[MUSIC PLAYING]
DOUGLAS WOOD: I'm Doug Wood, the Chair
of the Department of Surgery.
Welcome to the Surgical Grand Rounds,
and we've got a special morning this morning.
And I know that there are many more people trying to get here
because I just got a text that the line to get into S1
is 15 minutes long, and that there are still
people waiting to get into S1.
So it's a very special morning for us
because we have our own Dr. Pelligrini that's
giving Grand Rounds.
And I'm going to take advantage of him being our special guest
to give a little bit more of an introduction
than we would normally do particularly because we have
so many guests here, people beyond the Department
of Surgery from many other departments.
Dr. Pelligrini grew up in Argentina
with parents who were doctors, and if you
look at this first slide, you can
see that although he had a very happy childhood,
I guess some days, he didn't look as happy
as represented by the rest of his childhood.
But he grew up near Rosario, Argentina.
And one little known fact that most people don't know
but was an important area of connection
between Dr. Pelligrini and myself
was when he was a senior in high school he
was a foreign exchange student and actually
went to high school and graduated from high school
in Kalamazoo, Michigan.
He graduated from Portage High School in Kalamazoo, Michigan.
You can see him as a student in high school,
and he was a good student.
But I also want to emphasize he was somewhat of a nerd
as you can see from the well-established pocket
protector so popular in the 1960s.
So Carlos graduated from high school
in Portage High School, Kalamazoo, Michigan, returned
to Argentina, went to medical school,
and then completed a general surgery residency
in Rosario, Argentina.
He then had an opportunity to do a research fellowship
at the University of Chicago, and he was so well-received
there that they actually offered him another general surgery
residency.
So Carlos had the benefit of a second general surgery
residency in the United States after completing one
in Argentina.
And it was there at the University of Chicago
where he was mentored both by Tom DeMeester and David
Skinner, who were important influences in his life
and important aspects of him becoming
a prominent esophageal surgeon.
Carlos was then recruited to UCSF as an assistant professor
and actually has many connections
here at the University of Washington
from his time at UCSF.
As an assistant professor at UCSF,
he rose rapidly through the ranks,
both in terms of academic promotion and leadership
to the point that he was recruited
to be the chair of the Department of Surgery
here at the University of Washington in 1993.
So Carlos was the Chair of the Department of Surgery
for 23 years, by far the longest Department
of Surgery Chair ever at the University
of Washington, even exceeding the first Chair of Surgery,
Henry Harkins himself, who was chair for 17 years
I put up here-- and I think this speaks volume of the person
that Dr. Pelligrini is.
These are the things that he is most proud of.
And I want to talk a little bit about what Carlos
has done within the Department of Surgery
and within UW Medicine and why he is giving
this lecture this morning.
In the Department of Surgery under Carlos's leadership,
the of the faculty and the number of clinical programs
has more than doubled.
We now have 177 faculty in the Department of Surgery--
and only a fraction of this when Dr. Pelligrini came here--
and a breadth of clinical programs that are outstanding.
We have division chiefs and faculty that are leaders
locally and nationally.
At the same time, Carlos has developed 19 Endowed Chairs
and Professorships during his tenure as Chair, and many of us
are the recipients and beneficiaries
and support the research programs
in the Department of Surgery.
Carlos has been focused on the development of research,
an example being the development of the Surgical Outcomes
Research Center with Dave Flum, an example of his leadership
on the side of research.
He has also been focused on education.
We now have four residency programs and 11 fellowship
programs in the Department of Surgery.
And every single one of them is at the top of their peer
group in the United States.
That has to do with the leadership of our program
directors and the leadership of Dr. Pelligrini.
Of course, Carlos has made numerous scientific
contributions.
His curriculum vitae is a wealth of accomplishments
and publications.
But I think what people most respect and know him
for is his leadership.
The fact is he has been a leader of most
of the important surgical associations
in the United States--
the American Surgical Association,
the Society for Surgery of the Alimentary Tract,
the Society of Surgical Chairs, and probably
the pinnacle of leadership in American surgery,
the President of the American College of Surgeons.
He has honorary fellowships from all over the world.
In fact, it's kind of embarrassing
how many honorary fellowships and professorships he's had.
And he's a recipient of the French Medal
of Honor from the French government
for his contributions to surgery.
Two years ago, Carlos was named as the first Chief Medical
Officer at UW Medicine.
So we are now privileged to have his leadership at the highest
level in UW Medicine after his long and successful tenure
as Chair of the Department of Surgery.
While all of these accomplishments are terrific,
I think what most of us respect and appreciate Carlos for
is his mentorship--
and most of the seven the recipients of that mentorship
and support--
and his leadership and integrity.
