EP40 | Beyond Bioethics: Trust, Stories, and Durable Agreements in Healthcare Conflict

In every operating room, in every ward, in every clinic, and every team meeting, a silent battle brews. Conflict, negotiation, identity. Welcome to the Scalpel and Sword podcast, where I, Dr. Lee Sharma, physician and conflict analyst, Explore the hidden negotiations beyond modern medicine. Let's trade burnout for boundaries and learn the art of healing with precision and power. Hello, my peaceful warriors. Welcome to the Scalpel and Sword podcast. I am your host, Dr. Lee Sharma, physician and conflict analyst, and I am so thrilled to have on the podcast today the wonderful Dr. Habi Marum. Dr. Miriam did her PhD at the University of Virginia. She got her law degree at the University of Memphis Cecil C. Humphrey School of Law, and she's currently faculty at the University of Tennessee College of Medicine Health Science Center. She's also the principal at the Center for Conflict Resolution in Healthcare. She has decades of experience in conflict resolution, bioethics, and mediation, and we are very fortunate to have her on the show today. Javi, welcome.

Thank you. How did I get this old?

You, my friend, I've talked to you enough to know that you are not old and you never will be old. I think I had emailed you that one of the quotes that spoke to me when we first talked was when you talked about going to law school and you described it as drinking champagne from a fire hose. I can't even begin to tell you the impact that phrase has had on me because now literally just The appreciation of having guests on the show and listening to people who have this tremendous experience in conflict resolution. That is what this is for me. This is drinking champagne from a fire hose. So sharing that just really spoke to me. At what point in your career did you really start to see the importance and benefit of managing conflict in healthcare?

Early on. So a little bit of background. Okay. I did at UVA. A very, very conventional mainline PhD in philosophy, you know, Kant, Hume, philosophy of science, all that sort of thing. But I did have the good fortune to be able to teach my own courses, small seminars at that time. And so I could choose whatever I wanted to teach. And I taught bioethics a number of times. I've never taken a course in bioethics in my life. They weren't available. That's how old I am. Okay. But I taught a number of them and got increasingly interested in bioethics. So as I started to work my way to finish the degree and began in, in a setting of 10 to 1 unemployment of new PhDs in philosophy.

Okay.

What am I going to do with that degree? A, other than collect $5 from everyone who asks, what are you going to do with a PhD in philosophy? And then retire in opulent splendor without ever having to work. Got interested in it and then got with some friends that I had made. I also, just as one of my jobs during grad school at a local commercial radio station, besides jockeying the board on the weekends, okay, I did an interview program, kind of an hour-long single topic. Those of you who are old enough to remember Phil Donahue, Okay.

Oh yeah.

It was a filled-in type thing, some phone-in, but I was able to have some sessions among other things on bioethics, which this was the early 1970s. And one of them was the then dean, recently former dean of the medical school, Dr. Tom Hunter, who's a wonderful, wonderful human being. So I had had Tom on the show a couple of times talking about interesting, important bioethics issues of the day. And so as I broached the question, what in the hell am I going to do with a nice piece of sheepskin? I got on the phone with Tom. I said, Tom, you think they might be interested in somebody like me over at the medical center? And, you know, cutting to the chase, one thing led to another and some folks and I rounded up a bit of money. And so I started at UVA. On the medical school faculty as a very lowly assistant professor. And I worked with internal medicine, with primary care, with family medicine and so forth. And I realized I didn't know anything about medicine, just didn't know squat. And so basically I spent a lot of my first years just on rounds, sitting around in a conference room, walkarounds, room to room to room. And I began to see that what might pass for an ethics issue was really almost always about conflict. It was about not so much moral puzzlement. Gosh, nobody knows what to do. We have no idea. It was more often about the conflict of, I know what needs to happen, you idiots. Don't. Okay. Now, how do I get you idiots on board?

Okay.

