S1E8: The Good Word

How do the words we use affect the people we serve? What could be problematic about some of the common things we say as care providers? What happens when we listen to our words from a different perspective? Cal and Cathy welcome Anne Kelemen to the podcast to consider the question of language.

Check out Anne Keleman's course on Healwell's online course portal: https://online.healwell.org/courses/to-chart-or-not-to-chart

Anne Kelemen's articles:

Ambiguity in End-of-Life Care Terminology—What Do We Mean by “Comfort Care?” 

Poor prognostication: hidden meanings in word choices

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About Our Guest:

Anne Kelemen is the Director of Psychosocial/Spiritual Care for the Section of Palliative Care at MedStar Washington Hospital Center in Washington, DC, where she conducts patient care, teaches and participates in a variety of research activities. She also serves as an Associate Professor of Medicine at Georgetown University and as Associate Program Director for the MedStar Georgetown Interprofessional Palliative Care Fellowship Program. Prior to joining the Hospital Center staff, Ms. Kelemen instituted the first palliative care service at MedStar Good Samaritan Hospital in Baltimore, Maryland. She is board certified in hospice and palliative social work and is a board member for the Social Work Hospice and Palliative Network (SWHPN) where she currently chairs the membership committee.

About Interdisciplinary:

In this podcast, massage therapy educators, practitioners and positive deviants Cathy Ryan, RMT and Cal Cates, LMT will use research, science, experience and humor to explore the broad landscape of health care through a truly interdisciplinary lens. We will be joined by compassionate, self-aware humans who are actively participating or are interested in participating in interdisciplinary care to have honest, uncomfortable conversations about topics like access, racism, death, ageism, ableism, and equity that address the intersection of being a human being and providing quality care, so that we can expand our impact, confidently navigate new challenges, and together create lasting, sustainable changes in health care. You’ll always learn something. You’ll always laugh and you’ll come away better informed and with real things you can do in your own community and practice to create a more compassionate and collaborative system of care for all humans.

Transcript

Cal Cates 0:17

Hello, I'm Cal Cates.

Cathy Ryan 0:19

And I am Cathy Ryan.

Cal Cates 0:22

Welcome to another episode of Interdisciplinary. In this podcast, massage therapy educators, practitioners, and positive deviants Cathy Ryan and myself, Cal Cates, will use research, science, experience, and humor to explore the broad landscape of healthcare through a truly interdisciplinary lens. We will have honest, uncomfortable conversations about topics like access, racism, death, ageism, ableism, and equity. You'll always learn something, you'll always laugh, and you'll come away better informed and with real things you can do in your own community and practice to create a more compassionate and collaborative system of care for all humans. Please be sure to like us and share us and use all of your social media might to get the word out. Remember to leave us a rating or, better yet, an actual review with words about why you love the podcast, at Apple Podcasts or wherever you get your podcasts. Thanks for listening. And now the moment you've all been waiting for - this week's pun. How does Darth Vader like his toast?

Cathy Ryan 1:23

No...

Cal Cates 1:23

On the dark side.

Cathy Ryan 1:24

On the dark side, oh...

Cal Cates 1:27

It felt almost too easy, but... So Cathy, what's happening in British Columbia? Tell us everything.

Cathy Ryan 1:35

Well, let's see. It's winter, it's snowing. We're used to that. So it's definitely not a situation like, you know, what happened in the US, southern US last week. So I feel for those folks who are still reeling and recovering from that. And COVID is a real thing. It's still happening. And I'm just doing my best to stay masked, then washed, then distanced. How about you, my friend?

Cal Cates 2:01

Yeah, it's actually trying to be spring here in the DC area. And which is, it's good and bad. Our poor trees and flowers have this sort of annual schizo affective disorder where they're like, it's spring, it's time to come out. And then we'll have at least one more like week of really cold weather, and they'll all shrivel up and die and then they'll have to do it all over again, when March finally gives up the ghost. So but for those of us who have been just basically staying inside the building for most of winter, it's pretty exciting to be able to go out and get out, get out in the sun. COVID-wise, you know, Virginia is doing okay in vaccine distribution. I'm going to be on a call this afternoon with some folks in Fairfax County, which is just down the road here, who are working on vaccine distribution equity. So I'm hoping to learn some new stuff about how bad it is and how to make it better. So I think a lot of us could benefit from some conversations about that, so hopefully we'll be bringing that to you all listeners soon. But, as always, I'm really excited to introduce our guest for today. And actually, just to let her introduce herself, but we are pleased and honored to welcome Anne Kelemen to the show. Thanks for being with us, Anne. Who are you? Why should we listen to you?

Anne Kelemen 3:18

Thanks for having me. I am the Director of Psychosocial/Spiritual Palliative Care at MedStar Washington Hospital Center here in Washington, DC. I am a social worker by discipline. And you should listen to me because this is a passion of mine to talk about language and medicine. And a lot of this grew out of my clinical experience over the years. I've been in the field of palliative care for a little over a decade. And just things as a non medical trained person noticed about the ways that we often are dehumanizing and labeling patients. So thanks for having me.

Cal Cates 3:56

Thanks for being here. That's, that is a huge part of what we're trying to do on this show both directly and indirectly. So yeah, so tell us, what do you do? What do you teach? How do you how do you bring this topic into practice?

Anne Kelemen 4:12

Some of it is observations when I'm at the bedside. You know, other things happen when I read notes and things that occur in documentation. You know, one clinical example I can think of that really got me interested in this when I came to the hospital center six years ago, we're at a center that does LVADs and transplants. So I don't know how familiar anyone is with an LVAD, but it's basically a heart pump, and it's a big surgery, and there's a whole process to figure out whether or not somebody is, quote, a good candidate for this procedure. And I was visiting with a patient who was an, you know, an older adult, and he looked very worried and I said, "You look worried" and he said, "Well, you know, this committee is meeting and I hope that they vote for me, and I'm a good candidate for this." So that started me getting, you know, thinking just about the word candidate. And of course, I'm curious what your thoughts are, but when we use that in medicine, we're often talking about whether or not this person, you know, is appropriate for a procedure or a surgical intervention. But when I think of it, as you just, you know, a human, I think of it, as, you know, am I gonna, like endorse this candidate for office?

