How Tennis and Maple Syrup Made Me a Better Doctor

Podcast Transcript

Adrienne Boissy:  Welcome to another episode of Studies in Empathy, a Cleveland Clinic podcast exploring empathy and patient experience. I'm your host, Adrienne Boissy, Chief Experience Officer here at the Cleveland Clinic in Cleveland, Ohio. I'm very pleased to have Dr. Tim Gilligan here, who is, I don't ... You have a lot of titles that you'll tell me about in a minute. Welcome to Studies in Empathy.

Tim Gilligan:  Thank you. It's a pleasure to be here.

Adrienne Boissy:  Tim, tell me all your titles and roles that you have, and talk to us a little bit about what those mean.

Tim Gilligan:  I'm a medical oncologist. I focus on urological cancers, but I have spent most of my career since getting to Cleveland in 2005 focused on education, teaching fellows in oncology and then also teaching other doctors and clinicians, mainly around communication, how do we talk to people? I mean, I, at the Cancer Center, Cleveland Clinic right now I'm the Vice-Chair for Education because I do a lot of different educational work there and oversee the training programs. I played a leadership role at the Center for Excellence in Healthcare Communication, which is the Cleveland Clinic's group really focused on teaching people who work in healthcare how to talk to each other, how to talk to patients, how to improve our communities by strengthening our relationships. That's really what I'm most passionate about.

Adrienne Boissy:  I scribbled on my paper before you sat down, "Tennis, foodie, and maple syrup." I want to explain to our audience what that means. Let's start with I know you're a huge tennis fan. Racquetball.

Tim Gilligan:  I actually, I needed an escape from work, and tennis is that for me. It's a mindfulness moment. When I'm playing tennis, all I can do is focus on hitting this silly bouncing ball. The stakes are so wonderfully low. The worst thing that can happen is, the ball goes out and I lose a point, but what I've really learned from tennis is how you get better at something. I think people with communication skills often think either you're good or you're not, and either you know how to do it, or you don't, or you get taught it, and then you just automatically go do it. What's interesting on the tennis court is seeing that you know there are some things you're supposed to be doing and how consistently you don't do them unless you practice them very intentionally, very, very intentionally over and over again. I think in the teaching that I do, I try to remember that I'm trying to change people's behaviors.

I'm trying to teach them new muscle memory. The way that happens is by practicing, by having it broken down into individual steps. It's really helped me think about how we learn things and to realize that a lot of this kind of training is more about learning muscle skills, motor skills, rather than just understanding something. The important difference between understanding something and actually being able to do it is huge. In our interpersonal work, we often don't take that into account. When we teach surgery, we take that into account. We realize that to learn how to tie a knot, you have to practice tying knots over and over again. Similarly, if you want to give someone bad news, you need to practice doing that, and practice empathic statements, and see what it feels like.

Another analogy in tennis is, I was talking to my coach, actually, just this week about how some players get confused that he'll hit them the ball down the middle, and they feel like, "Wow. I'm really good. I can hit it," and then suddenly, he starts hitting it corner to corner, and they have to hit while running, and they start hitting the ball out, and they're confused as to, "Why am I suddenly playing worse?" I think it's the same in the hospital. You're having a good day. It's early in the morning. You're relaxed. You have a really good conversation, but then it's really busy. You're stressed, you're tired, and you have to have a difficult conversation, and suddenly, it doesn't go so well. It's the same thing. You're off-balance. You're running. If you're highly skilled, you can still perform at a high level, but you have to practice. I feel like ... I worry it's trite I'm a guy using sports as an analogy for life, but it's worked for me.

Adrienne Boissy:  I've known you for some time, so we'll forgive you that. The other thing is the foodie concept. There's, I'm going to try to draw an analogy here that we'll see how it goes, but you're a recipe follower to the T when you're cooking. Recently, you tried to teach me, it was maybe a couple years ago, how to make an omelet, or that there's a special way to make an omelet. I think about actually in healthcare how we're evolving these amazing checklists, right, for care and what we should say at the certain moments and why they often fall short. Talk to me about passion for food, and following checklists and rules, and how that relates to communication skills.

Tim Gilligan:  For me, it's really about excellence and the pursuit of excellence. The thing about omelets is, there are many different levels to an omelet, and anyone who cooks just about thinks they know how to make an omelet, but what they're making may not be considered an omelet by a French chef who knows how to make what the French consider a proper omelet. There was a very funny story in The New York Times by Jacques Pépin, who is a famous chef, used to cook for the President of France and then actually came over to the United States to be the Howard Johnson's cook designing their frozen meals, ironically enough, but he had a thing in The New York Times on how to make an omelet. The New York Times reporter described to Jacques how he made an omelet. Jacques paused for a moment and said, "Well, I sometimes eat eggs like that, but that's not really an omelet," but my point is that we can be good at something, and we can still aspire to get better at it.