He has an incredibly deep well of close friends.
In fact, I don't think there's anyone that he doesn't know.
Whenever I talk with him about somebody that I've just met,
Carlos says, oh yes.
I know them.
They're a very close friend.
I mean, it's almost ubiquitous.
Carlos knows everyone I have ever met,
and he is close to them.
He's shared a meal with them, they've stayed at his house,
and it's so extreme.
His generosity and the breadth of his connections
is remarkable.
And as you'd expect, it even extends to the Pope.
So this is no joke.
Pope Francis and Carlos are both from Argentina.
And one time I'm challenging him about
whether he knows the Pope.
And of course, he does.
And I don't remember the reason, whether they played
on the same soccer team or whether they
went to school together, but Carlos knows Pope Francis.
Most of us have been the beneficiaries
of the great stories that Carlos tells.
He is an amazing storyteller, and we've
been the beneficiaries of stories
of intrigue, excitement, embarrassment, accomplishment.
And some of them are even true.
Carlos, I think, is one of the best examples
that we can hold up as a person of honor, integrity,
and an incredible, deep, moral compass
and emotional intelligence.
And it's why we love you and what
we respect as your colleagues and as your friends.
And those of us here today are glad that we
are your close friends because those of us in this room are.
Dr. Pelligrini has had a long interest in ethics
and in the ethics of surgery.
And last year, he was honored to be
asked to give the John J. Conley lecture on ethics
and philosophy at the American College of Surgeons.
And so we are very lucky to have Dr. Pelligrini give us
this lecture again this morning that he gave to the American
College of Surgeons last year--
Trust: The Keystone of the Physician-Patient Relationship.
Dr. Pelligrini.
[APPLAUSE]
CARLOS PELLEGRINI: Well, Doug you out did yourself as usual.
I am honored that you'd introduce me today.
I was thinking Dave was going to introduce me,
and I would have loved to have Dave introduce me.
And I had thought about what to say about Dave, but not
about you.
[LAUGHTER]
I can say one thing about you, and that is, as the new Chair
of Surgery--
obviously, I'm delighted that you
have taken the Department of Surgery reigns--
you have an influence in the school.
I have never seen so many people come to Surgicial Grand Rounds.
And I realized on Monday night when
I was at [INAUDIBLE] department, and he
was making just announcements.
He announced on Wednesday, October 4, 6:30 in the morning,
everybody has to be in T625.
And I just thought, T625, that's where I'm speaking.
And I see Richard sitting there as well as so many of you.
So thank you and good morning.
Thank you all for being here.
I'm certainly very appreciative that you came,
and I'm confident that what I have to say
applies to most human beings.
So if you're a surgeon, this touches you
probably a little bit closer.
But if you are not a surgeon--
you know, we in surgery talk about surgeons
and the rest of the population, which we call non-surgeons.
So if you're not a surgeon, I hope that you
will find this of use as well.
I have no conflict of interest to disclose,
but I do want to disclose to you--
and I think Doug alluded to it--
that what I am about to tell you is not
the usual talk about techniques or outcomes in surgery.
But it is about ethics, it is about philosophy,
and it's about relationships with fellow human beings.
And I say so because if you think of surgery--
and if you think of Surgery Grand Rounds--
you sort of think, I think, this way, right?
You view in your mind a picture of an individual
with a few others helping, working, with his hands,
in this case, trying to solve a problem,
trying to change the anatomy, trying
to resect, remove, change what's going on there and take
care of an ailment.
And because of that, most people,
when you think of surgery, the reality
is that the focus is on the technical ability
and the dexterity that the individual has.
And most of the training that we tend to receive
has to do with technique and dexterity.
A lot less has been emphasizing ethics and philosophy
in general.
And today, my task is to convince you--
as I talk a little bit about some thoughts on ethics
and philosophy as I see them--
to convince you that focusing on the generation of trust
through adequate communications is an essential elements
of a surgeon's life.
I have come to believe that it goes
far beyond the relationship that we establish with the patient.
Because it is the relationship that we establish
with everybody around us that makes
surgery and the surgical results what they are.
To that end, let me tell you a little bit
about my own journey.
Doug told you my life journey.
I'll tell you my own journey into this particular field,
I joined surgery because I had that picture in mind
just as well.
And I was at the time fascinated and interested in the GI tract.
And I thought that surgery was a vehicle for me to make changes
to the GI tract with my own hands that will hopefully
improve the quality of life of other human beings,
and that occasionally I would cure somebody
from a dreadful disease, as it is
a case with esophageal cancer.
Most often I would prolong life or palliate somebody.