Cal Cates 5:27

Yeah, yeah.

Anne Kelemen 5:29

And you know, here, here was this man who, you know, no fault of his own, he's getting older and this is what his body is, is doing, was so worried about whether or not people were going to vote for him, and he had this image of a whole committee discussing his case. And that's also another word I don't like is case, because I think of insurance cases and we often refer to people as cases. And so I, I wasn't sure what to do about that. And I just sort of asked a question to the, you know, one of the heart failure doctors, I said, You know, I, I wonder about this word candidate, I think he's, he's concerned that, you know, this is putting so much pressure on him to, like, be this good candidate. And you know, how could he do this, and, and we had spent a while, you know, talking about, talking about that, you know, that word. And, and slowly, over time, I've noticed where there has been a shift, just, you know, we're one institution here. So, you know, sort of making this shift, and, you know, maybe, you know, not using that phrase, or whether or not is this surgery, you know, right for this person.

Cathy Ryan 6:38

So, it all seems very simple when you point that out, and I'm sure there are many other ways that we're using language that we could shift it so that it's less stressful for folks. So I'm interested to hear about some more of your examples of how we can rephrase or reframe things so that perhaps it's a more of a clear, but less stressful for people?

Cal Cates 7:08

Well, I'm curious to how much of the, how much of the language is based in an assumption that we can't just say what's true, that we're, we're always looking for words that will allow us to put some distance between, I mean, because the decision in let's say, an LVAD situation is, is this person likely to live if we do this procedure? And so I mean, you know, you don't want to make it a death panel or something like that, but, you know, to say that they're a candidate, it's sort of I mean, what we're saying is, you're gonna, we think you'll make it. And yeah, so we pick a word that feels very dry and clinical, so that we don't have to consider that that's really what's being discussed.

Anne Kelemen 7:50

Yeah, and I think sometimes, you know, physicians and, you know, clinicians just get so close to the language of their own discipline, that they no longer even hear what they're saying. So it's not that that was, you know, I think it's often well intended, but it's just, you know, something that might have been picked up through medical school, and then just never thought of, oh, yeah, what do we mean by that?

Cal Cates 8:11

Yeah.

Anne Kelemen 8:12

Oh, I haven't, you know, I haven't thought about that. And I also think it comes down to sometimes in documentation, whatever is sort of shorter to write. So rather than sort of explaining what we're really thinking and what we mean, we come up with these short terms, like poor historian, which I often see in notes.

Cal Cates 8:29

Yes.

Anne Kelemen 8:30

And that's one that I was, you know, coming from a social work discipline, when I saw that I'm like, can somebody explain this to me? And it was interesting that a lot of times, it was like, well, I'm not sure I just saw that in this person's note or that, you know, they're confused, or they weren't able to give me an appropriate history. And I said, Well, why aren't we writing that rather than, you know, poor historian?

Cal Cates 8:52

Yeah. Well, and I wonder, I mean, and some of it is, like, when you have a, when you have, like, let's say you have a patient who is nonresponsive, or is is not responsive enough to provide a history and so you have a spouse or a child or something who, you know, an adult child who's sharing the history and you have gathered things, maybe this patient has been in before and you know, things about their history, and as the reporter is sharing, you're like, that's not true. You know, like, and so you can't say, you know, "daughter is lying". What do you say to make it clear to other clinicians, like, so this person is not the most reliable source of information without, you know, being offensive or, but still being clear.

Anne Kelemen 9:38

Yeah, but still being clear. Yeah. Yeah. It's challenging. And I often think, you know, another word that we talk a lot about in the social work discipline is is the language and the documentation around noncompliant.

Cal Cates 9:50

Yeah.

Anne Kelemen 9:52

A social work mentor of mine always says, you know, that when social work begins where that word starts and like that's where our work begins, that word noncompliant. And you know, whether or not you want to change it to something that sounds better like nonadherent, you know, noncompliant really comes down to whether or not, at least in my experience, whether or not someone's taking their medication or doing what, you know, the clinical team is telling them to do. And we're often not taking into the factors of, you know, if it's somebody who's on dialysis, like, do they have transportation to get to dialysis three times a week? You know, do they, are they able to afford the medications that, you know, they are taking to be compliant, and a lot of times with heart failure patients, and so challenging to be compliant with, you know, heart failure diet and the restrictions that come with that. And I think, what's really, what I think about is, if you're putting that label into a chart, that's a permanent medical record, that's going to, going to follow this person around for the rest of their life. And then it really can impact what treatments they may be offered or not offered in the future based on this, you know, shorthand of noncompliant?

Cathy Ryan 11:06

Well, we're starting to really delve into what the struggles of compliance are for that individual. It may be that they want to be able to do these things but, as you say, there's some kind of barrier, whether it be economic or otherwise. Rather than just label them as noncompliant, investigate a bit as to what the challenge of the struggle is for them.

Cal Cates 11:29

Well, I wonder, how does bias come into this too, Anne, because, you know, I think about I mean, to even choose and feel comfortable using the word noncompliant relies on a bias that assumes that this person is just, just sort of crossing their arms in a way, you know, like, they just, they're, they're being a petulant child. And when you say noncompliant, it assumes that you, that you're not curious, maybe, or that, you know, this person just isn't going to benefit from treatment because they obviously can't follow the rules. And I wonder how much of, you know, in that same way, when you read a person's chart, the words that are chosen to describe this person support or question existing biases? And how does that figure in when you when you try to educate providers about their word choice, I can't imagine you becoming suddenly the most popular person?

