[00:00:00] Christine Ko: Welcome back to SEE HEAR FEEL. Today, I have the pleasure of speaking with Dr. Robert Smith. Dr. Robert Smith is a University Distinguished Professor of Medicine and Psychiatry Emeritus at Michigan State University. He is an innovator in teaching and researching patient-centered communication as well as primary care mental health since 1985. Dr. Smith has two major textbooks being used in medical and nursing schools in the US and internationally. One is called Patient Centered Interviewing: An Evidence Based Method, which is now in its fourth edition, and Essentials of Psychiatry in Primary Care: Behavioral Health in the Medical Setting, and that's from McGraw Hill as well, published in 2019. He has been interviewed and quoted in the Los Angeles Times, Ladies Home Journal, New York Times, Time, the Wall Street Journal, Newsweek, the Today Show, and Elle, as well as other places. Dr. Smith has his own blog in Psychology Today, and he is currently also writing a trade book for general audiences that is provisionally titled, Has Medicine Lost Its Mind.
[00:01:02] Welcome to Bob.
[00:01:03] Robert Smith: Thank you. Glad to be here.
[00:01:04] Christine Ko: I'm so glad to be talking to you. Would you be able to share just a little personal anecdote about yourself, just so that listeners can get to know you a little better aside from your biography?
[00:01:15] Robert Smith: Oh, sure. Most people don't know that I was raised to be a professional athlete.
[00:01:20] Christine Ko: Oh, okay.
[00:01:21] Robert Smith: Yeah. My father was very interested in athletics. Medicine only came to the fore after that.
[00:01:27] Christine Ko: What sport did you play? Or did you play multiple?
[00:01:30] Robert Smith: Oh, I played everything. Football, basketball, baseball, track, golf, tennis.
[00:01:36] Christine Ko: Did you have a favorite?
[00:01:38] Robert Smith: Football, I would guess, yes.
[00:01:39] Christine Ko: Oh, okay.
[00:01:40] Robert Smith: Yeah, and we did fairly well.
[00:01:42] Christine Ko: This podcast is titled SEE HEAR FEEL. I like to focus on our perceptions, what we can observe, what we can listen to, what we can feel. Given your experience, one of my initial questions is what are basic communication skills for everyone?
[00:01:58] Robert Smith: Pearl, in a recent book, Uncaring, articulated the culture of medicine. Its medicine's culture that you are basically working too hard and forced with too many hours a day. And the society that I was raised in, especially as a man, it is absolutely forbidden to talk about your feelings. So it's not just medical culture, it's the culture more broadly that wants to dismiss our own feelings and emotions, which on the other hand, are the very centerpiece of what keeps society together. It's how you and I and everybody else interact. It's through emotional lives. Paradoxically, society in general, medicine, in particular, suppressed them.
[00:02:49] Christine Ko: How did you learn emotional intelligence and gaining awareness of your own feelings having not grown up that way?
[00:02:57] Robert Smith: It's important to address your emotion. It helps to make it okay to talk about them, practicing just doing it. The first time you express an emotion to somebody else and you realize the roof doesn't fall in. It's still there. Everybody's still there. Nobody's laughing at you. These are basic interpersonal skills that revolve around emotions, and this is how society interacts.
[00:03:23] Traditionally doctors have just used so called closed ended skills, which means just asking questions, one after the other. How old are you? What kind of work do you do? Where are the symptoms? Do you have pain in the head? And so on and so forth. Those are closed ended skills, and they don't yield much information about the person.
[00:03:48] We advocate for basic skills. One of them is just being silent, pausing, giving the person an opportunity to talk. But probably more important are these focusing, open-ended skills. For example, you might say, Tell me more about losing your job. Focusing skills focus the direction toward the physical problem or toward the psychological dimensions. And both are important.
[00:04:18] This is how one generates a story unique to the person, not only physically but personally. But often we don't yet have the emotion that goes with the story. We have to ask about it. And the second key skill is emotion seeking skills. You might say, So how does that make you feel, losing your job? And, there are any number of ways to ask that, but that's basically what you're trying to get at.
