I read a short piece by Maria Castelluci in Modern Healthcare this month. She highlights the stress felt by residents (those who have graduated medical school but have yet to complete their full medical training) when they face thinking about talking to patients with advance illness about their goals. No doubt that talking about health care planning makes most providers uneasy. When I was a resident, how to have these discussions was not addressed formally as a regular part of my training or curriculum. If one of your supervising physicians happened to do this well you could try to get into a family meeting they were conducting to use them as a model. I remember the way Dr. Mike Strong, now the Chief Medical Informatics Officer at the University of Utah Hospital and Clinics, would approach these situations. I remember the way he would use body language and phrases that put people at ease. It was a superpower. I wanted to be like Mike. After the conversations were over I would step out into the hall, sit at the nurses’ station, and write down what I had observed him accomplish. But a doc like Mike is a swan in a flock of seagulls. A rare find. By the end of my training and into my early career I avoided talking about goals and planning because I felt like I didn’t have the skills, the family dynamics seemed tense and unpredictable, it took too much time, and it didn’t seem like a priority to the health system and my peers. I was wrong.

A few years later, after dealing with chronic illness within my own family, my focus changed such that healthcare planning became my passion. After in depth course work, practicing techniques and talking points with patients, and formal mentorship I felt prepared to have these goals of care discussions with anyone. I was wrong again. In some of these family meetings I fumbled, most were ok, a few were just awful. But a few were incredible. I could feel that they helped the patients and their loved ones. They became my fuel. I hadn’t felt anything as meaningful in medicine as I did these handful of special encounters. Slowly, and with many more patient interactions, talking about sensitive choices families faced became less stressful, more efficient, and clearly valuable for everyone involved.

When you think about how many heart attacks a training cardiologist takes care of in the cardiac catheterization lab or how many trauma patients a resident surgeon needs to operate on before they are allowed to see patients without supervision it’s a big number. Its 1000s of hours. So when I consider resident training in crucial conversations with patients facing difficult decisions I am thrilled that they are getting early exposure and instruction. Without the same practice and dedication to the art of conducting valuable family meetings, should those with just a modicum of training be the ones to ultimately have these discussions? Or should they be delegated to those who spend the majority of time making these meetings our “procedure”? At Iris Plans it’s not an “either/or” choice. We have found a way to take the bulk of the family meetings conducted by healthcare professionals whose expertise is conversation and facilitation. But, critically, we get buy-in from the primary care provider and specialist to do so and loop them in on clinical questions as well as the ultimate decisions. It’s a patient-centered model that supports the clinicians plan and relationship with the patient. We believe it’s the future of healthcare planning.


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