And so that was one kind of conflict. Another kind that I did observe, just kind of from my seat on the 50-yard line, so to speak, not on the field because I'm not a physician. I saw what happened to my physician colleagues when there was a lawsuit over medical care. And I would see, and this is long before I went to law school. I didn't start law school until I was 55. Okay. And so this is long before then. And I saw how crushing it was for my physician colleagues and as well as for patients because litigation of medical malpractice, or in Tennessee it's called healthcare liability at this point, it takes forever. And it is knocked down, dragged down, knock 'em out. Slugfest that sometimes is needed. I have to say, sometimes it's what needs to happen, but a lot of times it really doesn't, and it doesn't help patients nearly as well as a good conversation. Patients want to know what happened, the truth. And as long as doctors are afraid to tell them, and you're in the middle of this slugfest, mm-hmm. Nobody's gonna really find out the truth, including the guys in quality improvement. So I learned about conflict in a number of ways.

And because this is so cool, because you literally walked into this process as somebody who has this background, you know, you got your PhD, you're interested in bioethics, you are actually boots on the ground watching these physicians get into this. And as you're watching this and you're an observer, one of the delineations you make in your article that I think is really important Is that a lot of people do think about ethics. You know, I have an ethics committee at my hospital. So if I have an ethics committee, then I have an avenue to explore conflict, right? The Joint Commission says that we need to have a process in place to assess conflict in the hospital because we understand that conflict directly influences patient care. So we need to actually address this, but we have an ethics committee. So a lot of people might think that just having an ethics committee is enough, right? But you've walked through this and watched this and really very soon after observing this, you saw it, that conflict is something completely separate from this, this idea of an ethical decision or what's ethically correct.

Yeah. Yeah. Well put, Lee. Because, and the way I've watched ethics consultation, whether it's a profession or not, perhaps it is, but the way I've watched the evolution over the years, It seems like ethics consultants increasingly see their job, what they're asked to do, is to weigh in on an ethics issue. And I should not give a simplistic description here because for sure there are plenty of times when a request for an ethics consult actually comes down to a miscommunication and a good ethics consultant One who has experience is going to help sort of tease that out, sort that out. Oh, wait a minute. Here's the patient rejecting hospice, but in fact, the patient wants everything that hospice gives. So what we need to do is figure out how to provide those services in a way that avoids the patient's worst fears. So it can be a communication issue, not the actual content of what people are thinking that they want. Okay. In other cases, it's a need for further information. I remember a case in the pediatrics ICU of a local hospital years ago. And what the situation was, the patient had something nobody had any clue what was going on with this child. We've never seen this before. And no, it wasn't COVID. I mean, you could have a brand new Disease, and you've seen this occasionally pop up, the earliest versions of a new disease or one that's unrecognized. Well, okay, we don't know what this is. And really on that consult, my thought was, do you have colleagues that you can phone around the country? See if anybody else has seen anything like this.

Mm-hmm.

Let's see if there's more input. And actually the physician, you know, and they were so You know, in the fog of the moment, which is so easy in a terribly confusing and what shall I say, heavy situation of a child who is holding on by a thread. And you may not think of all your options. And so they did. They got on the phone and got some more insights from around the country that I think did help. So a need for more information. But once you've sorted through a lot of those, what you're left with is often conflict and how to address that. And conflict is not ideally addressed by somebody coming in and saying, well, I think you're right and you're wrong. Or, okay, saying, you know, the following, everybody has got a morally acceptable option. If you need me, I'm in my office. Okay. That's nice. And that's because sometimes all the options that people would like to do are acceptable. And if that's all I've got to offer, well, good. I should not go beyond my expertise. And if all of them are morally acceptable, I shouldn't pretend if one is artificially better than the other. And that's another place where conflict management comes in.

