again during our talk today is the importance of equipping staff to manage these challenging conversations with grace and compassion. And one way we do that is just by sharing back the perspective of the other person, the experience that they've had. So the statement on your screen here, this has been overwhelming for you, you just want this to be over. That's an empathic statement that we train our staff to use. That statement and many like it.

Additionally, we have other communication strategies that we use. We use hope, worry statements sometimes. Say things like it's evident how much you care for your mom. My hope is that our treatments will help her. My worry is that the virus has greater impact on those with the underlying health conditions that your mom has.

On the right side of the screen, you can see one way in which we're training staff. We're delivering micro learning experiences for them and I'll talk more about that in a little bit but how we communicate to staff, how we train them on how to have these conversations is important. Next question or next slide, please.

We're also seeing that those empathic statements or utterances of praise, those elements of the medical encounter that are essential to keeping the human touch in health care are actually less present in the video setting or over the phone. So we're having to approach these conversations with intention and purpose. We're acknowledging the distance and thanking people for bringing us into their home. So that first statement there, I want to thank you for welcoming me into your home today to talk about your mom's condition. Acknowledging that they're not able to be in the hospital with her potentially, not being here with her has been really challenging for you.

And then using other statements like, given how things have progressed this is a time where we have to refocus from treatment to planning end of life care. We're having to invest in specifically speaking to the challenges that our staff are facing around communicating with our patients. Next slide, please.

As we're supporting this rapid shift towards telehealth and we're trying to re-emphasize the importance of a human touch. As I mentioned previously those things that make health care special is often that human touch, interpersonal effectiveness. And we know that that suffers when we move to a digital platform, whether it be Zoom or we're talking to folks via phone.

Additionally our staff with the COVID-19 pandemic are exceptionally stressed. So we are having to deploy small micro learning experiences. So they can take and take those in and have pragmatic solutions relevant to the conversations they're having right now with patients, visitors, and their families. We're putting an emphasis, a particular emphasis, on interpersonal effectiveness. So we have a different group that manages the technical side of connecting with our patients virtually and their families. Our focus is really on OK, what are the things that we really need to do to make sure that they feel that human connection when we're connecting with them?

On the right side of your screen, you'll see this webside matter QRG we call it, a quick reference guide, and these are designed to be consumed in a minute or less. And again, we focus on solutions, things that our staff can actually say in the moment that will make those experiences a bit better for both the patient, their family as well as our employees. Next slide, please.

Additionally, we are embedding empathy and perspective taking and optimism into how we communicate policies both with our staff, our visitors, patients, as well as the communities around us. So some of the statements on the screen here emphasize how we might respond to a patient who has questions about one of our policies, like the no visitor policy for our hospitals. We might respond by saying something like it sounds like you and your husband are a great support system for each other. Our goal is to keep everyone safe, including you and your husband. He is in the very best of hands. You really wish that you could be here for him in the hospital.

Then we might go into actually offering explanation around that policy. But before we do that, we have to honor the impact that is being experienced by our patients by not having loved ones there in the hospital at the bedside as well as their family members who are at home or having to connect with them via Zoom or via phone and not able to support them the way that they once were.

On the right side of the screen, you can see just a sample of the numerous products that we've produced around responding to questions about our COVID-19 policies, masking and distancing, things like that. As well as we've additionally put empathic language into our communications to the public and to our employees just to acknowledge that this has been a trying time and it continues to be a trying time for everyone involved. So really in summary, the empathic communication or sharing back the perspective or the experience of that other person, really is the key we believe to effective communication. Next slide, please.

Currently there's misinformation that our patients are bringing with them sometimes into the exam room and we've developed a collaborative approach for are our physicians and our staff to use. When information is brought in, we assume it's under the best of intentions, but sometimes it doesn't quite align with what we know to be evidence based practices for preventing infection and things like that.