Very often we would be changing the function of the GI tract
and improving the quality of life of somebody else.
I did not embrace the study of philosophy or ethics
or read anything about it in the early stages of my development.
But as life went by, I came to realize that the power
to heal that I had, if any, the ability
to have good outcomes with patients
was directly related to the type of relationship
I established with the patient.
That the more I delved into the patient's life,
the more I established that relationship
between the surgeon and the patient
that was based on something that I couldn't describe then,
but I then realized later on it would be trust.
As soon as we established that bond,
the chances of having a better outcome,
as seen by the eyes of the patient,
increased significantly.
And [INAUDIBLE] and I started reading and studying
a little bit about what are the mechanisms that get two
human beings closer together.
I realized that that allowed me to understand myself
a lot more, to know what things ticked me off,
to know how to control myself when
I was facing one of those events,
and slowly to understand myself.
And as a consequence of this not because I programmed it,
but it came to the realization that we
work in a health system.
We work every day with other surgeons,
with physicians of other kinds, and that if I establish
the same relationship-- which is a relationship based on respect
and mutual understanding of caring for another human
being--
with the members of the team--
and when I'm talking about members of the team,
I'm talking about members of the operating team,
but I'm also talking about the nurses on the ward,
I'm talking about the residents that are on your team,
I'm talking about the Department of Surgery
faculty, the administration--
if you had that essential elements
that I will describe for you in a moment that
are the basis for the generational trust,
then life was better.
And to me the greatest discovery of this--
and maybe one day I can come and talk about that--
is the tremendous effect that this has in preventing work--
in preventing burnout.
Because I realized that as you become happier with what you
do, as you're welcome with a smile by people that are
working with you that day, as you find the friends that I was
talking about-- people that you establish a relationship that
maybe is just this story, a little something that happened
between two human beings that is a little bit different than
just the professional aspect--
that that to me personally is the biggest deterrent
to feeling burned out.
I wake up in the morning sometimes early, sometimes
very early.
And believe it or not, at my age of 71,
I say, how many hours before I go to the office?
It is that kind of thing that makes you not
feel overwhelmed or overburnt.
So the title of this talk was supposed
to be Trust: The Keystone of the Patient-Physician Relationship.
And I will keep it to that, but I just
wanted to give you that brief introduction in terms
of the importance, I think, that the generation
of those relationships are.
To the effect of this talk, I want
you to think for a moment of trust as a little red stone
there.
And imagine that little red stone for just a second.
And let me go back to the human relationships
that I talked to you about before.
And I think or imagine a human relationship as an arch
as depicted on this picture.
And I think of the physician on the one side,
and on the other side of the arch, I think are the patients,
I think of the physician herself or himself, I
think of the system that the individual relates to.
And so that's a human relationship,
and that little red stone that I told you there is the trust.
Now that stone, if you think for a moment,
you remove that stone, the whole thing crumbles.
The arch disintegrates.
It is that stone, the so-called keystone,
the concept that was actually developed by the Etruscans
2,500 years ago, that keeps that integrity
of that particular arch.
And that concept was not only developed by them a long time
ago but then taken up by the Romans who started perfecting
that keystone and started perfecting it to the extent
that they started using it on gates,
they started using an aqueduct, they
started using it on bridges as something that would have--
as the most important element of the arch itself--
would have the ability to keep that in its full integrity.
So I view trust then to a relationship
like the keystone is to an arch.
I think that it is essential to keep the integrity of the arch,
and it is with that concept that I
would like to describe trust in a little bit
more detail in just a minute.
But before I do that, if we have agreed
that this is a pictorial representation
of a human relationship with somebody else
or with the person himself, and if we have agreed
on the importance of trust as represented by the keystone,
I have learned that communication
is what sits in the middle of that arch between the person
and himself, or the person and the patient,
or the person or somebody else.
It is through communications that we
establish that relationship.
But I'm not talking about a verbal communication here.
I'm not-- I'm talking communication in the broadest
extent.
Communication is a smile.
Communication is looking at somebody eye to eye
like I'm looking at Roger right now.
Communication is recognizing somebody.
Communication is getting upset.
Communication is making a face.
Communication is not paying attention
when someone is telling you something
because you grab your telephone, and you
start answering a message.
So in every one of those behaviors that you model,
you're communicating something.
And you're communicating something
that sometimes you don't think you're communicating.
But you are communicating something
no matter what you do.
And that has become something that I
think if we look at it from a practical perspective, not
an academic perspective, is an important aspect
to preserve that.
So let me then start.
I'll give you a few thoughts about trust itself
as it relates to medicine and then
three or four slides on what I think communication is
and how communication directly relates to trust.