Yep. One of the things that I loved in the article that I read Is that you tell a story and I'm not going to go through the entire story, but it's a story that unfortunately in some shape or form, we've all as clinicians experienced where you have a child that's had a terrible accident. You have divorced parents. He's staying with the father. The father was asleep when this happened. So then the mother discovers that the father was asleep and now this child is in the unit. He's intubated, potentially not going to have a neurologic recovery. And so now we're sorting through the different conflicts that this is coming into. And the primary conflict, this was, who is the child going to stay with when he goes home? Who's going to have custody of the child? And so you are the person who's been called in to work with this conflict. And what I really loved as you were taking us through how you worked with this family and worked through this process of resolution is that you emphasized that this was a process that centered on trust. That you use a quote that the coin of the realm when you're working through conflict is trust. How do you, as the person coming in, helping resolve conflict, how do you build trust with the parties that you're working with?

Oh, I love that question. As preface, I am a mediator. I'm in Tennessee. It's called Tennessee Supreme Court Rule 31 listed mediator. And if you can pronounce that, you get to be one too.

Okay.

When I teach this bona fide mediation, especially I do teach it for healthcare clinicians and bioethics folks, 3 main principles of mediation, and I put it in a fairly colloquial way. I'm not here to take sides. I'm not here to tell anybody what to do. And really important, what you say to me in private stays private. Because if they cannot confide what they're really worried about, the backstory, you're not gonna be able to get at the kinds of things that are really at stake.

Yeah.

For these people, so as not to guide in the sense of telling them what to do, but guide in the sense of facilitate the kind of open conversation that needs to happen. And A lot of times that conversation might be everybody in the same room, but a lot of times it might be private conversations and another private conversation. But they need to absolutely know that I am not going to rat them out if they tell me something private. And if I think something would be useful to take to someone else who's involved in this, I will ask. I think it might be really helpful for this reason. Here's how I might frame it. What do you think? You're in control of your own information. So if you say you'd rather not, done deal, not going to happen. And so earning trust, I am not going to become another pair of fists in the fight.

Thank you for saying that, because that was one of the greatest quotes. And since you said it, because I was going to bring it up. Because I think that's such an important part of being a person who's coming in as a mediator or a conflict resolver. And you actually specifically use 2 phrases that sort of lead that person to possibly becoming another pair of fists in the fight, which is if the person helping to resolve the conflict says, you must, or you can't, that those are 2 phrases that sort of automatically put you in that situation. That you are no longer someone who is trying to facilitate for shared goals and communication. You are now somebody who's become another adversary. And you specifically use those 2 phrases. And I thought that was really instructive.

Well, and in healthcare, I started to mention that I am a mediator and that means I mediate lawsuits in the court as well as in the clinical setting. And in the clinical setting, I hardly ever use the word mediate or mediation because to a lot of physicians, It means I, or maybe a friend of mine, got sued. Some darn judge has told us we have to go to mediation. And now some darn mediator's running back and forth telling me how to give the other side money, even though I did nothing wrong. And if my insurer gives them a dime, I'll have a black mark for life in the National Practitioner Data Bank. So the word mediator is not the most popular. I like collaborative problem solving.

Wow.

So yeah. Okay. In litigation, typically when you go to mediation in, for a lawsuit, the outcome is a binding contract. If the parties come to agreement, it's a binding contract. And if 2 days later you don't like what you signed, tough nookies. Okay. Unless somehow unconscionable or otherwise not legally enforceable, you are stuck. In the healthcare setting, ain't no such animal. Anybody who does like end-of-life care or critical care, you know of the scenario where, well, the family agreed to a DNR and then the next day, hell no. Okay. But they didn't change their mind. They said yes because they may have felt bullied into it. And it was acquiescence, bullied acquiescence in some of these cases. So. You have to have actual agreement if it's going to be durable in healthcare. And you don't get actual agreement if people don't feel like it's truly their own resolution, something that they endorse. Yes. And it may not be a truly happy win-win. Yeah. Get that outta your mind for most.

Mm-hmm.

But it's something, yes, I can live with this. I see that this is about the best we're gonna get. Let's say yes to this. And if they don't say yes, it can fall apart in a heartbeat.