And so we're really equipping our staff to use validation, again that empathic communication and offering choice to our patients. We want to honor their beliefs and their perspectives. At the same time, we want to make sure that we're presenting the factual information that we have in a way that is appropriate for them to hear. So we've done that in a couple of different ways. One is we've developed a continuing medical education module for our staff, that's also available on ce.mayo.edu for the general public to consume. Next slide, please.

And I'll turn it back over to my colleague Heather Preston and we'll get the Q&A kicked off.

HEATHER PRESTON: Thank you so much, Ben. I want to start by just the first question that we received is what's the secret sauce, so what makes our approach here at Mayo Clinic different? And Sheila, I'll turn that over to you to answer that question.

SHEILA STEVENS: Thanks, Heather. I think that we communicate all day every day and we believe that communication skills are as important as surgical skills in health care. Even if we disagree with patients or give them bad news or we respond to their service failure, there's evidence that if patients feel heard and understood they have higher compliance rates to treatment, higher satisfaction and an overall enhanced experience.

So we hear all the time from providers, clinicians and people at Mayo Clinic how empathic they are and we know they are. But being empathic is different than communicating that you are. So we have specific skills, so you ask about a secret sauce it's really a specific skill. And when I say skill it's different than a strategy right? So strategy is something that you can check off a list. I shook their hand firmly. I had nice eye contact. Those are strategies but the secret sauce is really skill building which any skill takes practice and time.

And so there's many, many parts to our communication model that we utilize to communicate on all different things every day but during COVID that it was extremely important because emotions were so high. And I think one of the secret sauces is what Ben referred to as those empathic reflections back, sharing back what you hear people say, and it's not simply oh, I understand you're frustrated. It's really mindfully listening and practicing that skill so that we can utilize perspective taking and sharing back appropriately.

HEATHER PRESTON: Thank you so much, Sheila. The next question is around body language. So we talk about the importance of using empathic statements. What's important about body language? Jen, do you want to take that one for us?

JENNIFER PACKARD: Thank you so much, Heather. I'd be happy to. This is part of the secret sauce, the special sauce. Empathy and empathic communication is brought to life, it's brought to the patient in a way that they can really feel it through that eye contact, through the leaning in, through that making the patient feel like they're the only person that matters.

And right now during this COVID-19 pandemic I think it's particularly important to consider that in our video visits. We're good at that face to face, we're good at that in the office of bringing that patient into our bubble of attention through our body language. And I think it's very worth considering how we do that through these Zoom video visits. How do we continue to ensure that patients feel that warmth and understanding through that body language.

HEATHER PRESTON: So, Jen, our presence with the patients is almost as important, if not more important sometimes than the words that we're saying to them.

JENNIFER PACKARD: It's something that you can feel through patients will say and sometimes through channels in our surveys things like I felt like I was the only person that mattered. And body language is one way we can do that, right. Turning away from technology, having a clean desk, having no distractions, not looking at your phone and giving all of your attention, physical and emotional, to the patient when they're there with you and sharing your space.

HEATHER PRESTON: Thank you so much, Jen. At Mayo Clinic we've had to limit the number of visitors that our patients see during this time of COVID. So, Ben, I'm going to ask you, can give guidance on how to deal with family members that aren't allowed to be in the hospital, to be a support person to their family member during this time? And what if they become aggressive during that moment?

BENJAMIN HOUGE: Yeah, excellent question. And first, I think we need to validate why they're so upset, right? And it's because they're being prevented from being at the bedside with the person that they love, the person that they've supported for their entire lives. That's a really big deal. So before we do anything, even if they are upset, maybe even yelling, is we need to share back their perspective, that key to effective communication need to acknowledge them and say, this has been a huge challenge for you, your mom, you're not able to be there for her in the hospital and that's really impacted you.

Say that pause. See what happens. Often actually a good percentage of our patients will even if they're kind of nearing that point of really escalated behavior will de-escalate. They're looking for validation. They're looking for somebody to understand that. And we can both validate and also kind of stick to our policy and share the reasons for it. But they're going to be in a better position to listen and collaborate with you on how they can connect with their loved one once you've validated and shared back that experience.