So for trust itself, a definition that I like
is this one from the dictionary that says essentially it's
the assured reliance on the character, the ability,
the strength, or the truth of someone or something,
where I believe the key word is reliance.
And reliance from one person onto another person character
onto another person's strength.
And it's not only about the persons.
The animal kingdom shows us trust all the time.
Think of a flock of birds and think of the leader
of a flock of birds.
It's only trust on the strength and reliance
on the strength of the leader of that flock
that makes all the other birds fly in the same direction.
And that reliance is very important
because that reliance brings about vulnerability.
And so Edmund Pellegrini--
Pellegrino actually, a very famous philosopher
that wrote a lot about trust, talks
about the fact that to trust and to entrust
is to become vulnerable--
it's a vulnerability, because you
are relying on somebody's character--
and dependent on the goodwill and the motivation of those
who we trust.
And Bernard Barber, the sociologist
that writes a lot about trust, defines trust
with three sort of conditions--
persistent moral order-- remember that reliance
on somebody else is based on the moral order--
perform technical role properly when
relating to any profession--
so it's a commitment that you have--
and altruism, or will do so with a concern for others.
So there is these three conditions
that lead us to think that in medicine you can translate
those conditions from a practical perspective
in the possession of knowledge necessary to do something
to another person, the autonomy given to you
by the person necessary for you to practice and exercise
your skill and your set of values
hopefully with the understanding of the values
of the other person in the treatment,
and the fiduciary obligation to individuals or to society.
It is always the moral character.
It is always the permission.
And it is always the vulnerability and the altruism
that go together.
It's the beliefs on the benevolence
and morals of the physician.
In medicine, I view trust as having
five or six different twists that are not
seen in most other professions.
The first one is the affective nature,
the dependence that a person who is sick has on the physician.
So it is and like most other professions where perhaps
a relationship with a lawyer-- and I'm not trying to be
disrespectful to a lawyer--
but a relationship to an accountant or relationship
to a technical person, that relationship
is subject to less affection than it is to a physician.
You see embraces, and you see hugs,
and you see the kinds of things that most patients associate
with trusting their provider.
In medicine, it's important that we keep skills and values
very clearly up front because we can make the promise.
We have a contract, if you wish, with society.
We are relied upon--
as the original sentence that I showed you said--
to provide skillful work and that means continuous
learning throughout our lives.
There's a lot of papers that have
shown that trust is directly associated
with adherence to treatment.
And this gives a base to my original premise
when I started telling you that I thought that my power
to heal somebody was directly related to the trust generated
on that person.
And we know now from a lot of studies
that patients who trust their doctor,
as you would logically think, tend to adhere to treatment.
And so you can see they discuss a direct therapeutic effect
on the patient.
Interestingly enough, patient satisfaction
is directly related to trust.
So if you look at papers that relate the issue of trust
to patient satisfaction, you see that, again,
patients that have trust in physicians,
particularly when they have [INAUDIBLE] what
I will describe in a moment, a mutual trust.
That is they, the patients, perceived
the physician trusting in them.
And satisfaction indices are much greater.
It is not surprising to me that [AUDIO OUT]
pay a lot more attention to the issue of trust
and how to gain the trust of another human being
and how to deliver on the promise just for a business
perspective to get better patient scores.
And of course, in medicine, we go back to that vulnerability
that Edmund Pellegrino had described
when you rely on somebody else.
Vulnerability is something that happens
in every state of dependence, as the theory goes, right?
Any state of dependence [? is ?] spiritual,
the state of dependence, a learning state of dependence.
And you now can tie learning environment and the power
that the teacher has over the student, or the resident
or whoever it is, because that person is relying
on the teacher and that person is showing their vulnerability.
When the dependence originates from injury,
originates from disease, originates from something
that the person who gets it has very little control on,
and not only has very little control,
but has very little means of becoming non-dependent.
Unless and until that person seeks the care of somebody
else who has the power of healing, who
has the ability to heal, who has the skills to heal, et cetera.
So that poses, I think, an important philosophical duty
on us.
Is that fiduciary duty that, coming back
to the altruistic portion of trust, that we have to respect?
We have to be advocates, and we have to make sure
that we are not in any way exploiting the vulnerability
of a patient, because a patient is much more
likely to take my advice.
If I say I think you need an operation, I
am sure some of you have been patients, when the doctor says,
you need an operation, the patient
is much more likely to say yes because of an inherent trust
on the physician.
It is then our obligation to make certain
that we have disclosed the rationale,
that we have disclosed the risks,
that we have looked at the values
from the perspective of the patient to the extent that can.