I have seen this so many times, and I love how you talk about the idea that these are durable resolutions, that these are not something that people feel like they were coerced. And the one that came to my mind when you were talking about that in your article was I was an intern in my residency in Parkland, and there was a 19-year-old girl. Who had a placenta previa, so very high risk to have extreme blood loss at delivery. Her entire family were Jehovah's Witnesses, so of course they do not believe in transfusion. And so they were trying to counsel her in the clinic about how this was going to be managed. You know, if she truly did not want to have a transfusion, do we need to pre-bank for her? How are we going to need to handle this? And then as we talked to her, she said, but if I'm going to die or if my My baby's going to die, then you go ahead and transfuse me and that's fine. And then the family members were, well, you know what we believe. We don't believe in that. And so we were trying to figure out how the solution was going to be durable. And I think back on that situation because again, I'm an intern and I'm stupid. I don't know anything. And I certainly didn't know anything about managing conflict. All I kind of knew was I know the right thing to do. The right thing to do. To go ahead and agree to be transfused if this is not what you want. But in the grand scope of that situation, that was not the right thing. That, you know, coming to a place where all the parties understood exactly what they were talking about, agreeing to the implications of these decisions. But that was not language that we knew in 1993. That was not something we knew to talk about in '93 or, you know, even past that. So the work that you're doing in terms of helping people understand that trust is the coin of the realm, how do you achieve trust in that situation? You let people tell their stories and you listen to the stories behind the stories. And as you listen to the stories behind the stories and you keep secret what needs to be shared, that's how you build trust in the process. And when people go through that process once and they have success with it, they're going to be more likely to engage in that process.

You know, your case brings up Some interesting questions. As a mediator, a very important question is, who belongs at the table?

Wow. Yep.

And mediation, one thing we teach is the mediator, we don't opine on the substantive issues, but we are the guardian of the process. And that question of who belongs at the table is a very important one. In a case like this, I will say that the traditional bioethicist is going to say, well, if she has capacity, she's the only one at the table. What she says goes. She's 19, she's an adult, and mom and dad trying to bully her out of what she wants. And now we get into the complexities. Were they concerned that she might have terrible regrets?

Mm-hmm.

What's going on here? And for that one, for sure, I would want a very private conversation with the patient if she's in shape to do that. If she's in active agonal labor, and agonal, not the right word here perhaps, but if she's in active and very painful labor, it's hard to have that kind of conversation. If she has participated in ongoing prenatal care, That's a great conversation when she is in a good position. As an intern, brand new, you're probably in no position to have already had that.

Correct. And obviously there were other people in the room, but just that one, when you said, you know, who belongs at the table and the idea that as the people who are involved in managing conflict, that we are guarding a process, we are not defending a position.

Mm-hmm.

That, that's such an important mindset to have that we want people to, and I think over the decades you've done this, when you see people be witness to the process working, that they're walking into what they feel like is an untenable situation, they walk out of it feeling like they have a durable agreement and they're looking at this process as this process works. They are going to be more likely to, when they see other colleagues, other conflict situations, Encourage people to take part in that process. And this is how we start to see conflict not become so pervasive as a negative in healthcare. It becomes something transformative.

I love that. Go for it. Yes. I mean, one can only hope.

So as you are working, because you teach a lot about people managing conflict in healthcare, like you said, you're helping Physicians, bioethicists, the Joint Commission now wants us to have conflict resolution processes in place in hospitals. What are some key things that you really want people to understand as they are learning how to work with conflict in the healthcare workplace?