In the Julia Child Mastering the Art of French Cooking, there are page after page about how to make a proper French omelet. It's actually really hard. In some restaurants with high standards, they'll actually ask for someone who's applying to cook there, they'll ask them to make an omelet to see whether or not they really know what they're doing or not. It's a high-level test. Maybe it's similar to forehand. I can hit a forehand in tennis, not the way Roger Federer hits a forehand in tennis. The reason that analogy has come up for me is that in the hospital, there are lots of people who think they're good communicators, and that's fine. They may well be good communicators. I'm not going to argue with that. There's no reason they can't aspire to be better communicators, and oftentimes, learning very specific skills and taking the time to practice something is what's necessary to go from being good to being great.

I think in a lot of our work that we've done together, we've tried to appeal to people's professionalism in the sense of, you want to be the best you can be, so even if you're already good, don't you still aspire to be better the way a professional in other things does? A baseball player wants to get better. An opera singer wants to get better. Don't we want to get better? It takes effort and practice.

Adrienne Boissy:  That's right, and I know in the work that we did, right, we actually demonstrated that no matter where you are in terms of your baseline skillset, you can get better with effective training.

Tim Gilligan:  Yes. I think of Steve Jobs' famous line, "Good enough isn't."

Adrienne Boissy:  You have more references than anyone I know. Talk to me, you wrote this really interesting article on a conversation you had with a patient about maple syrup. Talk to me about what that-

Tim Gilligan:  Yeah, so that-

Adrienne Boissy:  ... taught you.

Tim Gilligan:  That was a profound learning experience to me. It was ironic, because in the course that we were teaching at the time, we had a slide for the participants that said that if you are working with a patient, and you're finding it hard to like them or get along with them, try to find something that you can authentically praise or authentically respect. I didn't really know what that meant until I saw this patient that you're referencing. I go, and I'm rounding one day. It's on the oncology service, so you can imagine how sick everyone is. There are patients who are dying. There are patients who are having terrible abdominal pain. There are patients who can't stop throwing up. We are desperately trying to help very, very sick people. I go into a room with my team of residents and a fellow, and the patient's furious at us, and I have no idea why.

She says, "What are you doing? Are you trying to kill me?" I said, "Why? What happened?" She said, "My pancakes came with sugar syrup rather than pure maple syrup." Of course, my first instinct was, "This is not the biggest problem on the unit this morning. Why is this the patient who's angry at us," but honestly, the second thought that was on my mind is, "Oh, my God. There are medical students in residence, and the fellow watching me. I'm supposed to be a good communicator, and I'm really pissed off now, and so what can I say to this patient?"

I thought about that slide at that moment, interestingly enough, and I said, "How can I connect with her?" It's good you mentioned the foodie-ness, because I'm interested in food, so I said to her, "It sounds like nutrition is really important to you." She said, "Yes, it is. I try to cook healthy for my family at home. We buy organic fruits and vegetables. We try not to eat too much sugar, try to eat whole grains. I'm trying to take care of myself, and I come into the hospital, and I'm served unhealthy food."

Suddenly, I realized that's a whole different way of looking at this, and suddenly, maybe she's not as unreasonable as that initial accusation sounded. We talked. I said, "That's great. I wish all of my patients were so attentive to their nutrition, because I think nutrition is really important to our health." We formed this great bond, and then the next day I came in, it was like we were best friends. The really touching thing is, she sent me probably the sweetest note after she got out of the hospital saying, "I'm so glad you went into medicine."

It was interesting. I turned ... Not "I turned." The skills I had learned turned this potentially very negative encounter into actually an incredibly positive encounter by not reacting to her anger in the moment, but instead trying to understand her perspective and making a partnership out of it. It was really important learning for me. The last thing I would say about it is, it changed my perspective with so-called difficult patients to really think it's not their job to be likable. It's my job to find something I can relate to and connect with, and if I can't, then maybe I'm not the right doctor for them.

Adrienne Boissy:  Well, I'm glad you went into medicine, too.

Tim Gilligan:  Thank you.

Adrienne Boissy:  Your patients are lucky to have you. You do a lot of coaching in your role, so we've trained, just for background, we've trained four or five thousand clinicians here at the Cleveland Clinic in relationship-centered communication skills, and several thousand beyond our walls. You've been a huge part of that, and some of your work, I know, specifically, is around coaching. In the environment today, can you talk a little bit about what you've seen as you stand beside clinicians and physicians who are trying their best to communicate effectively with patients and what they've taught us about how we can help?

