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Michael Carrese: We've probably all been in an awkward situation or two by now, related to COVID-19 for instance, what to say to friends who want to come by for a visit or how to tell someone you'd prefer if they were masked or didn't stand so close? Well, today we're going to get some concrete advice about how to handle moments like these. Our guides are two physicians at the university of Vermont Medical Center whose jobs involve having difficult conversations with patients and family members and thinking through complex decisions. They're Dr. Robert Gramling, he's the Holly and Bob Miller Chair in Palliative Medicine at the Lerner College of Medicine at the University of Vermont and Chief of the Palliative Medicine Division. His clinical work research and teaching focuses on understanding and promoting high quality communication between patients, families, and their clinicians in the context of advanced and life threatening illness. Dr. Gramling thanks for being with us.

Dr. Gramling: Thank you, Michael pleasure to be here.

Host: And we also have Dr. Tim Lahey with us, he's Director of Clinical Ethics at the UVM Medical Center and a Professor of Medicine at the Lerner College of Medicine and a particular relevance to our discussion today. He's also an expert in infectious disease. Welcome to you, Dr. Lahey.

Dr. Lahey: Thanks for having me.

Host: So, I thought we'd start by having a, share some of the basic principles here of having an awkward or difficult conversation. And then we can get into some COVID specific examples, but what are a few key elements that can make these successful encounters? And Dr. Gramling, let's start with you.

Dr. Gramling: I love the topic of the show because we're encountering these new types of conversations every day and the rules, or at least the social rules that we've learned about how to engage one another in conversation, they're just different. And so I'm thinking of a couple of different types of conversations. When I imagine the awkwardness, Michael, and there may be others, and certainly are others, but you know, certainly one is, you know, the virtual hug, the virtual handshake, the goodness, I really wish I could come over and give you a hug or engage with you in the way that I typically have. And I find that, that or the, you know, wow, I'm wearing a mask and I'm keeping my distance. And that might've felt standoffish six months ago, but now it feels like being a good steward to things. And I think sometimes that just kind of naming it in kind of a good natured way and kind of finding the awkwardness is just part of it. Just saying this is strange. I really look forward to the time when I can give you a hug again. Can I just give you a virtual hug today?

Host: So, are there particular situations or I guess language you could give people to kind of broach one of those situations?

Dr. Gramling: Just following the example I gave, I think that you know, sometimes we'll just intuitively come up with, gosh, I wish I could give you a hug. And sometimes in some settings that might feel like I'm asking permission and potentially add to the awkwardness, depending on how well, you know, the person. So just pivoting from the, I wish to, I look forward to the time when I can, just kind of makes it clear out of the box that I'm not asking for you to kind of lift this norm from our relationship. And we're just going to acknowledge it's here. That's one, I think simple thing that can keep you out of an unintended worsening of awkwardness or just right out the box, I guess, you know, I love your mask. What a nice design, you know, it feels good to be helping to get through this together, you know, and then I look forward to when, or just something that kind of acknowledges the newness of what we're doing.

Host: Dr. Lahey, what would you add to that?

Dr. Lahey: I agree with what Dr. Gramling said you know, I'm thinking that whatever the difficult communication, whether it's about the etiquette of COVID-19 or something else difficult that comes up a dispute between two neighbors, I think some nice rules for the road are to be approachable and to use humor, to be transparent about the awkwardness of the situation and to avoid blame. So I figure if perhaps I'm in a conversation with somebody who has forgotten to put their mask on, or is a little too close, the last thing I want to do is alienate them by coming across as kind of judgy. And instead to, you know, maybe roll my eyes a little bit and say, man, it's hard for me to remember all the time to wear my mask, but I should probably remind you smile. Or you know, gosh, isn't it a pain to have to do all this stuff, but you know, it's a good idea just so that neither of us have any regrets, maybe make a joke out of it. I think sometimes in COVID-19 when people can feel anxious or even fearful for their own safety, it's easy to lapse into finger pointing kind of communications. You should know better to, you know, and you have to do this don't you care, you know, that kind of communication. And that's the kind of stuff that I think is incredibly important to avoid.

Host: Well, right? Yeah. There's heightened emotion for the safety reasons that you mentioned. And then of course we have this unfortunate sort of political overlay about mask wearing particularly. So how do you keep emotions in check and keep them from being an obstacle in a situation like that.