I would say when that fails, and occasionally it does, but again not most of the time. We have other strategies that we employ to set boundaries and expectations around behavior. But again, we don't typically get to that point if we're really validating and being there with a loved one and explaining the reasons for these policies.

HEATHER PRESTON: Thank you, Ben. Dr. Siddiqui, I would love to hear your perspective, having working with patients directly on the front lines. What have been some of your experiences with having to communicate with patients that they aren't able to have their family member there with them or in communicating with the family members when you're talking to them distantly.

MUSTAQEEM SIDDIQUI: Yeah. No thanks, it's a very important question. I was just on hospital service last week taking care of patients who have blood cancers that needed to be hospitalized and we have a no visitor policy. So each of these patients is by themselves in the hospital. They're able to communicate with their family members through phone and FaceTime but there's no one allowed to be physically present at the bedside.

There are some exceptions and we can talk about those but to answer your question, it's really challenging. We have these conditions that are life threatening, that require hospitalization that are occurring during a pandemic. And if it weren't difficult enough to be going through treatment for cancer, now the pandemic has added additional layers of complexity not just for treatment but also for visitors.

So what has happened? Just last week I had a 70-year-old woman who is in for a complication of her treatment, who has been with her husband for 50 plus years. And they are caregivers to each other. So she takes care of him and he takes care of her. But now she's hospitalized and that 50 year bond is under strain because they can't be with each other. And she is so distraught, she said, listen, I can't stand being here. I've got to be able to see my husband and why can't you let him come and visit? And she immediately broke down crying.

And we're having these conversations on a daily basis but they never get easier. And she breaks down crying and I just took a moment. I took a moment and I said, it sounds like you and your husband have a very special relationship. It sounds like you really care for each other and you're each other's best friend, support and rock. And at that moment she then realized yes, somebody gets it.

What could I have done? I could have said something like oh well, it's only for the time being. We'll get you out of here soon. And oh sure, it's for your safety as much as your safety of your husband. But those would have all been very dismissive of how she's feeling.

We have to take a step back and recognize what she is telling us, acknowledge it and then can we plan a course to move forward about how we might get around the issues. In her particular situation we had to get her better to get her out of the hospital but we have to acknowledge, you have to reflect and then make a pivot and say, would you mind if I shared with you a little bit of background of why you're still in the hospital or would you mind if I shared with you a little background of why we're not able to have your caregiver at the bedside.

HEATHER PRESTON: Thank you, Dr. Siddiqui. Some of you on the call may be thinking, boy, I don't have time to sit down and have those kind of conversations with my patients. I'm already having to move through my patients on rounds very quickly. So Sheila, I'm wondering if you could speak a little bit to does this take more time or how do we effectively have these conversations so it doesn't take more time?

SHEILA STEVENS: Good point. I think that a lot of people think it takes more time, it actually is a time saver. And the reason being is because people oftentimes repeat or show frustration when they haven't been heard and a lot of people think if I'm courteous, if I'm nice that that's what I need to be and that's important, that's a foundation. But it goes beyond that to this empathic way of showing that we get what they're saying. And once we can share back appropriately, it's so important you have your husband here and it feels unfair to you, and we can let them know here's what you're going through and I want you to get it. They might not be happy that they can't have what they want but they feel understood and validated.

If we don't get that step and we just go into here's what the visitor policy, we're doing this for your own good and here's what we can do to help you. If we respond to the policy and not respond to the patient in a way that we want to connect, they will continue to bring that up but you don't understand. I don't think I'm going to get well without him. This is different, I need him here. He needs to come in. They want to keep telling you their story.

So it oftentimes can take more time than if we simply just be mindful of everything that we're seeing, hearing about the patient. What do they value, what's important to them. What's the message here? What's behind the message? What am I hearing? What are they feeling? What's their entire experience?