Anne Kelemen 12:25

No, I do try to frame it around, you know, if we have, you know, medical students or residents, I'm wondering why you documented it, you know, this way, or I'm wondering what you were thinking, you know, when you were documenting it, or writing about it in this way. And and I often share, there's an article, which is old now, because the early 90s is old among the times...

Cal Cates 12:49

Hey, hey, hey....speaking of things are true, but inconvenient.

Anne Kelemen 12:54

Actually, I mean, let's be fair, like early 2000s is old now...

Cal Cates 12:57

True that.

Anne Kelemen 12:58

..to some people, but the title of the article is "Is There a Person in this Case?" and, you know, it's talking about how we're talking so much about labeling a patient that we lose sight of, you know, who the person is. But there's a great quote in there that is, you know, care imitates language. That is we tend to, you know, write and talk about people the same way, or wait, so now I'm messing up this quote, we relate to people the same way we write and talk about them. So it's like care, the care that you're going to give the patient imitates this language that you're documenting about them. So if you're writing noncompliant or I often see like behavioral problems, that's already informing your judgment of somebody before, you know, you go in and meet them. Because often you're reading the chart before you go in to see the person at the bedside. I tend to not do that in my practice anymore, because I just found where I would, like, want to know everything and I would read all of this. And then I'd go in and I'm, like, this doesn't match, like the person I'm seeing in the bed here doesn't match with this behavioral problems and noncompliance. And so I try to share that with the, you know, people who are rotating, you know, with our service and, or if I hear a lot of labeling of a patient, while I wonder if you know, they're having difficulties getting to dialysis, so I wonder how we can help them be more adherent with their medication?

Cal Cates 14:24

Well, and I love this idea that you just suggested about sort of going in somewhat uninformed and that, you know, I feel like, as a massage therapist for instance, we often will get an intake form for a client in outpatient practice, and certainly we are invited to read the chart before we see an inpatient. And I know in our, in our courses we see students are regularly shocked by you know, the picture that they formed in their head before we go into a patient's room totally doesn't match when you get into the patient's room and that.But we want to know, right, we want to be able to go into the patient's room and say, I see that you've had blahdy, blahdy, blahdy blah, and like I know about you? And is that actually good care? You know, can you, can you shift your perspective to say so, you know, I know that you've had a lengthy hospital stay, or I know you're coming in today with carpal tunnel syndrome. Tell me about that. And, and to just, it doesn't make you a bad clinician to not already have memorized their history. And I think that that's kind of the expectation is that you almost want to know more about them than they do before you make your first contact. And that sets us up.

Anne Kelemen 15:34

Right? It's like, it's almost like, it's almost like dating in the early 90s, when like, we didn't have to Google people and you just learned about them when you met them. Isn't that great?

Cal Cates 15:43

Yes, yes.

Anne Kelemen 15:45

Think of it that way. But I've had patients where I'll go in and I had a woman recently be like, didn't you look at my chart? And my response to her was, actually I didn't, because I find out that there's so much information in there that's not right, and I just like to learn how I can be most helpful to you. And she was like, oh, okay.

Cal Cates 16:05

Yeah.

Anne Kelemen 16:06

You know

Cal Cates 16:07

Am I on Candid Camera?

Anne Kelemen 16:12

Yeah. So, I think that's just how I have changed my practice and I have learned because I've just found so much information that is just not true or, you know, a different perspective when you're actually at the bedside.

Cal Cates 16:26

So do you work with clinicians in terms of like, because I know people always want us to, like, do role plays with them or basically tell them exactly what to say? And so do you say like, where you would say 'noncompliant' how about try this? Or how do you go about inviting clinicians to consider and shift their language to be more accurate? And, yeah, just accurate, again, is really what we're going for.

Anne Kelemen 16:50

Yeah, I do that a lot. And I had created, around the time of COVID, almost just a one-page flyer that we handed out in the ICU of instead of saying, like, you know, we have no more ventilators or, you know, whatever the language that people were worried about during COVID, consider this, and then kind of a column for a rationale of like, well, why you would consider this. And I did that around canonacy. Another one that I can think of is, I had a patient recently, who was just very appropriately and I have seen clinically where there's everyone sort of has an excuse to get out of the room. You know, we're all busy, you have a lot of people to see and, you know, whether that's I've seen, you know, physicians do it, can I or nurse practitioners who have a stethoscope, can I listen to your heart, and that's sort of the signal of like, this visit is going to end soon. And there was a woman who was just very angry the one day and when I sat down and listened, she was a former nurse. And she was like, I've been a nurse for 40 years and I know what good care looks like. And she said that everyone that's coming in here is telling me they have other patients to see. And she said, if you have so many other patients to see, then why is no one seeing me? And so I was like, well, that is a brilliant quote.

Cal Cates 18:05

Yeah.

Anne Kelemen 18:06

And I, I had went and talked to the most recent surgery team that had been in there. And you know, the resident said, yeah, I said that, like I have other patients to see, I can't spend all day with her. And I said, well, I wonder if the next time you go see her, you tell her when you come in the room, I have the next 10 minutes to be here with you and I really want to see how I can help you in the next 10 minutes. And he was like, okay. Because that's the way, you know, I rarely would see anyone if someone said that, to me, I have the next 10 minutes to see how it can be most helpful, then you know that there's a time that it's going to end but you're, somebody is going to be really present with you for the next 10 minutes rather than sort of being like, okay, I've had enough. You know, I gotta, I gotta go see, you know, some other patients.

Cal Cates 18:49

Yeah, well...

Anne Kelemen 18:50

That's a practical way.

Cal Cates 18:51

I feel it's valuable to to the clinicians, as well, because you, if you do have a lot of people to see, you go in the room with just this amorphous sense of pressure. And, you know, it's really easy to be like, oh, well, there's nothing new to learn here, I gotta go. And you just sort of like figure out an excuse to duck out. But if you, in your own mind, say, I am in this room for 10 minutes, I can take a breath in this 10 minutes and know that like, that other patient will be there at the end of that 10 minutes, but I am like fully here right now. And, and maybe that leaves room for if nobody speaks for 30 seconds, that's okay. It's not a signal that this visit is over. Maybe the patient is thinking, maybe, I mean any number of things could happen that then good care gets to continue on the other side of the silence and you create that bubble of possible sharing, I guess I would say.

