September 22, 2021

Rounds: Hard conversations

Jeff Balser, MD, PhD

Difficult conversations are a hallmark of medicine. Patients and their families rely on us to share the facts about their illnesses that are sometimes hard to hear. While many clinicians begin to do this while training, our effectiveness in these conversations develops throughout a career. Telling a young mother she has an aggressive cancer or a teenager he’ll never walk again requires a challenging blend of objectivity, compassion and emotional intelligence. Even for those senior and experienced, it’s never easy.

In our ICUs we are having far too many difficult discussions informing patients and families with COVID-19 about the dire nature of their condition. Given the vast majority now dying from COVID-19 are unvaccinated, these tragic discussions would be far less common if as a society we were able to have the right conversations about science and public health. Discussions about what is true and real — in our homes, workplaces, schools and communities.

Given the polarity of public opinions, conversations about COVID-19 and vaccination may seem to us as difficult as the hard conversations about a poor prognosis — evoking conflict or even anger. And like other hard conversations, these also take an emotional toll.

As humans, most of us don’t gravitate to conflict any more than delivering bad news. We take a deep breath before sharing a poor prognosis just as we do when confronting patients, co-workers, friends and family who hold untenable views on vaccination.

As we do this, it may seem as if we’re talking into a void as we watch ICUs bulge even as our country struggles to persuade millions to get vaccinated. Yet it is vital that we rise to the occasion and have these hard conversations. And there is a benefit that extends beyond our hope of convincing those we encounter.

The larger benefit is trust. Vanderbilt, and institutions like us across the country, are reservoirs of public trust. Recall the early days of COVID-19 when trust in health care professionals spiked as grocery shelves emptied? Our communities turned to us for reassurance and guidance.

As I told Vanderbilt University School of Medicine’s 2021 graduating class, trust is a funny thing. It is strong yet fragile — and most definitely it is fickle. What we have seen throughout the pandemic is a deep kind of trust — a trust that only could peek through the fog when the world turned upside down and when staying alive is what matters most.

We sustain that deeper trust by speaking the truth regardless of how receptive the audience may be. While it feels as if we are awash in patients who aren’t hearing the message, what we don’t see is the millions who are — including people who were on the fence, but decided to be vaccinated because of people they know, trust and admire at Vanderbilt. The public’s trust in the care we deliver is as important to healing our patients as advancing our treatments and diagnostics.

People remember for decades when we speak the truth in times of turmoil. And the hardest conversations are those longest remembered.