Eat the ice cream first.

If I’ve learned one thing over the years, it’s this: when the power goes out, eat the ice cream first. Of course make sure everyone’s safe and have a plan and activate that plan, but then… eat the ice cream first.

Life’s too short to let good ice cream melt, so make the most of a stressful situation and go to town.

FYI, this principle also applies to a really hard day at work, locking yourself out of the house, any kind of rejection or loss, and forgetting your child’s favorite stuffed animal halfway into a seven hour car trip.

Best case, worst case.

This is a communication framework developed to help surgeons discuss the risks and benefits, and most likely outcomes, of different interventions with their patients. When used well, it’s an effective way of presenting outcomes in a narrative manner that’s easier to comprehend in the context of one’s goals and values, and helps formulate a recommendation based on these values.

One of the things to remember with the Best Case, Worst Case framework is to never assume you know what your patient considers “best” and “worst.”

I met a patient recently who was no longer interested in chemotherapy. I wondered if hospice might help him stay comfortable, and spend more time at home with his family. To me, this sounded like a Best Case scenario. But he didn’t like the sound of this. To him, the Best Case scenario was a sudden death, preferably sooner rather than later, ideally before he even left my clinic. He was ready now, why wait any longer?

It was a good reminder that there’s no universal definition of what’s best or worst – this is why exploring your patient’s unique goals and values is so important!

To learn more about Best Case, Worst Case check out this great site from the University of Wisconsin.

Watch a good movie.

Or a bad movie, whatever makes you happy. This weekend I took the kids to see Marcel the Shell with Shoes On. It was wonderful and funny and incredibly moving at times, and a great reflection on life and love and the value of family. I highly recommend it.

And if you want to watch a really good movie that pretty perfectly captures what it means to be a palliative care doctor, then I recommend watching Inside Out. There are few movies that are perfect for kids and poignant enough for adults, and this is one of them.

What are some of YOUR favorite, go to movies?

Thanks for all you do.

As a devastating storm system tore through Western Pennsylvania this weekend knocking out power to over 40,000 people in the greater Pittsburgh area, I was reminded to thank people for all they do for others. Specifically, the men and women of the electrical crews who worked nonstop in sweltering heat to restore power to many in just under 24 hours.

Thanks for all you do.

Make a recommendation.

With curiosity as your framework, get to know your patient’s goals and values and formulate a recommendation based on these values. Too often in medicine we use the “buffet” approach to communication: give as many choices as possible to cover all options, and ask the patient to choose.

This approach is understandably overwhelming, and incredibly confusing. Not to mention the fact that typically our patients aren’t medical professionals, and have no idea what the “best” choice might be. It’s our role to use all that medical knowledge to figure out the best path forward based on our patients’ unique goals and values.

So ask permission and make a recommendation. “Is it ok if I share my thoughts based on everything you’ve told me so far?” or “Would it be ok if I made a recommendation?” are great ways to start. Then give your recommendation in clear, concise language and see what your patient thinks. If you’ve come to a recommendation that reflects their priorities, then it should feel like a natural transition moving forward.

Give a prognostic range.

Often, from a place of good intention or perhaps overconfidence (or something else), patients and families are given very specific prognoses. “It’s going to happen tonight” or “there’s less than twenty four hours left.” The reality is this: health care providers are very, very bad at estimating prognosis. And if we give a very specific prognosis and are wrong, it often causes tremendous distress and second guessing.

Instead, give a prognostic range. Say “hours to days” or “days to weeks.” Acknowledge the uncertainty, it’s absolutely OK to say you don’t know. Patients and family members often appreciate the honesty. Acknowledge the fact that you don’t have all the answers, and let them know that if you sense things speeding up or changing, you’ll be open and transparent.

Oftentimes knowing that someone is readily available to provide empathetic and honest updates about what’s going on, and answer any questions big or small, is a great source of comfort for patients and their families at the end of life.

Evolve your style.

The best communicators are able to shift their communication style depending on the situation or the people with whom they’re speaking. Never get stuck in one way of communicating, or the “I’ve always done it this way” model.

Some patients need more empathetic exploration, and active tending to emotional distress. Others want information without any frills or distractions, they’re the “just tell it to me straight” crowd. Some people don’t respond well to a strategy of silence, while others don’t respond well to naming the emotion. Once you’ve figured out how your patient communicates best, shift your style accordingly.

Remember: effective communication is about conveying your message in a way that resonates with your patient, not necessarily in a way that makes you feel most comfortable. Sometime they’re two very different things. That’s why we practice!

Gauge perception.

Differences in understanding and perception of medical information are significant sources of conflict in the hospital. A great way to make sure everyone’s starting from the same page is to gauge perception at the beginning of a conversation.

“What is your understanding of what’s going on?” or “What have you been told so far about your health?” are great ways to open. The key is to see what your patient and/or the rest of the family knows at the beginning so any misinformation or misunderstanding can be addressed. Once you’re sure everyone is starting with the same information, you can then move onto sharing new information and exploring goals and values further.

If you don’t gauge perception in the beginning, then you may find yourself starting over in the middle of a meeting because key pieces of information were missing from the start. Save yourself some time, and gauge perception first!

Pay respect to what came before.

This weekend the topic of grandparents came up, and we started talking about my grandmother, Ahbu. My son wanted to hear the story again. So I told him how she sacrificed so much and worked several jobs to keep her family clothed and fed, and how she married my grandfather, who was in the merchant marines, in order to smuggle her family out of China and flee the Communists. How she raised her family in Taiwan in the middle of a war, and supported her daughter’s love of English literature and culture and I Love Lucy until a tall, scrawny foreign Rotary Scholar arrived, and the door to America opened.

“Wow,” my son said. “She sacrificed a lot. I wouldn’t be here if she hadn’t done what she did…”

“Neither would I.”

We smiled, and took a moment to pay respect to what came before, the tides that keep on pushing.

It’s OK to make a mess.

My kids are, let’s face it… kids. They’re full of energy when I’m not, they’re silly and goofy and loud and above all else, messy. Early on, I’d say “ok go have fun but don’t make a mess!” Then I started to wonder what kind of message this was sending. Have fun, but hold back? That didn’t seem quite right.

I had a friend once who refused to use a wet wipe while eating a bucket of buffalo wings. His reasoning? “If you’re gonna eat buffalo wings, you might as well eat buffalo wings.” I’ve come to see things from his point of view.

I’m not touting this post as expert parenting advice in any way. All I can say is this: once I started saying “ok go have fun, and if you make a mess please clean it up!” the kids seem happier, and the house is… well, the house is still messy.

But the kids don’t implode as much when it’s time to clean up…