One thing I think that is important, and it's very hard, take a beat. You know, one of the things I do here at University of Tennessee College of Medicine is For the 3rd year medical students, when they rotate through pediatrics, we get together. And when they rotate through medicine, we get together and I have them submit cases from their own experience ahead of time. And I'm going to try and remember this off the top of my head. A case that recently came through, a sort of middle-aged woman and her adult daughter. The middle-aged woman was the patient. And the woman and the daughter, who was some kind of healthcare worker, were kind of resistant to some of the exams that the resident wanted to do. And so the resident said, now I'm going to palpate your abdomen. And the patient pushes his hand away. And as the student described it, the resident's response was, well, now you came for healthcare and I'm here to give you healthcare. And if you want it, then you need to do what I ask. So what we have is a conclusion butting heads with another conclusion. And so what I'm thinking is, you know, maybe that's the time to take a beat and say, I sense you've got concerns. I wonder if you've maybe had some bad experiences in healthcare before. I would like to know where your concerns come from because you might, A, earn an enormous amount of trust by being willing to listen to where the patient is coming from. And B, quite likely learn something very important about why that patient is coming from where she's coming from. And so in response to your question, I think a good first response is just take a beat. And if something strikes you as, wait a minute, darn it, find out where it's coming from. One of the things that I try and have over the years, we've had sessions trying to teach residents conflict management techniques. One of them is, you know, skills of active listening. And I'm sure many people in this podcast audience know exactly what I'm talking about. And to be willing to pause that moment and actually care about where the patient is coming from or the family member, really be curious because you're almost— give that benefit of the doubt. Almost guaranteed you're going to learn something you really do need to know.

Yeah. I also love how when you were starting that story and you talked about when this, the resident and the patient wanted to be examined, that you didn't talk about this or phrase this as the resident and the patient having a conflict. You phrased it as a conclusion butting heads with another conclusion. And the reason I love that so much Is because when people are talking about conflict, it's very easy to tell the story as the person having the conflict, as opposed to an ideation or an assumption having a conflict. We're taking it off the individual and we're actually creating that situation. It's like, we're not pointing fingers. We're not assigning blame. We understand that there is a conclusion butting heads with another conclusion. Mm-hmm. What are the stories behind those conclusions? And can we get to those and can we tell them? I think that's huge because when people start to place, when, if you're looking at a person at the source of the conflict, so we're talking about people in conflict, it becomes very personal and people get very defensive. And once people get defensive, it's really hard to get them to buy into a process. But once you phrase it as you have a conclusion that I'd love to hear a story about, it's really hard for people to get defensive about that.

Oh, I love that. You're hired. Yeah, no, I like that. I like that a lot.

What else, like as people are walking into your teaching residents, you know, they're barraged with so many duties there, but you're also wanting them to have these skill sets walking into conflict. Do you get feedback from them after you've helped them with these kinds of techniques and you've given them this knowledge? Do you ever get to circle back with them and see how it's influenced their practice and how it's helped their And not a huge amount of that, but another kind, which is fun.

One of the little tools that I try to give the residents is when you don't know what else to say, 3 magic words, tell me more. And sometimes I'll hear the residents say, tell me more. And it's a moment of resonance, which I really like.

See, that's so cool because it's something very simple. When I do trainings at my hospital, when I started doing this work, like in labor and delivery, what I used to teach them to do was tell me your story. If they felt like they were in a conflict situation or, you know, they felt like they were, you know, seeing it start to develop, it's like, just tell me your story. It's really hard for people to get upset with you when they're sharing a story with you. And as they tell that story, you will find out way more about what's going on behind this conflict and it will illuminate so much for you. But you're not doing it by asking what's wrong, what's going on, what are you after? I think those are all phrases that automatically people's guard will go up. Um, because tell me more is gold. Are there any other phrases or things that you let them keep in their back pocket that they can use?

You know, right now my cheat sheet is not in front of me. I will say a very important Albeit sometimes difficult tool is called affect labeling.

Okay.

You put a name on the emotion that you are seeing. So in the case that the student described, you might see, I see you're troubled about something, or I see that this is hard for you right now. And so just as a lead-in, but where you're capturing what they are feeling. Affect labeling is not easy and you can blow it. As one of the people who taught me about affect labeling, try it on your Starbucks barista. Try it on your spouse, your— maybe not on your spouse on second thought. Might wanna get better at it before you try it on your own spouse. Okay.

Just, yeah.

But really trying to capture what is the emotion I'm seeing. And if you're wrong, that isn't necessarily bad because they may, Very lightly correct you. No, I'm not angry. I'm disappointed. And one of the things I'll say when we talk about affect labeling, I mean, among residents, the 2 emotions they recognize the most easily are anger and frustration.

