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

2. 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

3. 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

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

5. 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

6. Sample Crucial Conversation
Evaluation of an Intern

7. 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

9. Stress Physiology
Adrenals
Cortisol
Epinephrine
Dopamine
Tachycardia

10. http://img. thesun. co. uk/multimedia/archive/00832/raymain_832448a

11. During a normal talk

12. In a Crucial Conversation
The Scream,
Edvard Munch

13. 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?

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

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

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

18. 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.

19. 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

20. 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

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

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

23. 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.

24. 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

25. 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

26. 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

27. 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

28. 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!

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

30. Summary of Group Activity

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

32. Information
Walt Mills
Jeff Haney
707/