If she were your mother.

This is another one we hear quite a bit in medicine: “what would you do if she were your mother?” It makes complete sense for someone to ask this question, it’s a very healthy and relatable thing to wonder especially if the person in question can’t answer for themselves. Patients and their families not only want advice, they want the best advice, the same advice you’d give your own family if everything was on the line.

I’ve seen some people come straight out and answer this question with a direct recommendation. “If she were my mother, I’d do the surgery.” The tricky thing about this approach is that it presumes your mother’s (or in fact your own) values and priorities are the same as your patient’s. It ignores, and downplays, all those wonderful things that make each of us different. And it risks swaying someone toward a particular decision based on your values rather than theirs.

So if you don’t take a direct approach to answering the question, how then might you respond? I’ve also seen some people answer by saying “I can’t answer that question because she’s not my mother,” which I feel gets a little closer to the underlying point. The approach that I’ve settled on over the years is one with a little more validation, and a little more redirection. I might say something like “you know, I would do exactly what you’re doing right now. I’d weight the risks and benefits, and think about what my mother would say if she could hear everything we’re talking about. And the truth is, it may be very different from what your mother would say. What do you think your mother would say if she could hear what we’ve been discussing?”

I’m sure there are other approaches that are just as, or even more, effective – but the above is what I’ve found works best in this situation.

What have you found works best when asked “what would you do if she were your mother?”

Request for nondisclosure of information.

Has a patient’s family member ever stopped you outside the room and asked you not to share a diagnosis or key piece of information with your patient? If so, how did you react? And if this has never happened to you, how might you respond to such a request?

As a full-time palliative care doctor, I can tell you that requests for nondisclosure of information happens relatively frequently. We’re ethically obligated to share information with our patients if they want to know, but if they don’t want to know then we’re not obligated to share. Of course, we can’t just assume that our patient doesn’t want information because family members are saying so – we need to verify. This can turn into a pretty tricky situation, one that risks fracturing trust and rapport while compromising patient autonomy and right to know.

I’ve found that the best approach in this situation is one of curiosity and validation. Spend some time outside the room mapping out the concerns. “What are you most worried about?” or “Tell me more about your concerns with sharing this information” are great ways to start. Then respond with empathy and acknowledge and validate the often very human, and loving, emotions behind the request. Often times the family member’s afraid of causing more distress, or “speeding things up” due to depression or anxiety or added stress.

By acknowledging the emotion behind the request, and validating humanity, you can move on to the necessary next step: protecting your patient’s autonomy while also respecting the family member’s concerns. In my experience, the best way to do this is by clearly setting the expectation that if the patient wants to know, then we must share the information. If he doesn’t want to know, then we don’t need to discuss further.

I then negotiate for information sharing. I’ll say something along the lines of “I’ll ask if he wants to know while paying particular attention to your concerns.” But I won’t stop there – I’ll take it one step further by sharing exactly what I’ll say to the patient. After this, I’ll ask for feedback from the family. “What do you think of asking in that way?”

By validating the family member’s concerns and then aligning your strategy through negotiation, you’ll come to a shared communication approach where there are (hopefully) no surprises. This technique helps you tend to potential distress in your patient and their family, as well as team distress caused by fear of withholding information.

Ice cream soup.

When I was a kid, that’s how I’d eat ice cream: I’d stick it in a bowl and churn until it became a thick, soupy liquid. I suppose I could’ve just gone for a milkshake every time, but there was something deliciously rewarding about blending that rock hard chunk into a smooth and silky ribbon.

The other night we went for ice cream and I told my daughter the story of my childhood and she looked at me like I was crazy, and said “why would you do that?” I started defending myself when my son said “she’s just yucking your yum.”

I said “oh, kind of like potato/potahto from the song Let’s Call the Whole Thing Off!” which of course got me thinking about Fred Astaire and the amazing ceiling dance sequence from Royal Wedding.

When I finally finished explaining how they shot the scene, everyone’s ice cream had melted.

The moral of the story? Eat your ice cream however you want, it’s your ice cream.

If you’ve never seen the dance sequence from Royal Wedding, then here it is you’re in for a treat and a good, long smile to start your week.

Do what’s right for you.

One of the most important bits of advice I received as a fellow was “don’t let anyone ever tell you that work is more important than your family.” I’m not sure the person who told me this knows the impact she’s had on my life since then.