Dr. Lahey: You know, I think when we are facing somebody whose behavior is a little bit different from what we want, it's easy for us to leap to conclusions about that behavior having bad motivations. When in fact it's probably, you know just a normal human behavior to forget, or to be confused or to just have been misinformed from, you know, for some other reason. And that person is just like us just trying to get through the day and doing the best they can. And I think if we have that framing in our head that forgiving, compassionate framing toward that stranger we're talking with, I think it's easier to remember to communicate in a way that's sort of more approachable and less likely to lead to conflict. And I think it's good to approach things that way because it's likely to lead to a friendlier interaction. And I think a way that we can keep ourselves motivated to have that framing is that it really doesn't work to have conflict. If two people start to square off about whether to wear a mask we've seen the results are not good, and nobody wants to have that kind of interaction.

Host: What about you Dr. Gramling and advice about emotion?

Dr. Gramling: I really love how Tim's kind of acknowledging the humor in it all. I mean, I think that some of this is just odd and even funny and being able to find that space in yourself to say I'm really trying to do something I've never done before and cut yourself some Slack. So you don't bring to it either guilt that you're not doing a good job communicating or something like that, just be kind to yourself and then try to offer that to whoever you're talking with, whether you say it out loud, sometimes it's really just internally just offer up a little bit of kindness to say that person's probably trying to deal with us something totally new as well. And I think just giving that benefit of the doubt is going to get you off on a far better footing. It won't solve everything. There's going to be some conflicts. Totally understand that, but there's going to be lots of avoidable ones. And I just find that, that little bit of funny, a little bit of internal compassion for the person you're talking with goes a long way

Dr. Lahey: You know Bob you raise a great point that that maybe leads to a nice metaphor. Once upon a time, I would waste my time getting frustrated by other drivers on the road. I would be driving in Boston and kind of feel like I was going to instruct them in the proper way to drive. And I think I've learned to tell myself a little story about that person that cut me off in traffic or otherwise I might've thought was driving rudely. And I imagined that they're racing to the hospital where they've just learned a loved one is sick, and that makes me feel much more understanding of their behavior. And I think we can use the same sort of trick with COVID-19 etiquette. It may just be that they need a reminder as we all do from time to time, but if they aren't responding easily to that, I think it's useful to tell yourself a story that, hey, maybe they got some bad information on the internet, or maybe they're distracted by some difficult news that they're dealing with. And I think that can you know, we're not trying to absolve people of personal responsibility, but it helps you free yourself from the idea of the misconception that you have to be responsible for their behavior.

Host: Another scenario that I've heard folks bring up is say, they're invited to some kind of function. This was going on the summer about graduations, and it'll be coming up with holidays and so forth. And the awkwardness of wanting to find out how the hosts are going to be handling all of this without seeming like you're, you know, an inspector or judging them or, you know, that sort of thing. So Dr. Gramling what do you think about that?

Dr. Gramling: Well, if there's anything I've learned in my career it's that I'm a really bad mind reader. And I just ask, say, you know, Hey, I'd really like to come and I'd be more comfortable coming if people are also observing some social distancing. Do you have any sense of that or is it okay for me to ask the host?

Host: What do you think Dr. Lahey?

Dr. Lahey: I think that's great advice. I've done that myself. I've also found myself after asking that question in settings where I was a little uncomfortable with how things actually went. You know, we ended up seated more closely to other people than the six feet rule. And I think one trick that I'm using more recently is when I have that upfront conversation, as, as Bob suggested saying, Hey, you know, can you tell me a little bit more about physical distancing? So I know I'm blamed by the rules and doing the right thing. I think you can also anticipate that possible moment and say, you know, I hope it's okay if it just turns out there are lots of people that are there, and it's hard that, you know, you won't take it personally if I have to leave a little bit early or something like that, just so that it's a little easier for you in the moment to react the way that's most appropriate without feeling uncomfortable about it. So you can kind of set the stage.

Host: Yeah. So much of this does seems like getting the right frame of mind and having the right attitude and thinking about, as you're saying, sort of thinking it through and being prepared and having some language to use some strategies to get out of a situation, and then you could probably avoid direct conflict it seems?