That we recognize we are not inside that patient.
We will never know what the real values are, right,
for that individual.
But it is incumbent upon us to make sure
that we remember the tremendous vulnerability
that the state of dependence caused by an injury cast
on a patient.
That is particularly relevant at a time of incentives.
Some of you have heard me talk about incentives before.
We work in a system where every service that we provide
is remunerated in some form or fashion
and you receive, I receive, and every one of us
does, a certain amount of payment for the services
that we provide.
We are in a system that, by the nature of fee for service,
the system is potentially facilitating
the exploitation of the vulnerability of a patient.
Now, I do not want to get too deep.
This is not a political talk about how the system should be,
but perhaps I give you my own thought on my stance.
The system of fee for service is one
that has to be used very carefully by us,
the entrusted parties, if we want
to deliver the fiduciary duty that I was talking about
before, because the system is asking us to do more.
And for those of you who think that I
am talking against a value based system,
value based does not solve this problem at all,
because on the value based system
we have the opposite, right?
On the value based system, we are asked to do less.
The system is asking us to do less.
On the fee for services system it is asking us to do more.
And in either case, we can err in delivering the entrustment
that the patient had to us.
I believe that it is very important for us
to learn a little bit about how to generate that trust.
To learn a little bit about the philosophical aspects
of how do you deliver the moral contract that we
have as physicians.
Whether we are in the fee for service system
or on the value based system, how
do we guard the rights of those patients,
and how do we protect the vulnerability
that I was talking about?
Because of these underlying currents that systems have
developed, there is a whole chapter in ethics that is
the ethics of distrust and the ethics of distrust in one word
is to say we cannot trust that.
How do we get around that?
We get around that with a contract.
What we do is we convert, we transfer the trust
from the person to person relationship
to a formal obligation in the form of a contract.
And that could be a living will, a power of attorney, an advance
directive.
That would be the consent that we sign every day for surgery.
As you think about it, when the signatures come into place
and when you do a lot of promises
that this is going to happen, or I
will give you permission to draw my blood, to hit my head,
to putting my picture up on the web.
Whatever it is that patients give permission to,
those are contractual relationships
that, to a certain extent, are the result of someone
having lost their trust on the person to person issue.
If you go to practice in underdeveloped areas
of the world, you will see that, for some reason,
trust has been preserved in those areas
to a much greater extent, and contractual obligations are not
as commonly set.
Those contractual obligations sometimes
have problems because people tend
to write down what they think they would like
to do in a certain position at a certain time,
when that has never been faced by the individual.
Sometimes that eventually conflicts
with the values of the persons.
I told you a little bit about the mistrust that
has occurred in our culture as we become more pervasive.
The rise in suspicion that patients
harbor towards physicians.
Occasionally, the degradation of social trust
in our political systems, and the general erosion
of trust between employees and employers.
That leads to something that society has created to replace,
I think in a very imperfect fashion, trust.
And you have to be careful what you write in an advance
directive, you know?
Interpretation of wishes, as this cartoon says.
As one is telling the wife, just so that you know,
I never want to live in a vegetative state
dependent on some machine.
If that ever happens, just unplug, OK?
How that is interpreted by the other person
is sometimes important to remember.
Two more aspects of trust before I
turn it to communications briefly,
and that is the physician's trust in the patient.
It is also extraordinarily important.
We know that when the patients believe
that there is mutual trust, the potential consequences
for both parties, studies have shown that,
and these are mostly soft studies
based on philosophical analysis, that physicians derive
a substantial amount of pleasure when
they feel trusted by patients.
And not difficult to understand, patients
derive a substantial amount of pleasure
in their relationship when they feel the physician trusts them.
To the extent that you can with your patients, entrust them.
Just like in other states of dependence, like learning,
we tend to empower our residents.
Show them that we are confident that what
they can do by allowing them to do something that
goes a little bit further and perhaps beyond what they think
they are capable of.
And as that little stretching, carefully done over time,
whether it is in a procedure or in a conversation
with a patient or a decision making or something,
that empowers another human being, that
shows the other person you have trust on the person.
That is an important element that patients
come in with trust in the institution,
they establish trust to patients,
they trust a physician, trust a patient.
That eventually leads to more enhanced treatment,
more satisfaction, and better outcomes all together.
The last element of trust in this medicine part
is the social aspect of trust.
Social trust is a little bit of a different animal,
but it is essentially based on people's experiences in life.
So every one of us, just think of you at any time,
you walk into an environment.
In this case, let's make it that the environment
is the hospital, or the clinic, or the place where you
are going to see a physician.
You walk into that area with a certain amount of trust
in the system, in the institution, right?
