Crucial Conversations Walt Mills, M.D. Jeff Haney, M.D. Santa Rosa Family Medicine Residency

Objectives By the end of the session you will be able to: Define a crucial conversation Assess your usual approach to stress Describe a framework for a crucial conversation Develop a faculty development session using reflection in action

Acknowledgements Crucial Conversations Getting to Yes, Getting Past No, Leading Change, Switch NIPPD+, Penelope Tippy, M.D. and Colleen Conry, M.D. Kaiser Permanente Jessica Muller Lexicon and Jargon

Why should you listen to us? Lots of practice Kaiser, Sutter, Community Health Center INTJ, ENFP Boomer, Gen Xer We love the residency

Agenda Example of a Crucial Conversation Define Crucial Conversations Review our defaults in stress Discuss the seven principles of effective Crucial Conversations Role Play a Crucial Conversation Report what you discover

Sample Crucial Conversation Evaluation of an Intern http://www.youtube.com/watch?v=09bp__4Muh8

Ingredients of a Crucial Conversation Strong Emotions High Stakes Opposing Opinions What makes a conversations crucial? Opposing Opinions, Strong Emotions and High Stakes Two things happen when the conversation turns crucial: The stakes rise – permanently changes perceptions of each other and the relationship we have with other people in the conversation. We behave like animals. It is natural to look outwardly when things get crucial – we focus on the other person instead of ourselves. Learn to focus on yourself – it is the only person you can change

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Stress Physiology Adrenals Cortisol Epinephrine Dopamine Tachycardia

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During a normal talk

In a Crucial Conversation The Scream, Edvard Munch

During Stress We are Impaired Do you sugarcoat? Do you demand your way? Do you run or avoid? Do you resolve through dialogue and relationship?

Violence Safety Pool of Shared Meaning Safety Silence Actions/Results that hold relationship at the center Safety Pool of Shared Meaning Safety Silence

Your Approach to Conflict Avoidant? Aggressive? What parts of the relationship do you focus on in conflict?

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Online Testing Tool www.vitalsmarts.com/crucialconversations_book.aspx (it does require you to join for free)

Your Style Under Stress: Silence or Violence: How does it manifest? Dialogue: What are your strengths? To move to dialogue you should: Start with Heart – what is it you really want to get out of this dialogue – be specific about your goals. Learn to look – is a member of the dialogue moving to silence or violence? If so, then step back out of the content and Make It Safe for everyone. Tell the person you respect their opinion and want to hear what they have to say. Master My Stories – take control of your emotions; take control of your stories. State my Path: work to say things in the most acceptable way possible. Say exactly what it is you want from this dialogue. Explore others paths – what is it they want? I learned a new term during some diversity training that I participated in a few ago. That new term is constructivist listening – no expression – just concentrate on what the person is saying. Listen with your whole heart, mind – do not think about what you will say next, do not judge the person. Move to Action – decide what action needs to be taken and get it done.

Types of Silence and Violence Withdrawing—Pulling out of communication completely; physical, emotional, psychological Avoiding—staying away from unsafe topics or issues Masking—understating, sugar coating, sarcasm, selectively showing Controlling—coercing others through how we share our views—interrupting, overstating, absolutes Labeling—trying to win or have others give in through ridiculing their ideas Attacking—making sure others hurt; emotional, physical, psychological

The Seven CC Principles Start with Heart Learn to Look Make it Safe Master My Stories State My Path Explore Others’ Paths Move to Action 1. Start with Heart. The clearer you are on goals, the less you’re controlled by fears. 2. Learn to Look. What you see is what you get. Worst: see nothing. Good: see S/V. Best: See safety. 3. Make it Safe. Defensiveness is not a sign of too much candor, but too little safety. Worst: s/v. Good: water down content. Best: Step out. 4. Master my Stories. To take control of your emotions, take control of your stories. Worst: give in. Good: suppress. Best: influence. 5. STATE my Path. How to be persuasive without being abrasive or evasive. Work to say things in the most acceptable way possible. 6. Explore others’ Path. When you learn to do this you have a responsibility to increase the pool of shared meaning… 7. Move to Action. How you end a crucial conversation is as important as how you begin it. At the beginning you need safety, at the end closure. Tricky parts are beginning and end. CPR C= Content P= Process R=Relationships

ME Pool of Shared Meaning OTHERS See & Hear See & Hear Tell a Story Act Feel Feel Act

Principle 1: Start with Heart Identify motives - Functional Dysfunctional *The Sucker’s Choice

Principle 2: Learn to Look Identify when the conversation becomes crucial Look for signs of deteriorating safety. CC calls it “using the third eye”… I call it “Jeff, Do you have two minutes” or… Step 2. See it as safety problem not personality disorder. EX: TOUGH feedback you’ve absorbed. Why? Mistake is we assume content is the problem. It’s the back wheels! First step is seeing the warning signs (conditions not content) Water it down or force it. Second – making it safer. Next skill. When people turn to silence or violence, we assume the problem is the content. Can’t discuss this! Those who learn to look for safety can talk about anything.

Principle 3: Make it Safe Identify Mutual Purpose Work Toward Mutual Respect Signs that Mutual Purpose is at risk – debate – accusations – hidden agendas – circling back to the same topic Signs that Mutual Respect is at risk – interruptions – pouting – name-calling – looks of fear, pain, or hurt feelings – anger – raised voice – insults - threats

Principle 4: Master My Stories Know your unbiased story Encourage clarification of your story Recognize the bias that enters your story because of your stress tendency

Principle 5: STATE My Path Share your stories Walk them down the path Help them see point A through point Z Avoid antagonism, stick with facts Answer questions/clarify

Principle 6: Explore Others’ Paths What do you do when others move to “silence” or “violence”? “Inquiry versus Advocacy” Make yourself curious… learn “Go to the Balcony” Listen when others move away from dialogue

Principle 7: Move to Action How do you make the decision? Make a plan and follow up MAIN POINT: A great conversation can be ruined at the end because of violated expectations or failure to follow up. Move to Action: Who, What, When, and How!

Group Activity Small Teams (triad) Think of a personal example or use one we give you Network Report to the larger group

Summary of Group Activity

Faculty Development Reflection in Action Necessary Resources Two Hours Access to Testing Some basic trust in the group Results

Information Walt Mills Walter.W.Mills@kp.org Jeff Haney Haneyj@sutterhealth.org 707/583-8800