Cathy Ryan 19:42

Well, and I think it helps to set a parameter for individuals. I'm a introvert and slow processor, you know, and I certainly have had clients in my practice who I started to notice that five minutes before the end of the treatment session was when they started to give me really important information. So if we can frame it in a way that lets the person know, you know, this is the time to really give me this information, if you can, it may help those individuals upfront deliver that information in the first five minutes, and then have that five minutes to talk about rather than sort of general chitchat for eight minutes and then the physician or care provider, whomever has said, okay, you know, here's a stethoscope, and now I have to go. So I think it would really help people have that sense of, okay, this is my window of opportunity, I'm going to use it in the best possible way, when they can.

Anne Kelemen 20:39

Yeah. Yeah, and I, and I find that, you know, most, most of the time when you bring up, you know, just ways to frame things differently, people are welcoming to that or again, they're not even thinking of, you know, the way that they had framed that or the way that it may have come across to the patient.

Cal Cates 21:04

Yeah, well, and I'm thinking like, certainly, I mean, we've been talking about charting, but I remember a patient that you and I had occasion to see a couple years ago, Anne, and this poor gentleman had been waiting for the bus in his neighborhood and was hit, if memory serves, by a stray bullet and wound up in the hospital and the bullet had grazed his heart, apparently. And you and I were visiting with him when the cardiologist came in and she came in and kind of her body language and her language language just sort of left both of us going, huh, I might have done that differently. And, you know, she came in and she clearly had somewhere else to be and almost like, sort of, like, flew in, like, oh, I'm just going to pop in to this sort of life and death situation. And she was coming in to share test results with this person, and they, he had had, I think, an echo or something and they were looking at, had the bullet damaged his heart. And he's lying there, in the ICU, missing work, missing his family - I can't imagine not questioning, like, I was just waiting for the bus and I got shot. And like, I was just going about my business and that this physician comes in and says, "You're so lucky." And I, my memory is that both of our mouths sort of like dropped open. And I was like, did she really just say that to him? And you and I and the patient in the bed sort of, like, froze like, did she just say that. And I know that she was trying to be hopeful, you know, and she was excited that this was at least one patient who was unlikely to die from his injuries. But there there seemed to be no awareness on her part that this was a massive and terrifying disruption in this man's life. And it was really like a one-way communication. And she sort of tapped his hand and said, "So, okay?" and he sort of nonverbally, like, acknowledged that she was in the room and then she was like, "Okay, I'll see you later." And off she went. And I wonder, do you, do you work with clinicians in that way? And sort of just talking about, like, I don't know if you would pull aside that particular clinician, if you had been in that exchange, and we weren't working together? Or if, you know, if that's, if you do call outs and call ins around stuff that you actually see live? Or, you know, do you talk about, sort of, I don't know, yeah, perspective shifts and like, imagine that you're this person lying in this bed and like, here, I'm gonna, I'm gonna come in the room the way that you just did, and like, let's talk about options for communication.

Anne Kelemen 23:50

Yeah, I remember that because I remember, it was like, no acknowledgement that we were there, you know, right? So it wasn't like, "Can I come in?" like, you know, I, this sounds so basic, but I keep saying I can't believe I have to keep reminding people that you should knock and wait for the patient to say yes, like you can come in, right? Like if the door's closed. In the ICU, the doors are rarely closed - well, with COVID they all are, but and I just remember thinking she even see us here? You know, she kind of just breezed in, she said that, and those are the times that you can't really stop the provider because they're on their way. But I think I remember saying something to him, or I wish I did if I didn't say this, "I bet you don't feel so lucky." Because that or something because there needed to be....

Cal Cates 24:34

I can't believe she said that.

Anne Kelemen 24:34

Yeah, there needs to be an acknowledgement because he sort of was like looking at us like, "Did that just happen? Did she tell me I was lucky?" And I can't tell you how many times that, that just happened to me this week where, you know, I'm in the room and it was like I was invisible and this team just breezed in, said something quickly to the patient, and breezed out and he just gave me this look and said "I wish I could ask them a few questions." He said something that was brilliant like "They were really talking at me, not to me."

Cal Cates 24:34

Yeah.

Anne Kelemen 24:41

And that reminds me of that situation. She was really just talking at him. She wasn't really engaging him in the conversation.

Cal Cates 25:10

Yeah.

Anne Kelemen 25:11

And, and so that's, that is challenging, I think, because there's also just, you know, dynamics within a hospital. I think she was a cardiac surgeon and I'm a social worker, and so there may be times where I'm like, okay, I'm gonna let this one go and...

Cal Cates 25:29

yeah, yeah.

Anne Kelemen 25:31

You know, unless it was, you know, there are times when it's really upsetting to the patient and then I'll figure a way to circle back and say, Hmm, I wonder if, you know, next, it could have been helpful to ask him how he was feeling.

Cal Cates 25:45

Yeah. Yeah, absolutely. Well, and I like, Oh, go ahead, Cathy.

Cathy Ryan 25:51

No, I was just gonna say, you know, and I think you use one of the most important words that we need to be mindful of as practitioners, as care providers, and that's engagement. It's about engaging with the patient, you know, and I always try to be mindful of not saying something like, why I'm working on this person, you know, that, that this is a relationship here. And that requires bilateral communication?