Dr. Lahey: I think a really key way of thinking about this for me, that's informed partly by public health work in the HIV field is that I think sometimes when we're worried about COVID-19, we want 100% of people to behave exactly. As we've learned from public health authorities, they should, and then it can be anxiety provoking to see people not behave like that. And in public health work, you realize that what's most important. Is that just about everybody do it right. Just about all the time and you don't need to sweat the little exceptions as long as that's the general rule. And so I always feel proud when I walk down Church Street in Burlington and see that most people are wearing masks. And I remember to take solace in that and not get distracted by the totally predictable reality that not everybody's on the same page. That's okay.

Host: Dr. Gramling?

Dr. Gramling: When you were both talking about the setting of a party or a group brings up for me, something we're learning a little more about is that, you know, the conversations we're having now, or a little bit farther away, they've got, you know, a covering that covers your lips, mouth, and cheeks. There's sometimes other sounds that are able to intercede into that place and we're not touching people. And all of those cues, sight sound touch are part of how we converse and how we engage. So there are plenty of people, including myself. I have a, a visual disability makes it harder for me to see things that are a little farther away, is it may be harder for us to understand what's being said. And so I had a conversation, I think just as an example is, you know what, if we're a little farther away and someone's hearing is not so great or the vision's not so great or whatever happens to be it's good just to speak up and say, gosh, I'm really enjoying talking with them.

Also having a hard time, understanding what you're saying. I had a conversation with someone the other day comfortably sitting on the grass, you know, six feet or a little more away comfortably wearing our ear butts and talking on our seeing, and hearing devices that we all carry in our pockets. And it was a lovely conversation. It was strange to be talking with someone on the telephone who was right there, but we could talk in a regular voice. We could hear each other's emotion, we felt connected and it worked. So I think it's just, my point of bringing it up, is just to acknowledge to the many people out there who may be having a harder time hearing or seeing is, be creative. There's a lot of opportunities to think about what a conversation can be right now.

Host: Last question before we have to go is about family members. And this is something I've been hearing about as well as a common problem. So say you have an aging parent and they just are not wanting to comply with this all the time mean it's been particularly difficult on older folks who felt kind of trapped where they're living. So, how do you deal with, you know, an older person who say is making unnecessary trips to the store or, you know, doing that sort of thing, and you understand, you know, you don't want them to feel like they're in prison, but you also want them to understand what the risks are. How would you approach that?

Dr. Lahey: Yeah, I think it's a great question. You know, of course most older people feel more vulnerable in the age of COVID-19 and so we're probably, you know, more likely to toe the line with precautions, but this isn't always true. And so, what to do. So, partly I think you want to have that friendly, nonjudgmental conversation, and I think it's totally appropriate to sort of in that way, clarify your position. You know, so if you sort of say, you know, I'm sure you're a member that we're supposed to wear masks that is a healthy reminder for them. If that person is, it turns out sort of resistant to the message and maybe is not believing that this virus is a big deal or otherwise misinformed like that. I do think it's perfectly appropriate to shape your own behavior in response to that. And I don't think you need to sort of do that in an angry way or feel like you can't. So I say, for instance, I hope you understand, you know, I respect your point of view, but I hope you understand that since I'm really worried about this virus, and I want to make sure I'm doing my job as a good neighbor, I'm going to have to leave, or something like that. So that they may realize that they may experience a consequence of an ill informed decision, but they experienced at the hands of somebody that they can only see as being pleasant and respectful.

Dr. Gramling: What Tim said was beautiful. I mean, I think that that your behavior is what you have control over, and you can do it in a kind way that acknowledges that we're all in this together. And I think that was a great example.

Host: Well, I'm afraid to say we're going to have to leave it there, but this has been really interesting and a pleasure to be with both of you. And thanks for taking the time to provide all this advice today. You've been listening to Dr. Robert Gramling, the Holly and Bob Miller Chair in Palliative Medicine at the Lerner College of Medicine at UVM and Chief of the Palliative Medicine Division and Dr. Tim Lahey, Director of Clinical Ethics at the UVM Medical Center, Professor of Medicine at the Lerner College of Medicine and an infectious disease expert. For more information, please visit UVMhealth.org/Podcast.