And when I pay attention to that I can empathically say, Mrs. Jones, you've been through so much, you're alone here. It's so important to you to have your husband by your side. Then I can say, would you mind if I share the importance of why we're doing this? And then I could even legitimize and say, I this is not what you want to hear. I know this is not what you expected, here's the rationale. Oftentimes we jump to too quickly to that rationale and it ends up taking more time.

HEATHER PRESTON: Thank you, Sheila. Very helpful to understand that perspective and the time saving that it can actually be when we really are getting to the root of what's causing some of the emotions of our patients and their family members. Jen, I have a question for you. Just curious how patients respond to this type of empathic approach and when it doesn't go the way we would anticipate it to go, right? If it doesn't work, if you will, what are some suggestions for fallback communication?

JENNIFER PACKARD: Oh, good deal. Great question. Thank you so much, Heather. How do patients respond? Right now patients are so fearful and so anxious that their shoulders are pinned to their ears and they have tunnel vision and they're not hearing everything that we're saying and they're not perceiving everything that is around them because of that fear and validation of that fear, empathic reflective listening statements that build trust, you can see the shoulders start to come down away from the ears. You can see the field of vision open up. And you can feel anxiety come down in a way that that patient is able to understand your suggestions and understand your explanations in a way that they couldn't before. It's such a necessary step to validate and empathize and also ask permission before you share information because you need to build a therapeutic alliance with an individual and also with the public before you share information that is crucial that they take in to get better.

And the second part of your question I think if this fails what do you do next? The patient's perspective is crucial and continuing to acknowledge the patient's perspective that what I'm sharing with you doesn't seem to be connecting with you and I see that because I'm paying attention to you. I'm not only listening to what you're saying, I'm watching your face, I'm picking up on your body language, the patient's body language. And I'm seeing them shake their head or squint their eyes and I'm understanding how my words are impacting them.

And I can keep on changing my strategy and acknowledge it seems like what I'm saying isn't quite connecting with you and asking open questions, how can I explain it better or how am I missing the mark? Or what is your biggest worry, how do we make sure that we connect with your biggest worry today? But continually starting from where the patient is, is truly a tested way of connecting with folks that will work if you keep on coming through the window in the back door.

HEATHER PRESTON: Great. Thank you so much, Jen.

SHEILA STEVENS: Can I just jump in here on that one? That was great. That was a great question, a great answer, Jen. I also think that if the strategy doesn't work and the patient goes around and around, we have other strategies. We utilize empathic redirection to bring people back and that's a way to let them know that you're here if it's OK with you, I need to move to this.

It's a full set of strategies, we can't go through the whole course here but there are other ways to bring patients back. The other thing I wanted to just add to that is if the strategies don't work and the patient's escalating, then we have to address that too. So we do have some boundary setting and some other strategies that we do to follow through on any kind of boundary settings that we put in place if the patient becomes abusive, inappropriate or disrespectful.

HEATHER PRESTON: Thank you, Sheila. The audience is wanting to know a little bit more about what does de-escalation mean when it goes beyond that initial validation of frustration and I can share just an experience that I had when I first started working with patients at Mayo Clinic, I was validating the emotion that was present in the moment. So certainly they were frustrated based off of the tone of their voice and those types of things. And so I would often say, you're really frustrated about the experience that you're having. That was my initial validation. Ben, can you speak to a little bit more about kind of going deeper there with that validation when that initial frustration or initial validation isn't really kind of settling with them?

BENJAMIN HOUGE: Yeah, absolutely. And it's a great question because while 99% of our patients, even those that become upset, for their family members have become upset, with that validation that that's going to be all you need really in most cases. But in the rare cases that validation and empathy isn't working and it's getting to the point of verbal abuse perhaps, then we need to assert ourselves, we need to make it clear to them what is and is not acceptable in that environment.

So we use something called contrasting statements. We say, you know what, Mrs. Jones, what I can't do today is continue to have this conversation if you're going to scream and swear at me. What I can do is continue this conversation if you're willing to communicate with me in a way that's respectful.