Cal Cates 26:19

Yeah, yeah. It's rarely a two-way... we wrote an article, my colleague, Kerry Jordan and I wrote an article a couple years ago about intake, and an intake as a sort of experience and experiment in curiosity. And, in the article, we put two intakes with the same client sort of back to back and said, like, so here is an intake conducted by a clinician who is really interested in making sure that the patient knows they are smart and that they know what they're doing. And here is an intake by a clinician who is really curious about what's happening for the person they're about to treat. And the two intakes take the same amount of time but, in the first intake, the clinician does most of the talking and, in the second intake, the patient does most of the talking. And it just, I wish we could, I'm sure we can over time, but shift that perspective for clinicians that our job is actually to be quiet, and to be curious, and to, to not show up with our heads so full of what we know that we're unable to receive surprising, or just new, information.

Anne Kelemen 27:33

Yeah, yeah.

Cal Cates 27:35

So if you could fix that, Anne, that would be great.

Anne Kelemen 27:38

I'm working on it, I'm working on it.

Cal Cates 27:39

Well, I wonder, too, Anne, how this dovetails because I know you also do some work around illness and intimacy and, sort of, sexual health and illness. And I feel like some of these things do overlap in terms of what people are willing to talk about or just, you know, that you don't have to be an expert to invite conversation about real issues. And yeah, so if you would share with us a little bit about how you, how you do that? And, yeah.

Anne Kelemen 28:11

Yeah, and then sort of around death too, right? Because these are topics that we think, well, I don't want to talk to the patient about dying, they're not thinking about that, or I don't want to ask them about their, you know, sexual health or intimacy because they're not thinking about that, or they'll bring it up if it's important to them. You make, you know, all these assumptions. And I remember, you know, just, if you are showing up and listening, all of these issues come up, and they do, you know, people do want to talk about it and, and often I'm hearing, well, I brought this topic up around, you know, whether or not it was, you know, for my outside provider, I brought up about, you know, some sexual health and a prescription for Viagra and I was told, oh, don't think about that now, focus on, you know, feeling better. So then you're dismissed so then you're not like, willing to bring that up, because you're sort of, you know, this is not a safe place to talk about that. And I found that there's just, you know, showing up, asking, so you don't even have to ask a lot of questions. You are just asking, you know, what are you thinking about? How can we most help you? A lot of these, you know, conversations come up around sexual health or, and sometimes it's not even, it's not about the fact of a medication, right, where we are, it's, it's about I want to talk about how hard it is to like, not be able to, like be around my grandkids, or I just feel so lonely or I'm worried about, you know, being a burden to my family.

Cal Cates 29:43

Yeah, yeah. We don't have to solve it if somebody shares it. I think that's the, that's the thing, right? It's like, oh, it makes sense that you'd be concerned about that.

Anne Kelemen 29:55

Yeah.

Cal Cates 29:55

You know, I mean.

Anne Kelemen 29:56

I think that's what can be so hard. In that situation you talked about where the doctor came in and said, "You're so lucky" is that he was sad and like, it's hard for people to just be there with that sadness and not want to fix that. Yeah, you know, I've been in so many family meetings where as soon as somebody gets emotional, somebody is shoving a box of tissues in their face or something because they want to, you know, and that message is stop, you know, the meta message kind of is stop crying

Cal Cates 30:23

Right.

Anne Kelemen 30:24

And you can't just sit with that and just allow somebody to, you know, cry and to have a space to process what's really going on.

Cathy Ryan 30:33

What you know, and I'm glad you brought that up, because this is something that happened recently from my practice too, and this has never happened with this particular client before, but came in, was working through some, some stuff with their body and started to cry. And sometimes I will say to a person, can I get you anything or, you know, I'm here for you. But just intuitively, I knew that if I said anything to this person, they probably would have stopped crying. So I just, I continued to work and, without me even asking, she said to me, just keep, just keep working, I'm okay. So I did. You know so I think that that is such an important thing to bring up because there are times where it does feel appropriate to acknowledge that the person is crying and say, can I get you anything, would you like me to... because in massage therapy school, typically we're taught to stop working but keep our hands on the person and ask them if they need anything. That's what we're taught. And sometimes that may not be the best thing for that individual because you don't want to interrupt when sometimes when you acknowledge that they're crying, they'll become very self conscious and stop themselves. And sometimes they just need to cry.

Anne Kelemen 31:52

Yeah.

Cal Cates 31:53

Absolutely.

Anne Kelemen 31:55

Yeah, yeah.

Cal Cates 31:56

Well, and we had a, we, we did a class maybe a year or two ago, and one of our sort of guest instructors was one of the physicians we work with at Children's. And we asked her to sort of do a, you know, a day in the life of a pediatric hospital-based physician, and she talked about how that's not a thing, first of all, that like every single day is very different. I mean, there's certain threads, but there are different patients, different situations. But when she, toward the end of her talking about what her average day is like, she talked about how, and I don't remember exactly, but I think it was something like 25% of what she does every day is what she learned in medical school. And the rest of it is interpersonal communication, navigation, listening. You know, when I speak, I try to say useful things like, and that I just don't think language actually gets the press it deserves. You know, we just love facts and science so much, and I'm a big nerd and I love science also. And when it comes to caring for people, science only goes so far.

Anne Kelemen 33:00

And yeah, and we spend, especially, you know, in palliative care, we spend a lot of time talking about communication, but we spend fewer time talking about like, word choice.

Cal Cates 33:17

Yeah.

Anne Kelemen 33:17

Actual, like, language and actual words that we're using.

Cal Cates 33:20

Yeah.

Anne Kelemen 33:21

And, and some, you know, another word that really I just do not like is often missing in a chart, like patient complains of pain.

Cal Cates 33:29

Yeah.

Anne Kelemen 33:29

And just the word complains.

Cal Cates 33:31

Yeah.

Anne Kelemen 33:31

And we talk a lot about that. Well, you know, why not 'reports' because you want to say like, the patient complains of frequent bowel movements?

Cal Cates 33:39

Right, right.