[00:04:45] Now, sometimes people will say something, Oh, I don't have any feelings. We were brought up in my family not to discuss that. And ,so you have to pursue it a little bit more. And you might say something like, I've seen other people out of work. They felt pretty upset about it. You can kind of plant it out there. And you plant it out there, use a neutral term.
[00:05:07] People often wonder: why all this focus on the emotion. It's the pinnacle of the interview. It is the essence of the interview and the doctor patient relationship. And as many people have shown, understanding others' emotions is essential to interaction in a broad society. And these are, these are vital elements that are often ignored.
[00:05:32] Now, having gotten emotion, the third skill you go to are the empathic skills. And we have devised a mnemonic for this called "NURS", N-U-R-S . And what that means is that, let us just say now that our person with chest pain, lost their job, said, When I ask about emotion, said, It makes me feel down and upset. And you would hear that for a while, and you'd start saying say more about being down and upset. And they would tell you maybe about their job and all the other aspects of that. And once you've heard enough of it to understand what they're talking about, you use the NURS skills. That's naming, understanding, respecting, supporting. Everybody always tells us, be empathic, but nobody ever tells you how.
[00:06:31] This is how. You name it. You understand it. You respect it, and support it. And these skills that we're talking about, Christine, apply in everyday interactions. You can use them with your spouse, with your kids, with the bank teller, with somebody you run into on the street.
[00:06:49] And so they are generally applicable.
[00:06:52] And in medical instances, people always worry, Wow, I'm gonna open a can of worms. I may get a bad story that I can't do anything about to help, so I shouldn't unearth it. And what I urge people to understand is that you don't have to fix it. It is helpful to that person simply to hear you be empathic with them. People don't expect you to solve their problem, but they would want to feel supported and accepted by you, and you do that by using these NURS skills. And you don't typically use all four of them at once. Sprinkle them throughout the interaction.
[00:07:35] It might go something like, Oh, so you were feeling pretty down about that? I can understand. 30, 40 seconds later you might say, Oh, was a tough time for you. That's a respect statement. But good for telling me about it. Those are both respect statement. 20 seconds later, Let's work on that together. You're variously using all of these different skills throughout the interview and the essence of the interview is communication and doctor patient relationship. Identifying emotion, asking about it, then NURS-ing it is where the communication maximizes and where the doctor-patient relationship is established.
[00:08:18] Just basically interpersonal skills. They have nothing to do with medicine. We have simply systematized them for teaching in medicine. And the mnemonic NURS is easily remembered. N-U-R-S that's not really a word. Everybody wants to fill in the word and put an E in it. And who's more empathic than the nurse? So it's an easy way to remember that.
[00:08:43] Christine Ko: There's a paper related to the Dunning Kruger effect. The Dunning Kruger effect being that we tend to overrate ourselves in a given skill. When you take a poll of say, a hundred people, most people will rate themselves on any skill at the 60 to 70% range in general. But obviously, of those hundred people, not everyone is gonna be above average. Meaning that even say for driving, I might think that I'm above average, but really, I'm average or I'm worse than average.
[00:09:12] There's a paper showing that Dunning Kruger effect, for communication between doctors and patients, showing that doctors rate themselves at 70%. Like I'm a good communicator.
[00:09:22] Robert Smith: Yeah.
[00:09:22] Christine Ko: And really patients rate them at about 20%. So I'm a doctor and maybe I'm really 20% in terms of how good my communication is, but I would rate myself at 70%. So why do you think that doctors overrate ourselves?
[00:09:36] Robert Smith: That's a good question. A common observation is when people first come in to an interviewing course, particularly if it's a required course, some people will really be interested in it, but others will say, Why am I here? I don't wanna do this touchy feely stuff. I know how to communicate already. And part of it is the simple fact that all of us have been communicating all our lives and they're talking, communicating, every day. And from their perspective, it works. It's what they do.