Okay.

And just learning an emotional vocabulary that goes well beyond. My wonderful colleague and co-trainer, Kim Best, who I think another of your podcasts. Yes. Shared with me something that we use all the time now, the anger iceberg. All the different emotions that might actually be at work when superficially it looks like anger is what's going on. It could be betrayal, it could be resentment, it could be confusion, it could be any number of things. And how people display an emotion can vary so much from one to the next, but it can be a very useful tool because When you have offered a really good affect label, people can feel heard in a way that nothing else can. You get me at a very deep level by capturing where I'm living right now. And so I love that as one of the tools that I like to teach.

That is fantastic. I've never heard it called that. I love that. It is something that we do and we talk about. in terms of trying to resonate with somebody you're in conflict with. I see that you feel, or I feel that you may be feeling, and try to, and I have done that and I have gotten it wrong. And I do think that when you are trying to accurately assess somebody's affect and you get it wrong, I do agree with you that I've never seen that backfire in a negative way. It's always been because you made an effort, you actually said, okay, I recognize I see that you're really upset right now. Would you like to tell me what's going on? And it's like, I'm not upset. I'm frustrated. I'm not upset. You know, you will let the patient walk into that at the same time, or you let the person in conflict work out, you know, walk into that really descriptive space of this is what I am feeling. And then I think naturally the story will come. And then once they start telling the story, I think it makes such a world of difference in building that relationship of trust, like you said. The idea that once trust is established, it's much easier for people to approach and buy into the process. 100%.

And part of that listening to the story is not just listen and then go on to the next thing. It is explore. There is a family member, not to be named here, with whom, you know, I have a very nice enough relationship, very cordial, but the pattern was if I Would say something about what I'm doing, what I'm up to. Oh, okay. Never a follow-up question. That's a pretty big clue, okay, about the level of interest in me and what is important to me. So that follow-up questions exploring from genuine curiosity and benefit of the doubt, there's something important. And in healthcare, let's face it. There are plenty of times when we think the patient or a family member is just bat guano crazy.

Okay.

That's kind of crazy. Okay. But usually they're just scared or they have framed things in a way that doesn't match the scientific theorizing. Okay.

Okay.

If you explore Arthur Kleinman years and years and years ago, he's an anthropologist. If you get into the patient's model of disease, of what's going on, What causes it? What makes it better? What makes it worse? Just listen to that and construct a, you know, in your own understanding, that person's framework so that you have a better idea of where they're coming from. Then you may be able even to speak in ways that make better sense for that person.

Absolutely. And it is absolutely one of my least proud moments as an intern, but I think it speaks to what you're talking about. I was taking care of a patient who Was, I think, 19 or 20, first pregnancy. She had pyelonephritis. She had a kidney infection. Of course, we hospitalized those patients, give them IV antibiotics. So the nurses called me saying that she's refusing her IV antibiotics. So I go down and I talk to her and I was like, so we really need to give you the antibiotics. You know, you've got this really bad kidney infection. We don't want you to have it all over your body. We don't want you to affect your baby. You really need to take this. And she's like, I'm not going to do it. And so in my mind, I mean, I'm an intern and all I'm really focused on at that point is taking care of myself. I'm just trying to cover myself because someone's going to yell at me if this patient doesn't get her antibiotics. So I go back and I'm going to get something for her to sign saying, okay, so you're refusing care. And she got really angry with me and I did not know what to do. So I went and found my upper level. My upper level goes and talks to her and my upper level who clearly has had way more wisdom than I had at that point, got her to tell the story. The story was that she had a sister who also had pyelonephritis who did get septic and actually did pass away while she was pregnant. And in the patient's mind, the reason why her sister died was because of the IV antibiotics. And so in her mind, getting IV antibiotics is how her sister died. And then once The resident got the story. It's like, no, no, no, no, no. Let me explain to you, unfortunately, what happened to your sister and explain to her what sepsis was and explain to her what antibiotics do. And it's like, this is what happened, unfortunately, to your sister. And this is why this is not going to happen to you. This is why we're treating this. This is why we're being aggressive about this. It's not the antibiotics' fault. Unfortunately, it was the sepsis' fault. We're trying to prevent that. And once she understood it, she got the IV antibiotics and she was fine. But it's a classic description of what you just said. Yeah. If we're just stuck on position, if we have conclusions butting heads with conclusions, I'm concluding that the reason why she doesn't want the antibiotics is because she just doesn't want to get treated. She's concluding the reason I'm being such a bitch about it is because that I'm just trying to force her to do what I want her to do. And rather than the two of us actually talking about what our true motivations are, we actually are at a place that fortunately a third party came in and did get the story. I think it's a classic description of what happens when you don't go to that point with it.