That is what I was talking about vulnerability.
How important it is that when somebody is sick,
somebody does not have any other place to go than the hospital.
Every one of us has a different degree
of trust on the system itself.
Think communities of color.
How they would feel when you think
of the Tuskegee experiment, or many other genetic experiments
that have been done on Native Americans and others.
How those communities feel with regards
to the trust of the system and the people that
populate the system that is us.
Physicians, health care providers of all sorts.
The interesting aspect of social trust
is that it is much easier to manipulate,
much easier to change, much more dynamic than the person
to person trust.
To me, that was a very important discovery
as I was reading because we physicians and health care
providers in general can really improve the social trust
by things that we do in a visit, or we
can decrease the social trust.
As shown, for example, that the patient that
comes in sort of like, what is this going
to be like, I am going to see a doctor, the doctor
makes a lot of money, doctor has abused my community.
You know, those kinds of things.
And finds a person that greets them with a smile.
Finds a person that maybe is a little bit late
and apologizes for being late.
Takes responsibility for being late.
How that starts working on the social trust of that patient
that is looking at that individual.
Think for a minute of the opposite.
Think that you walk in and you say,
I did not know you were here, I work in this place
and they gave you an appointment at the wrong time.
They had me overbooked.
it is always the same.
In this hospital, they overbook me all the time.
So what is your problem?
And think of the two differences on how the person there
would perceive the trust in the institution or the improvement
or the disapproval of trust.
Trust in general, as I told you before, is to the relationships
like the keystone is to the arch.
It is essential for the integrity.
Without it, you cannot have a good relationship with
a patient.
And you can translate this to the other health care
workers that work around you.
With it, I think you not only improve the patients,
but you also improve yourself.
So, communication.
How does communication come into play in my mind with regards
to the trust?
Communication is the act or process
of using words, sounds, signs, or behaviors, OK?
To express or exchange information,
or to express ideas, thoughts, feelings.
Communication is a very broad perspective, first of all.
Remember when I talked to you about the smile,
when I talked to you about the things
that we do to pay attention to somebody else who was talking
to us et cetera, is the behavior that
becomes part of communication.
Wikipedia defines communication as the act
of conveying intended meanings from one entity
to another through the use of mutually understood signs.
I do not think it is always intended meaning.
Sometimes you communicate a lot that is unintended.
You did not mean to offend somebody
when you said something, when you
make a smirk on the face, when you did something different.
You did not mean it.
So, it is not always intentions.
I am not giving you all of that just because I
want to make it more complicated,
but because I wanted to bring you to this graph
that, to me, it was very revealing the first time I
saw it.
Communication starts with intent,
and I would say to you many times, starts without intent,
so I differ a little bit of this sort of mechanism
that I am putting in here for you.
Let's assume that there is an intent in your brain
to communicate somebody do something.
Your brain very rapidly composes a message.
Is the message going to be a smile?
Is the message going to be being upset?
Is it a word?
Is it a scream?
Very rapidly then the brain encodes that message
and then the brain transmits that message usually
through movements, through expressions, through behaviors.
This is all, more or less, part of your control.
Then the other party receives the message, right?
Remember what we talked about social trust and so forth.
They decode that message but then
they have to interpret the message.
You can see that, in any aspect of communication from here,
the way you compose and encode it, the way you transmit it,
the way the other person receives the [? codes ?]
[? and ?] interpreted, it is possible that at the end
of the day, you actually relay the intended message or that
you did not.
And that the message perceived by others was not what
you actually intended to do.
First of all, it is obvious that communication
is much more than words, right?
Let me show you this slide, and then I
will tell you what I was about to tell you a minute ago.
This is somebody that studied what people hear or interpret
from actions from other individuals.
Look at how little verbal, how much
more tone, and how much nonverbal communication exists.
This is not scientific.
This is philosophy and ethics and interpretations
of observations of human life.
They are not statistically significant.
But it just gives you an idea that what we say
is tiny, little.
it is what we do.
It is the way we walk the walk of life that that really means.
My personal tips.
Knowing that from the intent to the interpretation,
there will be a lot of potential changes.
Whether I am talking to a patient to a colleague
or to somebody else, it is first of all,
I love this sentence, do not attribute
ill intent to anything that you hear.
My first posture when I do not understand the message,
when a message as I have decoded it in my mind
and as I have interpreted the message,
is not in parallel with my values
or with the values of the other person,
is to not attribute ill intent.
It is very easy to get upset otherwise.
It is very easy to just attribute ill intent.
I believe most human beings are this
and most human beings have values similar to mine
and therefore I give them the benefit of the doubt.