Anne Kelemen 33:42

You know? Why do we use that word with pain? And so that, you know, that's another area to just, it just, I think, you know, I'm sure if I went back and saw some of my notes from, you know, years ago, or, you know, even not that long ago, that it would probably be in there. And so much of the electronic medical record is copied so like how many times are you copying like, you know, an H&P or or something that then you're not even really reading, you're just quickly trying to do your note. And, you know, one I can think of is in the first line of the HPI, where I often see that just drives me crazy as when it's, you know, 42 year old homeless female. And, you know, rather than that, information can be important, but why not, why not put that in the social history? And I remember talking to a resident one time and I said, well, you know, I'm not sure if the person lived in, you know, a single family home in Fairfax, Virginia, we would document that in the first line, the HPI.

Cal Cates 34:42

Right. Yeah.

Anne Kelemen 34:43

It's often just the negative things that we're, you know, or perceived negative things that we're documenting.

Cal Cates 34:48

Yeah, absolutely. Well, I'm, like you said, it just sets up. If this is, these are the descriptors we choose and, as a clinician who's new, treating this person, these are the first three adjectives that I see about this person, and it, it does, it changes how I think even, even despite my best intentions.

Anne Kelemen 35:06

Yeah.

Cal Cates 35:07

Yeah.

Cathy Ryan 35:08

Well, and I think that's a classic example of assumptions or biases that are formed before you even have the opportunity to speak with that person.

Cal Cates 35:18

Absolutely.

Anne Kelemen 35:20

Yeah. Especially if that's copied because what if they had a history of, you know, housing instability but that was a decade ago.

Cal Cates 35:27

Right.

Anne Kelemen 35:28

But that note was just copied, and?

Cal Cates 35:30

Yeah, absolutely. Now, when, you know, in terms of interdisciplinary care, which, you know, we obviously are very excited about on this show, one of the things that I find really interesting and, and sad, in my experience in hospital practice is that you and the chaplains, the social workers and the chaplains are the communicators. Like, if a family is unhappy, if a patient is struggling, if there is something that requires sort of a higher level of communication ability, they just call a social worker. I mean, I've been in rooms where a doctor will see a patient start to cry and say, you know, what I'm gonna call the social worker and they like, hightail it out, right? So, you know, that doesn't sound like interdisciplinary care as much as maybe multidisciplinary care. And, you know, do you ever, do you ever find yourself actually pushing back or sort of like inviting the person who called you in to care for a person to say like, hey, so, you know, yeah, like, this is this is my area. And also.

Anne Kelemen 36:36

Yeah, I find myself saying that around like, well, they're just so sad, can you come back and see them? And I was like, one happy to come back and see them, we can go together, but I'm also not going to make them less sad.

Cal Cates 36:48

Right?

Anne Kelemen 36:49

My intervention is not to make them less sad about the fact that they're dying, right, or cry less. And just to try to, you know, normalize that, and I actually share this, the social work mentor had shared this with me one time about well, you know, what, what do we want from patients? Like, how are we hoping that they will act? And really asking yourself that question, well, if I'm calling the social worker because this person is crying, like how am I hoping that this person will act? Because there's so much around, oh, like, they're crying too much. Or, you know, I remember an oncology fellow was excited to communicate to somebody that they were in remission, and he came out of the room and I said, "Are you okay? You look, you look sad." And he goes, "Well, I am. She just wasn't as excited as I hoped she would be."

Cal Cates 37:45

Oh, sorry.

Anne Kelemen 37:46

I thought he was really honest. And I said, oh, I said, Well, it sounds like you had an expectation of what you were hoping from her. And she didn't meet this expectation. So I, you know, I go back to that, because, you know, in the ICU, there's so much of, oh, can you come see this person, their family has never come to see them? Or oh, this family's, you know, this, can you come help because this family is always at the bedside, and they never go away? And I often will say, well, is there a right amount of time? Like, is there something that's just in the middle that we're hoping for from patients or families where we don't get concerned that, you know, there's, there's not enough support or there's too much support?

Cal Cates 38:25

Yeah, yeah, I feel like this is so much of, so much of what we, what we could do better in caregiving, comes back to our very human and neurotypical creation of explanation without even knowing that that's the thing that we do. I remember I had a client years ago, very early in my oncology massage career, who was, while I was working with her, she reached the end of her road with tamoxifen. And so, as a breast cancer survivor, she had been taking tamoxifen for, at that time, I think that protocol was five years. So she had every, on a regular basis for five years, she had been taking this drug to sort of maintain her hormone balance to hopefully prevent the cancer from recurring and I, being a new person to this and thinking, boy, I bet I would hate that, when she came in for her session, her first session after she was done taking I said, you're done with tamoxifen, you know, and I was like, had my pompoms out and everything and she started to cry. And I was like, oh, I wonder what I did. And she was like, I have nothing to keep the cancer away now. Like, like a really comforting kind of guard rail. And now like, I have one appointment a year, nobody's checking on me, I'm not taking any medication like so, yeah, I'm glad to not have to take this medication, but mostly, I'm just scared now that I have nothing defending me from the cancer. And, and she really did kind of look at me like so, I hope you don't do that to anybody else. And I was like, oh, yeah, you're right, that was, I didn't even know that, that was - eeks. I wanted to have a party with you, but you weren't partying mood.

Anne Kelemen 40:02

But I bet you learned and you probably didn't do that.

Cal Cates 40:05

I sure didn't. And I, and I now I just say so you know, like, if it comes up, how do you feel about that?

Anne Kelemen 40:12

Yeah.

Cal Cates 40:12

And then if they're excited, I get to be excited. And if they're like, this sucks, then we get to be in the suck together. But they get to tell me what, what the mood in the room ought to be.

Anne Kelemen 40:22

Yeah.

Cal Cates 40:22

Yeah.