We name the behavior specifically that's happening, we never tell people calm down. I'm sure everybody can guess what happens when you tell somebody to calm down, that tends to have the opposite effect, especially anybody married listening knows exactly how that goes. So don't tell people to calm down or stop that or that's inappropriate, name the behavior. Mr. Jones, you're swearing at me, please stop. And then if necessary we also put some consequences there. Mr. Jones, I've asked you to stop swearing. If it happens again here's the consequence. Here's what I'm going to do and those of course will be very specific, the consequences will be specific to your institution. And even the specific department that you're working in.

HEATHER PRESTON: Thank you, Ben. And the audience has asked when do you kind of get to that tough love conversation and Ben, you alluded to that a little bit, that there are times when we need to manage the escalated patient when empathic communication isn't working. And so really putting in some of those boundaries where the inappropriate behavior or misconduct that's happening in the moment isn't being respectful to the person in front of them to the organization. And so certainly there are times when we have to shift the communication approach and get more into that kind of tough love, if you will.

Ben, I'm going to ask you another question only because I know you've done a lot of work around misinformation. So there's a lot of inaccurate information that's out there at people's fingertips or maybe there's politicized views, right, on policies and recommendations. So how do we handle those types of conversations from our patients and visitors and their families?

BENJAMIN HOUGE: Yeah, absolutely. We stick to the facts, right? We stick to what Mayo Clinic says, here's the evidence, here's our approach to managing this pandemic. And that's the information that we share with our patients. At the same time, we can't ignore the information that they bring with them, right? Into the exam room or discussions with us.

So the first thing that we'd like to do is reflect and validate and we're saying that a lot today but that's important. So if somebody comes in and is sharing with me that how awful this is COVID-19 stuff is and how it's impacted their children and how they're just not going to wear masks anymore. And they're not going to get tested despite having symptoms, whatever that might be, rather than just saying, oh my gosh, this is the really important information for you to hear, before I do that I need to acknowledge and say, Mrs. Jones, the pandemic, the distancing strategies have really impacted you and your family and you're worried about the social lives of your kids.

I need to acknowledge that and then pause and say, ask permission just as Dr. Siddiqui shared with his story, if it's OK with you, I'd like to share with you some of the strategies or the data that we've gathered here at Mayo Clinic, would that be OK? And even if the person doesn't necessarily want to hear what you have to say right then and there, 99% of the time they're going to say yes. And you've opened that opportunity to share with them the information you have. We're starting with that validation, offering choice and taking a more collaborative approach to correcting any information that may be clinically important for us to correct.

HEATHER PRESTON: Great. Thank you so much for that, Ben. Sheila, as our quality administrator we're getting a lot of questions around training staff. So we talk a lot about the importance of using these types of skills and strategies with our patients and their loved ones. How do we do that at Mayo Clinic?

SHEILA STEVENS: Yeah, so we have a model of communication that has overarching principles and then it has elements and strategies as part of the model. And so those strategies such as that key, sharing back, asking permission, legitimizing, there's just a whole range, information exchange, how we educate, advise, and exchange information with patients. How we use partnering language. So there's all these different elements and we try to use those same elements in all of our training. So that we hard wire the skills in our staff.

And by the way, the skills that we teach aren't just for patients, they're for our interactions with each other as well. So we can have challenging encounters with each other, we can address misinformation with each other. And we can validate and hear one another.

We certainly did a lot of workshops with a lot of role play before the pandemic hit and so times have changed and we've responded to that by making a lot of our courses digital. We have learned very quickly people like things in quick bites. We have what we call lively lessons where we have three minute little bits of information and education that is very helpful to people.

We also do for some of our, we talked a little bit about when the conversation gets abusive. We also have what we call SAFER and safer stands for step up, address the behavior, focus on our value of respect and E is explain our expectations, and R is report a document or record a document. And so we have a whole list of those trainings wait listed, people want this training. So that they can address misconduct in many ways and other challenging conversations.