Tim Gilligan:  Yeah, absolutely. I mean, I think the first thing that I've really learned is that it's really hard to watch yourself. Atul Gawande's piece in the New Yorker about coaching, and he talked about once you finish your medical training, no one watches you anymore, and no one helps you get better. It's like once you have your graduation certificate from your training program, that's it, and then it's up to you. He got one of his old professors to come and watch him operate well into his own practice. He wasn't in training anymore, and by having this expert watch him, he was able to improve Gawande's surgical approach, because he could see things that Gawande couldn't see himself, because, obviously, it's harder for us to watch ourselves.

I think that's the sort of thing that I see. A powerful example, for me, was, I saw a doctor working with a patient, and the doctor was doing a procedure on the patient. It was a young boy about seven years old, and the doctor had numbed the patient up and assured him that it wasn't going to hurt, but in the middle of the procedure, the boy was trying to push himself as far back into the chair he was sitting in as possible. It was a procedural chair. There were tears streaming down his face, and the doctor stopped the procedure and said, "Don't cry. Smile. It's not that bad." I thought, "What a bizarre thing to say in that moment," but there was no awareness, and so the doctor actually, he took me to his house afterwards, and we had tea to talk about what had happened, not just that incident, but the whole time I spent coaching him.

I ran the incident by him, and he was kind of shocked to hear it. Then he remembered it, and he had some insight into it, but I think for me, it was sort of one of those moments that it's, I just, I wish we all could have coaching, because I think we all could learn, not that we all necessarily would say something quite like that, but I'm sure there are things I do that I'm not aware of that aren't helpful. It's hard for me to know what those things are. I mean, I could videotape myself.

One of the just sort of overall things about coaching is, we all need coaching, and if we open ourselves up to it, I think we can all get better. One of the main, main, main things I've learned by shadowing doctors, listening to them, watching them, is just how much we talk and how much we expect the patient to listen to and absorb. I think that if I were to make one change that would have a positive impact or that has had a positive impact on people, it's really, it's just to stop the talking and to listen more, and so to maybe enter the room with curiosity rather than enter the room and say, "Well, here are your test results. This is what we know, and this is the plan." We can enter the room and say, "What's your understanding of what's going on? What have other clinicians told you about your situation? What questions do you have?" Letting the patient play a more active role in their care.

The whole idea with coaching in terms of relationship between the coach and the coachee is, we're trying to help the person develop their own solutions. I think often in life, we think, "If only I can find the expert, they'll tell me what to do." I think we really vastly overrate the value of expertise and advice, and coaching is really trying to increase self-awareness so people can come up with their own solutions. That can also be applied to patients, so there's sort of a parallel process there. The big learning, for me, out of this is that we need more coaching, because physicians are out there on their own trying to get better, but they don't even have a good metric of how they're doing. It'd be like me trying to improve my tennis game without having a coach from time to time help me figure out what to work on. Then the second thing is just slow down, talk less, listen more, let the patient do more of the work. It's better for the patient. It's better for us. I think we get better relationships.

Adrienne Boissy:  Can you talk to me about whether or not you think you can checklist empathy? I think sometimes, when people are trying to be more empathic, when you hear language that isn't authentic to them, like, "Gosh, you seem sad-"

Tim Gilligan:  That's-

Adrienne Boissy:  It's so identifiable, so in your experience, what works in sort of getting them to actually empathize in a way that's authentic?

Tim Gilligan:  I have to go back to tennis, of course.

Adrienne Boissy:  Oh, geez.

Tim Gilligan:  When learning a new stroke in tennis, you accept that there's going to be a period of awkwardness. One of the first things my current coach said to me is that, "If you want to get better, you're going to have to be willing to lose for a while, because it's not going to work at first. You're going to have to be willing to go through that phase when it's awkward and you're losing, but you're going to come out the other end, and you're going to be a better player, and you're going to win more." I think I can give a very specific example. There was someone who was working on my serve who, in order to get the weight transfer correctly, would have one of my feet up in the air and just jump off of the other foot just to feel that transfer. I'm never going to serve that way, and it feels awkward as hell. It's not authentic, but by going through that process, I end up in a place where I'm more effective.

I think the checklist approach and the steps to practicing empathy are very analogous to that, that what we have people practice when they do that, that's not the endpoint we want to get them to, but if they're not saying anything empathic, if they're just giving the patient facts, and reassurance, and trying to make everything okay, but they're never saying, "Wow. This really is hard for you, isn't it," or, "You're having a really hard time. I can see you're sad," or, "Upset," or ...