Anne Kelemen 40:22

And we've all done that, where I've done that, where I've said, there was a patient, and now I'm like, I can't believe I did this. But years ago, he had, you know, he was getting some kind of treatment for cancer, was, you know, probably going to get through it and be in remission, and I had saw him on an admission where he had decided to shave because he was losing his, losing his hair. And he had the big beard with long hair and it was really humid in the summertime here in DC. And I went in and I saw him and, this is somebody I had a relationship with, and I said, oh, I bet it feels, I bet it feels good that you shaved because it's so humid. And as soon as it came out of my mouth, I knew it was the wrong thing and he started crying. And then I was like, that was the wrong thing to say.

Cal Cates 41:11

Yeah.

Anne Kelemen 41:11

And you know, I just said that, because I was like, what are you thinking? But I, you know, looking back, I was uncomfortable in that moment.

Cal Cates 41:17

Yeah.

Anne Kelemen 41:18

And, you know, I just said this thing. And then I thought, shit. Well, you know, that was the, that was the wrong thing to say. And I acknowledge that. And later, you know, I was with one of our interdisciplinary providers who just sort of made fun of me for a time after that, like, I can't believe you said that. So, but I've never done that before or again, you know?

Cathy Ryan 41:39

Well, I think as humans, we have that innate sort of desire to make it, normalize it, or find the silver lining in it, or whatever the case may be. And you know, what, sometimes it just needs to be what it is.

Anne Kelemen 41:55

Yeah, I think is it Renee Brown, who says to try to avoid the "at least" statements?

Cal Cates 42:00

Yes.

Anne Kelemen 42:00

You know.

Cathy Ryan 42:01

Yeah. Yeah.

Anne Kelemen 42:02

Which I was trying to go back to, you know, which is so hard not to.

Cathy Ryan 42:07

Well, and Cal, you said one of those phrases that I think, again, is so important for us as clinicians is rather than making assumption about how someone feels, just simply ask them, how do you feel about that?

Cal Cates 42:18

Yeah. Yeah. And wait, you know, like, I might question and just leave the space for whatever the answer might be.

Cathy Ryan 42:27

Yeah. And don't get all in a twist if it's not the answer that you were, you had an expectation for, or wanted to hear, or would make you feel better in that moment, as a clinician.

Cal Cates 42:40

Absolutely. Well, and as Anne said, Anne and I both in our in our, and I bet, Cathy, you have put your foot in your mouth as well, like...

Cathy Ryan 42:47

Oh, for sure.

Cal Cates 42:48

You never want to do that but, man, there's no better way to learn. You know, and I mean, you're just not going to get to a place where you're not going to do harm, where you're not going to get it wrong, like, maybe you'll get it wrong less often. But we just and I think our sense that we have finally climbed atop the pedestal of perfection in our communication makes us more nervous. And that the more we can just come back to, okay, it's a new day, new mistakes to be made, you know, and, and really be willing to just know that you're gonna say some stupid things and and then you're gonna, oh, not say those again?

Anne Kelemen 43:27

Yeah, yeah.

Cal Cates 43:30

So Anne, what do you? I mean, what do we do? Do you have, do you have recommendations? Are there, are there books we should read? Are there, what can we do in our own practices? Maybe if we work alone, or if we work with a couple of clinicians like, and we now having listened to this conversation and probably other things out there, we're aware that this is something that needs to shift? How do we go about making those changes?

Anne Kelemen 43:59

Well, I think, yes, there are books and there are articles. And one of, I can give you the reference for the article I mentioned at the beginning that's from the 90s, because I think so much of that is true today. And it talks a lot about you know how to be mindful when you're, when you're documenting. I have been really encouraged recently, there was an article, even within the last month, that came out in JAMA around word choice, and actually having a table and one of the examples was poor historian and consider this instead. And so it's great that, you know, a journal like JAMA is paying more attention to that. I think you can always model good communication and word choice when you're at the bedside, especially when there's other interdisciplinary team members with you. It will be interesting to see what happens moving towards Open Notes, which I think is coming in April, so just a couple of months. Because I really think that'll be the change when the patients are starting to read things and saying, hey, why did you write this or I'm wondering and that will maybe help to change people's behaviors. And I think, when it comes to documentation, just being really mindful of a simple thing to start with is like not you know, not copying, you know, somebody else's HPI? Or if you do, then make sure you're editing it so there's not, you know, labeling language that comes across.

Cal Cates 45:22

Yeah.

Anne Kelemen 45:24

I try to, in my documentation, use like patient stated, patient reported.

Cal Cates 45:28

Yeah.

Anne Kelemen 45:29

Rather there no complains or denies, I don't, that's another word I don't like is denies.

Cal Cates 45:34

Yeah, yeah, I remember when I first saw them in a chart said patient denies pain. And I was like, wait, so do we think they're lying? Or what? I don't understand. Yeah.

Anne Kelemen 45:42

Again, I mean, it's sort of like, one thing we didn't touch on because there's a lot of articles and about, you know, metaphors, and metaphors and cancer, you know, specifically around like battle and somebody has lost their battle. And there's been a lot, you know, published on that and the reasons why we should not, you know, be documenting that. And, you know, I mean, that's the, you know, that's kind of a great place to start. And I also want people to get curious around just other things, you know, that we're documenting and that we're, you know, talking about amongst our colleagues and how you're talking about a patient. Because that will just, you know, come across and then people can sense that when you're going in to care for them. And I've had so many patients say that to me, I don't think this nurse likes me today.

Cal Cates 46:34

Yeah. Yeah, we have a lot of, a lot of work to do. And, and so much of the, the work we have to do is about making the unconscious conscious to start with, and just even noticing how these things can be perceived. And, and I think getting over the, you know, this idea of the good old days, and it's like, well, the good old days were when you could judge and marginalize people without being challenged. I'm not really sure what was good about those. It's, it is gonna require some heavy lifting to move to a place where we're more thoughtful about our language.

Anne Kelemen 47:14

And I don't think, right, I don't think it means, it doesn't mean that you're a bad person. Right?

Cal Cates 47:18

Right. Right.

