Reframing the “can of worms”

“…I didn’t want to open that can of worms”

The “can of worms” comes up often when people are learning new communication skills. What might this mean? Let’s break it down.

When I hear the “…can of worms” I hear

“I’m worried that choosing this path will bring up lots of emotions, and I’m worried I won’t be able to manage this”

And

“I’m worried that choosing this path will lead me away from the information I need to make decisions, and take up more time”

So let’s look at both these ideas. 

What’s your goal in a clinical conversation?  

I’m guessing you want to give your patients the whole package, to be a great diagnostician, create excellent management plans AND support their emotional needs, helping them feel fully seen, supported and respected.

Sometimes we act as if one action (great medicine) is a trade off for the other (great support), when in fact these both align. 

Recognising and supporting our patients through their emotions makes the medicine better.

As patients we know this, but as clinicians we may not always do this, due to the fears described above.

What information do you need?

I used to be anxious about the “can of worms” until I learnt skills that helped me respond effectively  to emotions and get valuable information, information that made decision-making easier.

Now when I sense an emotional cue, its a lightbulb moment

Now I’m paying more attention and asking myself

❓What is meaning behind this?

❓What are their Ideas, Concerns and Expectations?

❓What are their fears?

❓What outcome are they hoping for?

❓How does this fit with their options?

What can we learn?

Once we understand more about the things that mean the most to them, we can put this together with what we know of the medical options (tests, treatments), and the choices become clearer, easier.

“From what you’ve told me it is really important to you that ….

And you’d really like to avoid  ….

Can we talk about options that could achieve …?”

(note communication micro-skills here: micro-summary and asking permission)

Emotional expression is actually full of data that we can use to help make decisions. These are clues to what is most important and can guide our questions.

All the tests in the world will not tell us how about that person’s unique experience of their illness, or how each choice fits with their goals for their life.

This is the crucial missing information .

These are things we must address so the conversation and plan can move forwards.

But, what to do when emotions appear?

First, recognise that these are doors to understand what really matters for your patient - understanding what’s behind them will take you closer, not further away from your goal. And its quicker too.

Second, find some way to acknowledge and respond to these emotions. This saves you time, and gets to the point of what matters for your patient.

NURSE is a handy mnemonic for some effective communication skill options in responding to emotions.

NURSE Acronym

Using one or more of these skills, as you feel fits the situation, can have a huge impact on your relationship, build trust and help to move on to other parts of the conversation.

What not to do?

Of course there are no hard and fast rules, but where I have seen (and experienced) things going wrong it is usually when we try to push past an emotion.

We keep talking, we respond to emotions with more facts, hoping that this will provide reassurance and decrease the expression of emotion.

It is often well-meaning, we have our goal in mind. And we might be deep in emotions ourselves, searching for any way to reduce their distress.

But it can leave patients feeling misunderstood or even dismissed. And create a bigger mountain to climb when trying to build trust for the really hard decisions.

It will also slow the conversation down, as when we are deep in an emotion it is harder to process information.

Supporting patients with their experience of their emotions, will help them be ready to move on with the conversation.

Some other tips

If the person shares a particularly meaningful event with you, whether joyful or extremely sad (such as births or bereavements) pause to acknowledge them.

Even the briefest of mentions from them will contain a world of emotion and importance. Use one or more of the NURSE skills.

It might even be appropriate to sincerely show appreciation for their trust in you in sharing this.

“Thank you for sharing that with me, it can’t be easy to talk about”

If you are sharing some really difficult information, expect that this will raise emotions and prepare for this. Before you enter into the discussion be aware of your own emotions. Consider the “3 Ps”

Pause, Prepare (in order to be fully) Present

This helps you manage your emotions so you can be ready to respond to your patients emotions skilfully during the conversation.

Final thoughts

If you’ve read this far and plan to respond to emotions more intentionallly in your clinical conversations, take it slow.

Trying out new skills will feel awkward at first and trying too many at once can be daunting.

Perhaps start with noticing the emotions in yourself and your conversation partner.

Then try just one of the responding to emotion tools a few times and see how this works for you.

With practice, and experiencing the feedback of better outcomes, this will become more comfortable with time.

Emotions will no longer feel like a “can of worms”, instead they will be a door, opening to reveal what matters most for your patient.