Asymmetrical Information Warfare
December 2, 2019
By Geoff Frost, UBC Physiatry Resident
In between patients at work today, I glanced at my news app and skimmed through one of the recommended articles. It was an essay by an Emergency Medicine doctor in the US bemoaning society’s insistence on applying every medical intervention possible to a patient in the midst of their death throes. In the process, we ignore the harm this does to the patient in their dying moments.
I think every healthcare practitioner has felt the pain of this interaction at some point in their careers. A patient or a family member
asks for an intervention that is simply implausible, illogical, or downright harmful. It is a tricky conversation. They came to you with two things: 1) A problem, and 2) Hope for a solution. It is uncomfortable for the practitioner to be put in a position to: A) Refuse the request, and then B) Crush the hope. Handling these conversations is no easy task. You need to build trust with the patient, making sure they know you have their best interests at heart, and then discuss the viability of their request. You hope that by the end of the conversation, you will have demonstrated that their request is just not actionable.
I recently attended a lecture about coaching others in medicine and one of the key takeaways I got from the talk was a simple mantra: “You don’t have to win every conversation.” I think this is a game-changing mindset to take into these difficult conversations. You will not be able to convince everyone of your viewpoint. But it is worth explaining your viewpoint. And if the patient leaves the encounter furiously googling all the new-fangled technology that proves the validity of their request, so be it. Fighting will not solve the problem, this is not warfare.
But this whole conundrum got me thinking. How did we get here? How did we get to the point that about once per year I see a PSA masquerading as an opinion piece in a major newspaper telling people to think through and sign advanced care directives? To me, it seems obvious that an advanced care directive will save me from unnecessary harm in the final moments of my life. Surely, everyone else knows this too? But I’m sure that the mechanic I called to fix my clutch over the summer thought the same thing. My clutch had obviously been blown for months, how was I driving the car? How did I miss the obvious truth in a vehicle I owned?
And that is the tricky nut to crack here. There is just too much to know. What is an obvious truth to me is another person’s deep mystery shrouded in unknowable facts. We live in an age of constant and unparalleled asymmetrical information warfare. You know what you know about things important to you. In my case, I know a few things about musculoskeletal medicine. And then it sort of stops. Sure, I know a few other things about general topics. But how many subjects do I know so much about that I can breeze past the common pitfalls associated with them? A minuscule amount. Yet, due to the specialization of all things, you can no longer just sort of get by in a field you know little about. Have you ever heard your grandparents boasting about how they always fixed their own cars? The idea of fixing your own car as a weekend project seems almost laughable today.
And every day as healthcare practitioners we get unwittingly conscripted into this battle. We must carefully navigate difficult conversations about meaningful function, life, and death from a privileged position of significant knowledge. How we leverage that knowledge is key to an ideal outcome. We are not trying to win the conversation, but we are trying to provide actionable information. We cannot be condescending. We must match the information we give to the education and knowledge level of our listener. We must understand the level of information the listener is seeking and meet them there. And most importantly, we must know when to stop giving information, and to just listen. This is no easy task.
And it is something we are woefully unprepared for. Sure, we all learnt how to SPIKES breaking bad news. But did anyone every walk you through the basics of explaining spinal cord stenosis to a patient who speaks English as a second language? I have learnt through harsh mistakes that neither my second languages nor my artistic skills are sufficient to carry me through these conversations.
This problem only gets worse day by day as medical knowledge continues to accumulate. As the body of known facts grows, we spend more of our professional day as chief librarians. We curate the information others bring to us, sift through the nonsense, and try to distill truth. Then we try to pass that knowledge on to those interested. And that last skill – the passing of the knowledge – is the critical skill I find myself honing day in and day out. What’s the right phrase to describe a nerve? Do I compare it to an electrical wire? Or is a rope a better analogy?
I certainly have not cracked the code on how to best convey knowledge to patients. Heck, I have only recently become aware of how critical it is that we pass along information in an efficient, digestible, and respectful manner. So while I drift in the ocean on this topic, I can only hope you the reader find this post to be nothing but tedium. Surely, you’ve beaten me to the end of this story, and have already mastered that all-important skill of explaining the Arcanum of medicine.
Geoff is a fourth-year Physiatry resident at UBC. He currently serves as the Director of Communications at the Resident Doctors of BC and is the host of the Pulse Podcast. Geoff is a professional engineer in Ontario, and prior to entering medicine, he worked as a biomedical engineering entrepreneur.