[00:10:12] We often see what we'll call reluctant learners or people that are not particularly interested in this. So how do you teach them? What you do is you work with them to establish a relationship and say, Yeah, that sounds frustrating for you to have be talking about this. I can understand that.
[00:10:33] You are NURS-ing them and carrying them out and developing a relationship. I did a workshop once that illustrated this with practicing doctors. We got started and you could tell they were unhappy. What the people that organized that hadn't told us is that they were all forced to be there because they'd had patient complaints. So we did not start teaching them patient-centered skills. We spent the entire morning hearing out their beefs and concerns about why they were there, how difficult their job was. They had too many patients. We heard them out open-endedly, elicited their emotion, and NURS-ed. By the afternoon, they were just learning these patient centered skills then. And one of 'em said to me, You used the same skills with us this morning that you're teaching us to use with patients, didn't you?
[00:11:31] Christine Ko: Especially with the COVID-19 pandemic, and short staffing across many hospital systems, and burnout, and the Great Resignation, and just the many tragedies that the world has continued to be dealing with, even beyond the COVID-19 pandemic: different natural disasters, the war in Ukraine ... One of the issues is that doctors aren't being heard themselves and so it's hard for doctors to listen to patients when you feel, as a doctor, the system isn't treating you as a human being either with real emotions and needs.
[00:12:11] Robert Smith: Exactly.
[00:12:11] Christine Ko: Is there anything that we can do about that?
[00:12:13] Robert Smith: Yeah, I'm glad you asked. Many people view doctors as real uptight and close to the belt and not wanting to express feelings. And as you can guess, part of teaching patient centered interviewing, we teach what we call self awareness, personal awareness.
[00:12:30] The first thing is, how do you feel about the interaction? What was your reaction to it? You develop their personal story and of course are empathic with it. Having addressed their personal awareness, they are more able to go in and actually do these patient centered skills. To teach these counterintuitive skills, you have to relate first to the learner using, in fact, the same skills. And we did a study on this once. We demonstrated that when residents could learn and participate in self awareness like this, they could recognize emotion and be responsive to it; that the interviewing results were actually better.
[00:13:21] Back to your question about all the trauma doctors experience in this day and age and burnout, people have to understand doctors, what their emotions are, and how bad they feel, and have to be responsive to that. Doctors are not automatons. If you give them a chance, they're quite open to talking about their feelings. It's just that they've gone through medical school and pre-medical stuff where this was not only not done, it was forbidden. It was off base. You didn't talk about these things. You didn't talk about how bad it was to get no sleep for two nights in a row. And it's a real revolution in medicine to get doctors to start talking about their own feelings. And the good news in that is when they're able to do it, they interact in turn better with patients and are themselves more empathic.
[00:14:18] Christine Ko: Absolutely. Many of the things you say I think are definitely true for me. I found medical training to be, in reflection, actually somewhat dehumanizing. It was only once I had kids, and I started reading books about emotional intelligence and thinking fast and slow, thinking about how we think, that I realized that I had a very poor education in knowing how I feel, being even able to name how I feel.
[00:14:52] Robert Smith: Yeah.
[00:14:53] Christine Ko: I think that NURS mnemonic: name, understand, respect and support, for me at least, definitely did start with myself. And the more I can do it with myself, the more I do have space, grace, and empathy to extend that same type of NURS mnemonic to someone else.
[00:15:10] Robert Smith: Yeah, it's important to NURS yourself. Isn't it?
[00:15:13] Christine Ko: I think very much so.
[00:15:14] Robert Smith: Yeah.
[00:15:14] Christine Ko: Do you have any final thoughts?
[00:15:15] Robert Smith: Oh, I'm glad to see you doing this. And you've written so eloquently about it in your book. It is really very important: this broader idea of emotion as central to not just medicine, but to all society. This broader idea is one that the public, these cultures, societal culture, and medical culture have not quite yet embraced. And it's important. Emotional awareness, emotional intelligence, is so important.
[00:15:48] Thank you for spending the time with me.
[00:15:50] Oh, it's my pleasure.