So we do feel that skill building and that practice is important. So we do a lot of Zoom trainings as well. And we do sustainment and boosters where we can highlight these skills. We also engage with partners around Mayo Clinic so that we're all speaking the same language using the same strategies so that the skills are hardwired.

HEATHER PRESTON: Great, Sheila. Thank you so much for sharing that. And please, if you have other questions about the training that we have in place at Mayo Clinic feel free to put those questions in the Q&A and we'll try to go a little bit deeper with any other questions that you might have. Jen, we've talked a lot about the health care organization, right? And how we respond to patients and how we respond to each other and support each other through this pandemic but we have some school nurses on the webinar this morning and they're asking about how do we communicate or use these skills and strategies to communicate with teachers, right? With children in the school system and other individuals, how can we utilize these same skills or are they comparable in those different settings?

JENNIFER PACKARD: I think that's a great question. Thank you for asking. Part of empathic communication, part of the heart of empathic communication is meeting people where they're at. And approaching people with genuine curiosity. And I think that that's applicable no matter who we're talking to, if it's family, if it's folks in other industries, in school, in government. High emotion impairs communication and fear causes high emotion and meeting folks where they're at with genuine curiosity using open questions, listening closely for the emotion behind their statements can connect us.

And so when you're responding or communicating to someone with high emotion, never ever respond to that high emotion with facts, with objective information, by explaining things, by saying let me show you the website. But rather, responding to emotional statements of fear, of worry, responding to those emotional statements with an emotional statement back that rephrases and reframes that emotion to show understanding. Because truly no matter who we're speaking to just really needs to feel heard and understood to build trust and that trust opens pathways where we can share information in a way where that information is going to be believed, more likely to be believed. That you are going to be more likely to be trusted as a reliable source of information when you've taken the time to do that, to meet people where they're at.

And so in that case of needing to communicate in the schools with staff who are really frightened, I can't stress enough that validating that fear and empathizing with that fear by rephrasing that and handing it back so they feel heard and understood and then asking permission before you share that information. Is not just for health care. Thanks, Heather.

HEATHER PRESTON: Yeah. Thanks, Jen. That was a great response. And certainly I think being transparent is another really important piece of the work that we do, right? Is not dismissing the fact that sometimes it can be uncomfortable for us as the person on the receiving end of those conversations to want to kind of just shy back and kind of avoid the conversation but we really need to be good support systems for each other. And this type of communication approach can really provide the support that people are looking for.

Dr. Siddiqui, you talked earlier about kind of your experiences in the hospital practice and working with patients and staff. Some questions have come through about supporting family and friends. So we've talked about the importance of communication but what else does Mayo Clinic recommend about supporting these individuals during this time of stress?

MUSTAQEEM SIDDIQUI: Yeah, take the extra time to have the conversations with family and friends. That is a huge component of what we do. Pre-pandemic we would have multiple visitors in an outpatient clinic along with the patient. For example, an entire family may come for a discussion about a new diagnosis of cancer but of course, that has now been limited to one on-site visitor in the clinic.

When we've incorporated that we have to still remember there is a family that is behind this individual who is seeing you in clinic that really would love to be part of the discussions and be a part of the support system. So very practically a lot of patients will say, would you mind if I got my son, daughter, spouse, on the phone with me and we have this conversation together? Would it be OK if I brought them in on FaceTime or video chat? We allow that, we encourage it because it's not just the patient. It's an entire family that you're treating.

On the hospital side of things because things are a little bit different there, we are not allowing visitors to the hospital with extreme exceptions. Again, the advice is take the time to have those conversations. If a patient wants to have their family member on the phone while you're there visiting, do it. It really goes a long way to helping the patient and the family member be more comfortable with the extreme circumstance that we are in. So take the time to do it.

As Sheila mentioned previously, yes, if you invest in the time now to have these conversations, you will find that you will have spent less time total because you've addressed the underlying emotion, you've addressed the underlying concern. You have used active listening and reflected back what the patient and family are trying to tell you. And so it becomes-- the conversations become much more rich, they become much more applicable. And instead of talking past one another, you're talking with each other. And I think that's a subtlety that is very often missed but is so, so crucial.

