Conversation is More Than Nodding Your Head – Chasing Life

A few years ago, Dr. Rana Awdish went out for dinner with a friend to celebrate a major milestone. She had just completed a three year fellowship in pulmonary and critical care at Henry Ford Hospital in Detroit. Her future stretched before her full of potential.

I was also seven months pregnant. I was newly married and looking forward really to the culmination of all of that training and getting to be an attending physician.

But as I looked down at her menu that night, she was struck by a terrible pain.

I honestly didn’t think the word pain described it adequately. I went outside the restaurant. I sort of paced back and forth and thought, no, this is this is really bad.

Rana instinctually knew she needed to get to the hospital, so her husband rushed her back to the very hospital where she had just completed her medical training.

I was already entering the early stages of shock. You know, time was really of the essence.

It turned out Rana had a tumor in her liver that had burst, sending blood into her abdomen and her organs into failure. Ultimately, Rana lost her baby. She would spend all of the spring and most of the summer in the hospital receiving care from the doctors she had once trained alongside. And as she slowly recovered, she began to notice something upsetting.

So, in the operating room the first night over hearing the anesthesiologist say, “we’re losing her, she’s circling the drain,” you know that as a patient felt like an indictment of my ability to recover.

Doctors made assumptions about what she needed without consulting her or getting to know her. And while many engage with her about the clinical side of her case, few of them attended to her emotional needs.

From my perspective as a patient, I had nearly died and it felt like something we should talk about, that I couldn’t even change positions without almost dying. And what did that mean for my future.

In the hospital, these kinds of breakdowns in conversation can mean the difference between life and death or comfort and anguish. But in just about any setting, miscommunications can leave us feeling alienated, disconnected, misunderstood. For something we get daily practice doing. It’s surprising how challenging human conversation can actually be. So often we’re focused on what we can say, what information we can get across, instead of what we can learn by listening to the person we’re talking to. So today, we’re diving into the science of effective communication, and together we’ll explore how simple techniques can help all of us connect with each other on a deeper level, no matter who we’re talking to or what the topic is. I’m Dr. Sanjay Gupta, CNN’s Chief Medical Correspondent, and it’s time to start chasing life.

Okay, so I’ll tell you the number one question I get anywhere in the world, this is not just an American problem, is some version of, “how do I change the way someone else is talking?”

Celeste Headlee is the author of the book “We Need to Talk How to Have Conversations That Matter”. She also gave the TEDx talk, “Ten Ways to Have a Better Conversation,” which has been watched now millions of times by people all over the world, myself included.

When I give a speech on conversation, I will always get some version of, “how do I get people to stop interrupting me? How do I get people to stop going on and on and on.”

But before Celeste became an expert in conversation, she had a self-realization.

I’d always thought I was good at conversation, and it turned out, nope, I’m good at engaging with people and connecting with people. But in terms of actually stopping talking and asking people really good questions to get at the meat of what they know and they think and they feel… I wasn’t great at that.

Celeste’s personal and professional journey to become a better conversationalist began in 2009. After years of working as a public radio reporter, she was hired as the co-host of The Takeaway, a daily interview program on WNYC.

A reporter doesn’t have to structure a conversation the way a host does. A reporter, I can ask questions in any order I want to. I’m going to edit them later. So it doesn’t really matter. But for a host you, you’re arching a conversation with a beginning and a middle and an end and how you ask a question really matters. So I started doing research into how to have that kind of conversation. I discovered that the advice we’ve been getting for a really long time was bad. The way they came up with it was they watched people have good conversations and they were like, Oh, when people are having a good conversation, they nod their heads and they, you know, gesture and they repeat back. So if you do those things, you’ll have a good conversation, but you can’t reverse engineer it.

So what do you… what do you… What is it that you tell people to do?

The first thing I would say is a focus on asking questions. We don’t ask enough questions. Questions are so powerful at making other people feel heard. Not even necessarily your first question, but there’s a special power to follow up questions that makes people feel that they are liked, that they are heard, and that you’re listening. Probably because follow up questions require you to listen to what they’re saying. Right. You wouldn’t have a follow up question if you didn’t hear when they said. But we focused so much on what we’re going to say when we go into conversations with people and we don’t focus very much on what it is we want to hear.