If I cannot reconcile it after some thought,
and sometimes I cannot, and you will find that in your life
many times as well, then if I cannot reconcile what I heard
with my values, [? our ?] feelings, viewpoints,
et cetera, then I seek a chance to re-discuss it.
I give it another thought, another chance,
and I tell the other person.
When you are talking with me, try
not to get the god damn phone and start answering messages.
It displeases me.
You are not paying attention to me.
You are doing something else.
You are diverting your attention.
I know that you do not mean it, right?
I try to go on that route.
Give the person a second chance.
In order to get here, I would not
say that every single time, that I do not like
something I go for a second go.
Sometimes I say I do not think I am
going to go anywhere with a second discussion,
so I just quit.
But in general, I think it is a good idea
to say there are these three steps that
are possible if you want to preserve a working
relationship.
The third one is the most difficult one by far and away.
For me anyway.
If it still does not work, maybe it is time to let go.
It is the most difficult one because if you
decide that you are going to let go, then you have to let go.
You have to do that.
You have to let go, meaning you are never
going to think about it again or talk to that person about it
again.
Just let it go, OK?
It is not worth it.
If this one did not provide the explanation,
then you can let go.
Sometimes you are not going to be able to let go
and you are going to hold a grudge,
and that relationship will, by necessity,
crumble because that communication led
to a falling of that keystone.
The trust that you have in that person is gone,
and that is OK too.
Not everybody is perfect, and sometimes human relationships
go that way.
A very important aspect of communications
is the patient centered communication.
Epstein, who has written the most about that,
defines it as, one that elicits understands and validates
the perspective of the patient.
This is very difficult to do as you know.
Understands the patient's psychological and social
context.
The more you read about this, the more
you realize how difficult it is for any one of us
walking into a clinic today and meeting another human being who
is facing a tremendous problem.
Really, really put ourselves in the shoes of that patient.
We should try it.
But it is extremely difficult.
If you do those two, you reach a certain understanding,
and then eventually you empower the patient
with that relationship.
The environment has a lot to do with the communication.
I like this picture, which is actually a picture of ours here
and it is on our own website, because I
see the right [INAUDIBLE] of this person really tight.
She does not have a neurological disease
she is just trying to use it to raise her head.
As an elderly person, it is very hard
to extend the neck muscles to look at the physician who
are standing up and talking.
To the extent that you can, try to make it look
like you are not in a hurry.
Try to sit down.
Try to put yourself at the same level of a patient.
Try to remember that, in all this communications,
there is a lot that can happen.
Studies have shown that we communicate
in a very different way.
We all, men and women, communicate in a different way
to women than to men.
I will let you read all those things for yourself.
We communicate differently to elderly patients.
Significantly different.
When we perceive somebody to be a lot less knowledgeable,
we treat those patients in a different way.
I am sure that if you look in your mind,
you will remember events in which you
gave no credit to somebody and you started describing
something in childish ways.
Wanting to realize that this person is an engineer that
worked all his life in Boeing and is now in 78 years of age.
But he invented the triple seven or something of that nature,
and you feel like an idiot and you should.
A particular aspect of the communication,
of course, that hurts us every single day,
is when we have to communicate with people that
speak a different language.
Many think that having interpretive services
is the key to that.
Well, remember, interpreters can only
tell you words that they know how to translate into English.
Remember that those words originate from somebody whose
social trust is different.
Whose experiences in life have been different,
whose culture, whose ethnic background,
whose beliefs on others are completely different.
There is a lot more than the words
that the interpreters can do that
have to do with the culture of the person
or where the person comes from.
I have tried to describe primarily for you today
aspects that I believe are important in the
patient-physician relationship.
I believe that, when that is enhanced
through the practical understanding of what
trust and communications are, that you
improve physician well-being.
I am absolutely convinced that for many of us,
it is a great deterrent to burn out.
I have told you almost nothing about the surgeon and the team
because a lot of this is related to this.
If this worked well, if you know yourself
and you can talk to your soul, and the only way that you
can talk your soul is when you walk the walk that we are
talking about, then this one almost automatically
works just as well.
All of that is to try to show you that trust is important.
That trust takes a tremendous amount of time to construct.
As this picture tries to show you, it is complicated,
it is fragile and it can be destroyed in one minute.
It takes forever to get it really
cemented as a bond between two human beings
and it can be completely destroyed in just one second.
Be aware of both circumstances.
You cannot accelerate the process by which somebody will
trust you.
You can certainly accelerate the process
by which somebody will not destroy it.
With that in mind, I submit to you,
take every opportunity that you have in your professional life,
in your personal life, to show other people that you really
care.