HEATHER PRESTON: Great. Thank you for sharing that perspective, Dr. Siddiqui. Sheila or Ben, I'm going to-- or any of you actually, but interestingly, the question has come up with that sometimes this can feel condescending or it can be perceived by the person on the receiving end as kind of talking down to them. So I'm wondering if you could speak to that a little bit, and maybe even give some examples of what it might sound like if we take an attempt for, an initial attempt that may not be a full empathic response. So just to kind of showcase the difference I think might be really helpful for the audience to hear. I know I put two of you on the spot, so maybe we'll start with Sheila.

SHEILA STEVENS: So I think that it is true. And since it is a skill it does take practice. And when you're first learning this skill what you tend to do is formulate in your head, oh, I'm listening but I'm formulating at the same time what I'm going to say. And what happens is you respond quickly with you're feeling frustrated, you're feeling really frustrated. And that's a go to. People are usually frustrated when they come with high emotions. And people will say, well heck yeah, of course I'm frustrated. So it does feel a little bit like why did you say that to me?

And as you begin to practice this where you can dive deeper into what you're hearing, so it's not just feel frustrated but it's really important to you that you came here for this. This is not what you got. This is not what you expected. You go to the core of their values. This is what you want, this is what you're concerned about. And putting that out there usually lets people take a breath.

But I'll give you an example, there is one time when somebody came screaming over a service failure and I thought I did a great job of just like, you came here, you put a lot of time to get here and you didn't expect this and this is what happened. Of course you're angry over it. And the patient screamed back, I'm not angry. Don't tell me that I'm angry. So can we say that this is miracle dust? No, but what we can say is 99% of the time when we get to the core and the heart and the deeper dive of what people are saying, we are able to connect with them in a way that makes them feel understood. Even if we can't fix or give them exactly what they want.

HEATHER PRESTON: Yeah. And Sheila, sometimes that's really paying attention to what they're not saying or paying attention to the underlying emotions that might be present there. Sometimes we react, right, to the loud tone of voice or the disrespectful words that are coming out of a patient's mouth. And rather than just responding to that, really stepping back to understand what's causing this frustration or anger that's coming to them. Yeah, thank you so much for sharing that.

JENNIFER PACKARD: Heather, can I just piggyback on that for just a second.

HEATHER PRESTON: Absolutely.

JENNIFER PACKARD: As a trainer in empathic communication at Mayo Clinic, I do see that there's levels of skill among our staff and it does take a lot of practice to learn this skill. And there are levels of reflection and simple reflections can seem very much like that. In the very first lesson when people learn how to do simple reflection they'll walk away from that thinking that sounded kind of condescending.

But truly wonderful, rich reflections, don't just reflect what you see and hear but they make an inference. They make an inference about what you haven't heard, you make an inference about what's behind what's being said. And they offer a platform for the patient to clarify their position and it comes across as curious and a genuine attempt to understand. And often a really well formulated compound reflection is even better than a question in evoking how your patient feels or anyone that you're talking to. So it takes a while to learn and it takes some patience to teach.

HEATHER PRESTON: Thanks, Jen. Ben, could you speak a little bit to that natural desire to want to jump and defend or jump and explain or provide rationale, often that's where we want to go and people are asking what's the reaction to that from people on the receiving end?

BENJAMIN HOUGE: Yes. So it's great, we sometimes refer to it as the writing reflex, and it's very natural, especially in health care, right? You have tons of education, you've put a lot of pride and effort into getting where you're at and to be there for your patients. And so whenever we hear something our immediate inclination is to jump in and fix, right, or provide correct information.

But I think everybody can maybe think of a time when they shared something with maybe the mother in law's on your back and they share something with a friend and they're like oh my gosh, the same thing happened to me and they kind of make the story about themselves or they tell you exactly how to fix it and you feel that little like disappointment where you just wanted to be heard. That that's a very human response and our patients feel that too.