Always do what’s right for you and your family. Because I’ve lived my life by this framework, I think I’ve been able to weather the sea of change our humble team has faced over the years. Because I’ve kept my eye firmly fixed on my priorities, I rejoice when others do the same. I’m not saying the above is the perfect framework for everyone, you must chose your own path. I’m saying it has helped me keep my ship upright in the middle of some pretty intense storms.

So yes, do what’s right for you. Do it, of course, with integrity and clear communication and feedback and planning. But when all is said and done, a good team will understand and find a way to move on because in the end what’s best for you is what’s best for the team.

Practice makes purpose.

The other day my son said “Why is the saying ‘practice makes perfect?’ Shouldn’t it be ‘practice makes better,’ since no one’s perfect?” He’s nine with the mind of a much older man trapped in his body, and I cherish every conversation we have together.

I told him that I agree 100%, and maybe there’s a little more to it, too. Certainly I practice my communication and leadership skills so that I can become a better Palliative Care doctor just like he practices his trumpet to become a better musician. But there’s so much more to it.

Living a life of practice – accepting that you can always learn more and grow more and better yourself – sets you firmly on a path toward purpose. Of course, purpose can be whatever you want it to be, and it’s different for each person. And it certainly doesn’t have to be tied to your work. Personally, I practice the things that give my life meaning: being a better father and husband, being a better writer, and being a better Palliative Care doctor.

Find the things that give your life purpose and meaning, and practice them. And if you’re not sure what gives your life purpose, then look for the things you keep returning to, the things you come back to again and again, the things you hope to get better at because you love them so much and because you must.

Trust your team.

This is my biggest piece of advice for anyone starting a new role or joining a new team, especially if the team is well-established. Many teams these days are multidisciplinary and full of experience and wisdom. Trust each other’s expertise, and figure out a way to build on each other’s strengths.

This was a lesson I learned early in my time at Mercy, and I learned it from a dear friend and colleague. Fresh out of Fellowship, I felt like I needed to do everything and see everyone and be everywhere all at once. I didn’t. What I needed to do was trust my team. I needed to learn how to ask for help, and ask for advice. I needed to lean on, and learn from, my colleagues.

Trust your team. It’s the only way to grow stronger, and get better, over time.

Introduce yourself.

Looking back, this probably should’ve been the very first entry in this blog. It seems like such an obvious thing to do, and yet I can’t tell you how many times doctors forget to introduce themselves. It’s such an important first step in building trust, and getting to know your patient better.

In my field of Palliative Care, it’s also a great way to introduce what I do and help correct any misunderstanding. Many people assume they know who I am and why I’m there, the assume that I’m Andrew coming in to “pull the plug.” Of course, that’s not who I am at all.

So introduce yourself, and help your patients understand who you are a little better just as you hope to understand who they are a little better.

I’m Andrew and I’m a Palliative Care doctor. And this is what I do.

Where things used to be.

Having lived in Pittsburgh for nearly a decade now, I’ve learned that directions are often given based on where things used to be. And we’ve been here long enough that a few things are no longer there.

Which got me thinking: if I were to look back on my life and draw a map of how I got here, would I give directions based on where things still are, or where they used to be?

Would I say “and I took a right at Baylor, and drove through Chicago?”

Or that I turned left at where my insecurity used to be, and that’s where my bias used to take up a whole city block.

And that’s where I left fear behind.

Be more forgiving.

Sometimes people don’t follow their doctor’s advice because they’re scared. Sometimes they show up late because they missed the transport van, or their car broke down, or they just overslept. Sometimes they lash out in anger or guilt, and storm off in a huff because they just can’t anymore. Sometimes they go back to the alcohol or the cigarettes or the drugs not because they want to.

Be more forgiving. To forgive is to embrace the humanity in each of us, the flaws and imperfections, the beautiful things that make us unique on this spinning rock in space. Forgiving doesn’t have to be a spectacle, it can be done in silence or with a simple gesture. By using the word “forgive” I don’t mean to imply that it’s our role to pass judgment, or to “pardon” our patients. Not at all. But our patients do, often, feel judged. They feel shame, and guilt. They see us roll our eyes when we think they’re not looking.

I’d like to think we don’t need to add to that heaviness. So whatever you call it, be more.

Understanding. Empathetic. Caring.

Forgiving.

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.