That way, as you [? transcend ?] the life of yours,
and through the winding parts of life,
keep remembering that as people [? he ?] said in other words,
no one will care how much you know until you show them how
much you care.
Thank you very much.
[APPLAUSE]
DOUGLAS WOOD: Stay up here.
[APPLAUSE]
Well, I think you can all see why there was value
in coming here this morning, including
canceling neurosurgery, Grand Rounds, and being here.
Thank you, Rich.
We have time for a couple of questions.
What questions do you have for Carlos?
Rich.
We will use the microphone.
RICH: Carlos, that was a wonderful talk as usual.
Have you ever gotten a patient that you say I will not operate
on because I cannot establish trust with?
In other words, someone who comes to you,
says I want a 100% confidence that you
will take the esophageal tumor out
or I will go somewhere else.
CARLOS PELLEGRINI: Yes, Rich.
The answer is yes.
Very rarely, because I have tried
to get around and show around, but I have had both situations.
Unfortunately, I remember one in particular,
walked away, feeling that I had disillusioned him.
He was a 60 some year old patient whose values, he said,
had nothing to do with mine and I was unwilling to help him.
So the patient walked away from me.
I have rarely, but I have occasionally found,
that I could not deal with a patient because I cannot trust
them.
I just tell them, look, I have been trying desperately
to help you.
That is why I chose to go into medicine.
I am unable to do that.
I am not putting a judgement on this--
I am just not the right person will help you.
So I can connect you with somebody else but I cannot
help.
And I think we have to be truthful with that.
DOUGLAS WOOD: You talked early on about trust
and about being educated about how
to gain trust, that there is obviously
courses and processes.
I was thinking about it and how much value we could
have in that, but also thinking about, in a sense,
a way that there are conflicts and incentives.
Trust can also be used adversely.
It can be manipulative.
Salesmen gain trust and use it to manipulate emotions
and to make us want something that maybe we do not need.
How do we navigate that and get educated
about how to gain trust better and use it sincerely?
CARLOS PELLEGRINI: I understand exactly what you are saying,
but I think that that relates back to the concept
that we were talking about.
I look at the physician in a way,
and it may sound paternalistic, but I look
at the physician as a guardian.
As a guardian of that trust that you want
to generate from the patient.
In order not to manipulate it, I think that the best we can do
is to remember what are the incentives that
drive us to do X or to not do X. And to then back off and say,
I have a commitment to altruism.
That was one of the three conditions of trust
that Barbara described, the sociologist that I showed you
earlier.
How do I best protect the interest
of this vulnerable person today?
What is my role in doing that?
I think if you know as much as you can,
what drives you to do that--
I want to sell this car to you, but I
have a moral obligation that that salesman does not have.
The person who is trying to sell you a car, for example,
does not have a social contract that obligates that person.
The trust that society has put on us physicians
is totally different.
Patients are not going to be checking you out,
usually, as much as they would check the salesman.
Knowing what drives us, knowing that the patient is vulnerable,
knowing our obligation to altruism.
I say, all I can do is try to navigate the best I can
with balance between what incentives I have,
what obligations to society I would have,
and what obligations I have to the patient.
There isn't a perfect solution.
DOUGLAS WOOD: Right.
Well Carlos, you kept a straight face
while this came down during the questions and that was a--
CARLOS PELLEGRINI: I kind of imagined.
DOUGLAS WOOD: That was impressive.
I am glad that you did that.
[? Barclay, ?] [? Acelle, ?] and Katie,
can you come back up here?
You guys disappeared.
You were up here.
In honor of Dr. Pellegrini's 23 years
as chair of the Department of Surgery,
we commissioned a painting, a portrait of Dr. Pellegrini
to be hung up in the hallway of the Department of Surgery.
We thought this was a great place to unveil it.
You have just given us the perfect Grand Rounds
on trust and on all the reasons that you
have had the leadership positions that you have had
and the reasons that we respect you and admire you.
So, three of our chief residents who
managed to navigate that down here,
because I could not find a place to hide it
upfront, and managed to navigate it successfully, good job.
I thought you guys would be the great people to unveil it.
CARLOS PELLEGRINI: I cannot see it from here.
[APPLAUSE]
Great job.
Great job.
[APPLAUSE]
Great job.
[APPLAUSE]
Thank you.
Thank you.
DOUGLAS WOOD: Thank you.
CARLOS PELLEGRINI: Thank you.
DOUGLAS WOOD: Thank you, Carlos.
Thank you all for coming to Grand Rounds.
Perfect.
Really appreciate it.
CARLOS PELLEGRINI: Very nice.
I love it.
[MUSIC PLAYING]
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