And part of that story, one of the things that I teach in mediation is dive down into the details. Maybe not in this case, but in somewhat similar cases, people have very different meanings for specific words. Antibiotics. And in your case, there was not a discrepancy about understanding, well, she probably had no Understanding of it. But you know, when doctors, when a patient comes in with an upper respiratory viral illness and demands antibiotics and the doctor said, no, you can't have them. They're not medically indicated. Conclusion, butting heads. Okay.

Right.

Well, what does the patient understand by the word antibiotics? My story on that is that someone who was the, a secretary in the department next door And I just overheard a conversation because I was standing in the doorway waiting for somebody. And she said to her friend, well, I was just at the doctor's and he said it was a viral thing. And so there wasn't much he could do, but he did give me these antibiotics for the nausea.

Oh my gosh.

I have heard the word antibiotics misused in the same way by reporters on major network news. Okay.

Yep.

So when you say that you would like antibiotics, can you tell me more of what exactly you're hoping that they would do? What are antibiotics and what do they do? And then you'll find out what they're really asking for. Or when you say you don't want hospice, tell me what it is about hospice that you especially do not want.

Yep.

And they probably have a hospice story where somebody was in hospice and was abandoned to death. And that's not trivial. And that needs to be addressed by the right hospice if the person still wants those services.

That's such a huge thing. The idea that we need to make sure as clinicians, we're not making assumptions about what people understand about what we're saying. Because I do think that happens so often when you talk about health literacy and even just terminology. The idea that we do assume in medicine that people understand when we're using these big old words and things that we think are, oh, of course this person knows what this means. We really do need to drill down, especially in a situation where we feel like there is a conflict potential. Are we all speaking the same language? Are we all speaking, using the same terminology for the same things? Because if we're not, we're never going to get to a point of not only just agreement or collaboration, but truly moving forward into a place that we're meeting shared goals. If we're not speaking the same language, we're not gonna get there.

Yeah. And clarifying that can be a nice little door opener to diving deeper into the story. And I know that there are plenty of clinicians who say, I don't have time. I think about return on investment because conflict costs enormous amounts of time. Conflict eats Yep. Because you keep returning to the same blankety blank blank issues. And why does this idiot not listen to me? It's because you're reciting the same thing over and over. And I got news for you. If it didn't hit the third time, something else is going on.

Yeah. Javi, this has been a joy to have you on the show. I want you to come back again because you've got like 4 other articles that I'm going to dive into. But if people are interested in learning about your courses, if they're interested in talking with you, how best would they reach you?

Are you able to offer my email address?

Yeah.

Sure. Happy to get an email and we can phone or add communication from there.

Fantastic. For all of us who joined us on The Scalpel and Sword today, thank you so much for being here. Javi, it's a joy. Thank you so much for being here. I love talking with you. You're just incredible. And to all of our peaceful warriors, until next time, be at peace. Every episode is an invitation to speak, to negotiate, to choose. I'm Dr. Lee Sharma. Join the dialogue by subscribing to Scalpel and Sword. Until next time, peaceful warriors. May your choices be sharp and your voice be even sharper. This podcast is a reflection of lived experience and research in conflict resolution. The Scalpel and Sword is not intended as medical or legal guidance. For personal matters, please consult a qualified professional.