Anne Kelemen 47:19

So we're set up to have these thoughts. So if you have these thoughts, and you're going in, and you're like, huh, what is this bringing up for me? Like, even just stopping the thing? Huh, why am I having this, you know, thought, you know, and it could be the, you know, judgment of this, you know, physician who's coming in and completely ignoring me, right? Like, I'm making a lot of judgments about that person who's doing that, too. Right? So what, you know, what is coming up for you in that moment? And then just to be curious about that?

Cathy Ryan 47:50

Well, you know, and I think that's it, you know, we need to be, you know, I think of our massage therapy profession. And, you know, certainly I've challenged different phrases in language over the years, that I think so many of us just repeat it, because we've heard it for so many years without really thinking about what that means. You know, I really loved what you said, Anne, early on about care models, language or whatever phrasing that you use. And, you know, one of my rants has been breaking down scar tissue, it's like, really, let's really physiologically look at that, is that accurate? And my issue with it is not just that it's incorrect language, but that it also sets a perception of how I should use my hands. And that's what I take issue with. So I think, again, it's just really important for us to really pause and hear what we're saying or question what's being said. Be curious about it. Explore that, where's that coming from? And certainly, you know, this is what this podcast is about, you know, with, for Cal and I, is let's, let's question some of these things that have continued on and on, like racism, for example. Where does that come from? And why do we have these notions in our head? You know, so that's, you know, it's just another example of, you know, we need to really start to explore as a as a culture as a people.

Cal Cates 49:18

Yeah, yeah, we did. I mean, when you were talking about the, you know, 44 year old homeless woman I see often in charts, you know, 36 year old African American blah, blah, you never see 25 year old white person.

Anne Kelemen 49:30

Yeah.

Cal Cates 49:31

It's not a thing. See, Hispanic, you see, Black, you see all kinds of if you're not white, that becomes one of your descriptors. But if you're white, it doesn't it doesn't show up. So.

Anne Kelemen 49:43

Yeah, yeah. Yeah. And why, and why is that?

Cal Cates 49:47

Yeah, yeah.

Anne Kelemen 49:49

There's not. Yeah.

Cal Cates 49:50

Well, and this is part of healthcare inequity. I mean, it's these little tiny places that add up to be a systemic shift in the way a person is perceived and the options that they're given and the way that their care is provided. So we are making a huge difference when we choose wisely, and responsibly, the words we use, and we look to be equitable and how and when we share those.

Cathy Ryan 50:14

Well, that's such an important thing to point out, Cal, is that it's kind of like white is the benchmark.

Cal Cates 50:21

Yeah.

Cathy Ryan 50:22

And then anything else outside of that needs to be noted.

Cal Cates 50:25

Yep. That's other.

Anne Kelemen 50:26

Yeah.

Cathy Ryan 50:27

Yes, that's other, you know, okay. That's a concern, that's a big problem.

Cal Cates 50:33

Yes, yeah.

Anne Kelemen 50:35

And just, you know, I mean, even the takeaway, is just thinking, this is a permanent record so whatever I am putting in this chart, right, is, is going to follow, is going to be with this human forever.

Cal Cates 50:49

Yes.

Anne Kelemen 50:49

And, you know, in Social Work school, we are taught, you know, do not document unless you are comfortable, you know, reading this out loud in court, or it'll be printed on the front page of the New York Times. So that's what our discipline teaches us about documentation. I don't know, sort of, what other disciplines are taught about documentation, but I always go back to that, and, and, you know, it even comes to when somebody is talking about, I don't want to be a burden to my family, or I'm really worried about my kids when I die. I tend to document more now, you know, like patient expressed some common worries and concerns around somebody with a serious illness. Because these aren't protected, you know, therapy notes, right? And, you know, I think about, you know, somebody's child who might request their medical record after they die and say, well, why didn't mom feel comfortable talking to me about this? Or, you know, whatever it may be?

Cal Cates 51:38

Yeah. Yeah, definitely lots of, I mean, once again, thinking beyond ourselves. And you know, it's really easy, even when you're on a team to sort of be in your little silo and in your little world, like you're seeing your patients, you have your census, you're writing your your individual notes, and certainly as private practitioners in whatever our discipline is, we don't think about the other providers and the other people who might interact with what we've reported about a patient and how that will affect their lives.

Anne Kelemen 52:08

Yeah.

Cal Cates 52:10

Yeah, well, so thank you so much for being with us, Anne. We, we will get the link for that JAMA article and I would also love to include a link to, I know you and our colleague, Dr. Hunter Groninger, wrote an article a couple years ago about comfort care, and sort of the phrase, there's nothing more we can do and how that's not really accurate, and that there are a variety of ways to approach those sorts of situations. And, if you have any other resources that you want to share with us, we'll make sure and get those in the show notes. I also want to remind everybody that Anne actually did a course last year with our colleague, Kerry Jordan called "To Chart or Not to Chart" and it is on our online.healwell.org educational platform so go check that out. It's a, it's an hour-long course just about these sticky situations and like Anne just said, you know, what do you do, when you see something that needs to be reported, but maybe it doesn't need to be written down? And how do you manage it and how do you write it if it is? So go check that out. Cathy, any other parting words?

Cathy Ryan 53:13

I love language, especially good language.

Cal Cates 53:18

Yes, indeed. Well, thank you all for being with us. Anne, thank you for being with us. Be sure to go and use all your social media might - like us, share us, leave a review or comment on Apple Podcasts or wherever you get your podcasts and remember that you can become a Patreon of this podcast. So go check that out. And thanks for listening. We'll see you next week.

Anne Kelemen 53:42

Thank you.

Rebecca Sturgeon 53:53

Interdisciplinary is produced by Healwell. Our theme music is by Harry Pickens. You can send us feedback at info@healwell.org. That's info@healwell.org. New episodes will be posted weekly, via Apple Podcasts, Spotify, and our Facebook page. Thank you.

Transcribed by https://otter.ai