Our house is a very, very, very fine house

Last week I spent three afternoons in a communication skills training course.  I had two real motivations for doing this, one related to my leadership role in the Department, the other simply because of my constant quest to find ways of doing things that are just a little bit better than what I’m doing.  At the Departmental level, I’m assessing what will be the best option for us to have in place for communications training for all of us- particularly with a view to creating shared language for our teams.  So, yes, trying to figure out how to do that best for all of us and our patients.

One of the best pieces I came away from the workshop with relates to patient/ family communication and was referred to by our fearless facilitator/ teacher as the “house model.”

Since we’re talking about effective communication, let’s be clear.  Nate didn’t mean, and I don’t mean, this House:

Negative role modeling, perhaps?
Negative role modeling, perhaps?

This house model, used effectively, gets us to a place of shared decision making with patients and families (credit to Bhang and Irengui for a less colorful but equally visual initial version of this):

House Model of Shared Decision Making
House Model of Shared Decision Making

If you look at this, it’s almost intuitive.  It certainly makes good sense.  For me, it put all of this information together in a way that I hadn’t synthesized it before- and perhaps most importantly that can be easily visualized.  If you think about a truly great discussion you have observed or had with a patient and/or their family, all of these things were present to help get to shared decisions consistent with the patient’s goals for their care.

The reality that often intervenes, though, is that the non-medical participants in the discussion get overwhelmed by the medical facts, and they don’t want to question the authority of the physician providing that information- or let us know that we’re speaking fluent doctor and gibberish for a normal human being.  And it’s too easy under pressure of time or emotion (feelings are SCARY- and they require time) for the medical participants to skip the “patient perspective” part of the discussion.  If you use the diagram I’ve drawn before, shortchanging either of those pillars gives you a lopsided house, a lopsided recommendation, and an incomplete ability to truly share in any decision making that occurs.

I go back on service on Tuesday, and I’m going to put my House diagram up in our call room as a reminder to myself.  I might even draw a second and/or third version of what it looks like when one side of it falls down as a reminder.  And I’m going to try really hard to consciously use these concepts over the next few weeks.  I hope that you’ll join me.


2 thoughts on “Our house is a very, very, very fine house

  1. Thanks for sharing this powerful image. When I look at the image and reflect on the moments that have felt most uncomfortable during family meetings, two components, the foundation (trust) and the roof (shared decisions) stand out to me.

    Clearly, trust (both from patients/families toward the health practitioners and vice versa) is essential. One challenge to achieving trust can be time. It certainly takes time to sincerely listen to families’/patients’ concerns and gain their trust. I have found nurses and chaplains to be infinitely helpful in this capacity.

    The second component, the roof of “SHARED decisions” is striking to me, because I have seen families feel overwhelmed when they feel the decisions lie 100% on their shoulders. Particularly when patients are not able to make decisions and families are serving as their proxy, there seems to be a sense of relief when the decisions feel “shared” rather than a burden born by the family alone.

    1. Heather, thanks so much for your really insightful comments. And I agree about ancillary team members playing a key role in helping to foster trust; I always, always have the really important meetings with the care team present. I feel it’s important for patients and families to see that what we do really doesn’t work as an individual.