If we don't have any empathic statements, we have to start somewhere, and when we start, it's not going to sound particularly expert. If we practice and we do it, it becomes fluent over time, and we end up in a better place. I think we encounter a lot of that resistance that we ask someone to do something new, and they complain that it feels awkward, but everything new feels awkward. The first 10 proper omelets you make are going to suck. Right? But you're going to come out with a better omelet, and if you're willing to go through that process, but I wonder if it's sort of like ... With pain, one of the key teachings in pain is to tell patients who are going through orthopedic surgery that they're going to have pain. They should not expect to have zero pain. I think it's similar with empathy. You shouldn't expect a new thing to feel fluent at first. The authenticity is important, but it may not come until you've practiced it enough that it feels natural to you.

Adrienne Boissy:  It reminds me of a brilliant neurosurgeon who wrote me after one of our classes and said, "I've been waiting my whole life for somebody to tell me how to do this stuff." What was so interesting was, there is somebody in pursuit of excellence in their craft, and yet in the language of communicating and connecting with another human being just didn't have a roadmap, like what does that even look like? I want to be the best at it, but I don't know, so I think oftentimes that checklist or model can be a frame-

Tim Gilligan:  Absolutely.

Adrienne Boissy:  ... and then people can play with it and adapt.

Tim Gilligan:  Yes. People need to know where to start, and then once they master it, they can start to improvise off of it, and riff, and make it their own, but they need the roadmap-

Adrienne Boissy:  I don't know how many doctors are riffing, but I see what you're saying. All right. Talk to me about empathy being hard. Right? In your world, in oncology, I worry sometimes we think it's this easy skill. You just name the emotion and move on, and that will go great. Yet I think that the hard truth is, it's really difficult to be empathic, especially in the moments you've described at the end of a day, when you're running late, when you've seen 30 patients. Tell me a little bit about, is it hard, do you agree, and if so, how, in your own mind, do you work through that or try to make sure you're still present?

Tim Gilligan:  Are you thinking hard difficult, or hard emotionally hard, or-

Adrienne Boissy:  Both. I think it's both.

Tim Gilligan:  Yeah, I mean, I think it's both. I mean, I think it takes, it's this active imagination, in a sense. I mean, it's, if I'm talking to a ... I'm an oncologist, so I'm talking to cancer patients, and so for me it's trying to imagine what it would be like to have a doctor tell me I had cancer or that my cancer had come back, or that we had exhausted all of the effective treatments for the cancer. That requires active imagination, in a sense projecting myself into the patient's world. Some people are better at that than others. If I'm really busy and there's all this noise in the back of my head about what's already happened during the day and all the charts I still have to close or the phone calls I have to return, it may be hard for me to be fully present. I think that ... I think around the difficulty, in a sense, it's, for me, it's mainly just freeing up the attention and the emotional energy to be able to do that.

That's why I think you can't do it 24 hours a day all the time. Fortunately, you don't usually have to. Not everyone's having a particularly emotional moment, in which case empathy may not be needed. I think the harder part for me is just the emotional drain sometimes. I mean, honestly, there are times I walk out of a room and I think, "I can't believe my job is to have these conversations," that even when I have them well, there's a ... This is an analogy you're probably not expecting. I was a big Star Trek fan when I was a kid, and they had an empath

Adrienne Boissy:  What?

Tim Gilligan:  They had an empath character. This is back to William Shatner, Leonard Nimoy one, but they had this character who could take on another person's physical wounds. It was this planet that was going to die, and these leaders of some other planet were trying to decide who should be saved. They wanted someone who was really caring and empathic to be saved, so they were testing how caring this person was in using her empathic skills, so they would beat up Captain Kirk and Mr. Spock, and then she would go in, and she would put her hand on them, and their wounds would transfer onto her. Then she would recover and heal.

There are times that that's what I think of when I walk out of a room that not that I have taken on the patient's suffering, because they still have their suffering, but there's a sense in which I walk out of the room feeling it at this very deep level. I feel like if you're going to do this, you need to take seriously this business of recharging your batteries and processing what you've been through, because I feel like it feels like deeply caring work, and it is draining. For me, that's the harder part, and that's probably why I really prioritize getting on the tennis court and getting somewhere where I can hit the ball as hard as I can and think about other stuff, get out my aggressions, and frustrations, and things like that. I think you need to take care of yourself to be able to do it, because otherwise, I think you burn out.

