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Crucial Skills Newsletter Volume 4 Issue 10 - "Being Shut Down" - Crucial Conversations

About Crucial Skills Newsletter Volume 4 Issue 10 - "Being Shut Down"

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March 15, 2006
Volume 4 Issue 10Previous Issues
  • Crucial Tip
  • Q&A: Being Shut Down
  • Letters to the Editor
  • Where Can I Learn More?
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    Respecting Privacy

    When you need to hold a crucial conversation or confrontation with an individual you interact with in a group or team setting, maintain respect and dialogue using the following tips:

  • Don’t violate privacy by masking a public performance review with inappropriate humor. “Well, look who just arrived. Forget how to find the meeting room?”

  • Don’t deal with individual problems in meetings by chastising the entire group. The guilty may miss the fact that they’re the targets of your comments, and the innocent may resent the fact that they’re being thrown in with the guilty.

  • Do hold the conversation or confrontation in private. No matter where you may encounter a problem, retire to your office or another secluded setting where you can talk one-to-one.

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    “Men willingly believe what they wish.”
    - Julius Caesar

    Being Shut Down

    About the Author

    Joseph Grenny is coauthor of the New York Times bestseller, Crucial Conversations: Tools for Talking When Stakes Are High.more

    Dear Authors,

    I work with patients with chronic kidney disease as a nephrology nurse care manager. I had a patient who was quickly worsening and whose vascular access—or fistula--had healed for nine weeks and looked developed enough to use for treatment. Because of the patient’s condition, we needed to start hemodialysis treatment ASAP.

    The problem was that the surgeon specifically told us to avoid use of the fistula for twelve weeks. That meant we would have to take the (in my view) unnecessarily risky step of placing a temporary catheter in the patient for access. So I went to the surgeon’s office to see if he would take a quick look at the fistula just to weigh in on whether it might be usable.

    The surgeon's response was "Absolutely not. Twelve weeks is my rule; I will not even look at his fistula today. You dialysis people keep ruining my accesses because you stick them too soon. They need a minimum of three months before they can be used." That ended the conversation and, in my view, put the patient in more pain and risk.

    What could I have said or done in response to this first statement (with a doc whom I didn't know) to shift the focus of the discussion back to the patient's best interests after being shut down like that?

    Conversational Failure


    The patient started dialysis one week later at another center—where the nephrologist and nursing staff felt the fistula appeared sufficiently mature,


    Dear Conversational Failure,

    I’m glad there are so many like you in our healthcare system. Thank you for seeing yourself as a “patient advocate” and playing the role so soulfully.

    Here are a couple of thoughts I hope are useful to you as you try to deliver great care to your patients and as you encounter crucial conversations with doctors about clinical issues.

    First, be sure to have the right conversation. The issue you’re describing is much broader than one doctor who has an idiosyncratic way of treating patients. Your problem is that you work in a system that allows for idiosyncratic clinical practices in some cases rather than demanding evidence-based protocols. You should be having conversations with the appropriate clinical leads about the pattern of decision making you see in relationship to fistula readiness. Do your best to point out inconsistencies in practice and to gather data about best practices to try to influence protocols—not just one doctor.

    Second, let’s talk about this doctor. You would know better than I that there is much in medicine that is still uncertain and subject to judgment calls. I’m not smart enough about fistula preparation to say whether this is an open or shut issue or not, so let me make a more general point. Your biggest challenge in holding crucial conversations in somewhat ambiguous areas is to ensure that you don’t let your motives move from “patient advocacy” to “being right” or “winning the point.” As you approach this doctor, do so with an open mind—where you're prepared both to share your data and to learn about issues you might not have considered. If you approach him with a goal of mutual learning, you will not come across as smug (which might be particularly tempting when you know the patient went to another center that agreed with your recommendation). Instead you will come across as curious, interested, and hones! t.

    Third, you can’t have this conversation with him if he doesn’t want you to. You’ll need his permission. Realizing that you should seek his permission to have the conversation will put you in the right frame of mind to make it safe. As you and I both know, the doctor is the final decision-maker in clinical questions. If you respect that fact, and don’t measure his character by whether or not he agrees with you, you’ll come across as far more respectful. As a result, he will feel safer with you. For example, you may create safety by proposing the conversation the following way:

    “The other day you and I disagreed over whether a patient’s fistula might be ready for access in less than three months. I’ve thought about that a lot since and wonder if you’d be willing to talk with me at your convenience so I can understand that better. I want to work with you well and I also want to do what’s right for patients. I’ve had some experiences that make me question the three month rule and would benefit from airing those with you as well as having you challenge my thoughts. Would you be willing to spend a few minutes with me on this?”

    Finally, before having this conversation, do your homework. Gather evidence whether it confirms or disconfirms your beliefs. As you engage in the conversation, lay out this evidence and allow the conversation to take you to whatever conclusion best serves your patients and his.

    Thanks again for your commitment to serve. If my kidneys ever fail I’ll come looking for you!


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    Re: “Abusive Friend” (Feb 22, 2006)

    Dear Editor,

    I had to respond to this because her friendship is not a two-way relationship. Sometimes you just have to let go. Friends like that suck the life out of you and if they are not willing to get out of their junk, then you can’t help them and you only make yourself codependent to their chaotic lifestyle (unless of course you feed on their chaos), and it isn’t always fixable with a crucial conversation. They like living in their chaos and they like pulling you into it. Let it go!  I had a friend who did the same thing, year after year—after year—and I used crucial conversations skills with her and her attacks got worse. She wanted someone to wallow in her misery. I am healthier and happier for letting it go too. I had become a coconspirator in her muck and didn’t even realize it.

    Thank you,


    Re: Tax Season Survey (Mar 1, 2006)

    Dear Editor,

    I think you left out an important option as a response on the survey. When I encounter any unethical or illegal options being discussed, I point out that the option sounds unethical or illegal and offer other options or ways to get better information. I don't consider this expressing "disapproval" but instead offering new information to generate a better outcome. However, if I think my company is at risk, I then will explain that it is important to report these things to management and follow through as appropriate.

    Best Regards,
    T. Miller
    Scottsdale, AZ


    Dear Editor,

    I remember clearly a time when someone proposed in a conversation inflating the amount of charitable deductions one could claim without the IRS finding out. (Obviously he was not thinking that if audited the burden was on him to justify the deductions.) My comment was simply how much is your integrity worth? $100 worth of contributions, $200? $500? The conversation ended quickly and I think I got my point across that some things shouldn't be bought at any price.

    Thank you for your interesting and valuable newsletter,
    A. Thornton



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