Adrienne Boissy:  I'm hearing you highlight this cognitive and affective empathy. Right? That ability to be curious without necessarily taking it on is that cognitive piece, and yet that affective, some degree we do feel, we should feel what that might feel like, but how do we let it go or show up the next day is something ...

Tim Gilligan:  I would throw in one other thing, which is, there is so much value in just showing up and listening that even if you're not feeling particularly skilled at empathy that day or maybe ever, just showing up, sitting down, and listening, and showing that you care, I mean, that's such a huge part of it. We sometimes think, "Oh, my God. I got to say this really profound thing," but oftentimes, there isn't anything all that profound to be said, but presence is really profound, not being scared to go into the room and sitting and listening to what they're scared of is so huge.

I think sometimes we forget that, and then maybe we don't go in the room, because we think, "I don't have anything really profound to say," and we forget that, honestly, there isn't anything that profound anyone could say, but showing up and being present means a lot to people who are suffering. They notice that a lot of people don't show up because they're scared, so if we can be someone who does show up, we're actually differentiating ourselves, and we're helping in a way that is often needed and useful.

Adrienne Boissy:  There's this idea we learned from Walter Baile and others around the bottom of the jug. Right? That no matter what is coming out of the top of that jug, no matter what the person's saying, "I don't like my maple syrup. I can't believe," that at the bottom of that is fear, and oftentimes they want to know that we can sit with them. Is presence something you think we can all do?

Tim Gilligan:  That's a great question. I mean, we're all different. I think most people can. I think that there probably are instances in which people have certain personalities that they may be better off having a member of their team play that role for them, to some extent. I've been in situations like that, where there's a nurse practitioner, or there's another physician, or another clinician on the team who is better at this stuff. That's the great thing about having a team. You try to get each player doing what they're best at. If someone's really good at playing first base, maybe you don't need them to play shortstop. I think most people can learn to do this. I actually think most people will enjoy their work more if they do some of this, but if it's really just not going to work, then an alternative is to have a team approach and to divide up those responsibilities.

Adrienne Boissy:  You mentioned burnout. When we trained clinicians, one of things I think we learned is that you could reduce emotional exhaustion associated with the type of work we do by reinforcing those relationships we have with patients, because for most of us, that's a tremendous source of meaning, and the more meaning we have as clinicians, the less burnout. You want to comment on that?

Tim Gilligan:  Yeah, I think that's very true. I think we're very lucky to get to do such meaningful work. There are many people on planet Earth who spend the day doing activities just to get by that don't necessarily have a lot of meaning to them, and so to be with people who are suffering and to be able to help them, whether it's to physically medically help them, or at least emotionally and spiritually help them, is very meaningful and profound work. If we can be in touch with that, I think we can cope with a lot of the stresses of our days a lot better, but pacing is important, and volume is important. We hear from clinicians sometimes that they're worried that, "Oh, if I let myself care about patients, then I'll be too badly wounded when something bad happens to them." I would just counter that with, "What's the point of being a doctor if we don't care about them? That's where the meaning is," but we have to find ways to navigate it that are healthy for us and healthy for the patient.

Sometimes, boundary setting is important for that in the sense that we do have to set limits as to what we're responsible for, and I think sometimes people don't step in because they're worried that once they make the first gesture, it's like a cascade, and they're never going to stop. I experienced that as a fellow, just I found that sort of bizarre that I'd go into a room and talk to a patient and give them this life-changing, devastating news, and then I'd leave the room and close the door, and the next big question for me is, "What am I going to have for lunch?" I'd think, "They're going to have to go home and live with this." I almost felt like I should go home with them, right, and help them, and answer their questions, and cook them lunch or whatever.

I can't do that. There have to be boundaries, and if we're clear about the boundaries, then I think also, I think that's important for burnout, because I've seen people burn out because their interpretation of caring means they're going to do everything. They give their cell phone numbers to the patients, and they're available when they're on vacation, and they never protect themselves, and then they burn out, and they drop out of medicine, and then they're not helping anybody.

Adrienne Boissy:  Truly, one of the most amazing clinicians I know. Glad to call you colleague and friend. We're lucky to have you not just in medicine, but at the Cleveland Clinic, so thank you for joining us today.

Tim Gilligan:  My pleasure to be here. Thank you for having me.

Adrienne Boissy:  This concludes Studies in Empathy podcast. You can find additional podcast episodes on our website, my.clevelandclinic.org/podcasts. Subscribe to Studies in Empathy podcast on iTunes, Google Play, SoundCloud, Stitcher, or wherever you get your podcast. Thank you for listening. Please join us again soon.