I mean, people have this desire to fill the silence, like even a brief millisecond of silence. And sometimes you just stop talking, like you said, and the person you’re interviewing actually has a lot more to say and maybe some of the best things that they were just sort of waiting, you know, to be empowered to say it.

That’s really true. If you are speaking to someone, you don’t have to jump right in. You know, it’s interesting, they did a a global study into how much space people leave between somebody ending their sentence and the other person responding. Right. And the global average was less than half a second. I mean, think about that for a moment. Right. I mean, there was no way you heard all the way to the end of what somebody said, processed it and came up with response in less than half a second.

That is that is interesting. And I think you said in your talk or you quoted somebody saying people are generally listening to reply versus listening to understand.

Stephen Covey, right.

That’s a good one.

It turns out listening is much more difficult for us, even though it’s more beneficial for us. We know that people who the less you speak in a conversation, for example, the more likely you are to enjoy it. Your enjoyment of the conversation goes up as you talk less. And yet that listening component of it is very, very difficult. And that’s partly because, you know, we know from research out of Harvard that talking about yourself, like your interest, the things you know, the things you like, activates the same pleasure center in the brain as sex and heroin. Right. It’s inherently pleasurable to talk about yourself, but the listening component is a much more deeper and fulfilling pleasure.

You walk away with a more joyous sort of experience. You’re saying, right? If you… If you listened more.

Yeah, because you’ll get a serotonin surge.

You get the serotonin sort of.

And the oxytocin, the “mommies hug hormone”.

The “cuddle hormone”. The “I want to develop a real relationship with this person”. Were you surprised when you started doing this research? I mean, was there something that you first came across that made you think, oh, my god, I’ve been doing this all wrong?

I mean, yeah. I mean, I think the biggest surprise for me was the one… And it’s one of the rules of don’t equate your experience with others. That was one of the biggest surprises for me. And that particular rule is our tendency when someone tells us about something that’s painful or a struggle, that we will tell them a similar story in response. I’m not talking about someone saying I went to see The Avengers movie, and you say, Yeah, me too. I’m talking about when somebody says, like, my dog died and you say, Oh my God, I’m so sorry. My dog died a couple of years ago. It took me forever to get over it. I started reading the work of a sociologist named Charles Derber, and this is a phenomenon he identified as conversational narcissism, which is a terrible word for just our tendency as human beings to turn conversations back to the subject we know best, which is ourselves. And it’s especially pronounced in these situations which are tough because we don’t know what to say. We think it’s empathy. We think that what we’re doing is expressing empathy. But that’s not the case. I think partly, you know, for a really long time, we’ve started a conversation by watching individuals either conversing or talking. And it has only been in the past, say, 10 to 15 years that we started to study conversation when two people are actually talking to each other, understanding that it is this group activity. Right? That you don’t have a conversation unless two people are exchanging information with each other.

You’re exchanging information. You are getting into a groove. Would you say with the other person? I mean, there is a cadence and flow, right? But I think then like, when do I talk? When do you talk? Like I’ll start to understand your flow and you’ll understand mine if it’s a good conversation.

There is often inherited awkwardness in conversations as we try to sync up our conversational style with another person’s. And we tend to overestimate the impact of that awkwardness. We’re so self focused on the way we’re screwing up that we didn’t notice at all that somebody else did something that they think was awful, right? So, yeah, there’s there’s an inherent sort of, as you say, ebb and flow, but there is an inherent sort of adjusting.

And speaking of awkwardness, I’ve got to say, two and a half years of screentime has done a number on all of us.

So we know that Zoom fatigue is a real thing. And part of that is because, you know, conversations are really high cost cognitively. They require energy. They require focus. The thing is, is that the benefits that you get are higher even than the cost, which is why you’ll come away from your conversation either on the phone or in person feeling better. But on video conferencing, the high cost is even higher.

When you say cost, what do you mean? Why is it costlier?

There’s a bunch of different reasons. I mean, first of all, oftentimes there’s a lag between you hearing my voice and the movement of my lips. There’s this tiny microsecond difference, but your brain is trying to fix that all the time. That’s number one. The other thing is that there’s this illusion of eye contact, right? In order for me to to you to make it look to you like I’m looking at you, I have to look away from you on the screen. And again, this is something that your brain is trying to fix that all the time. Also, we’re not really getting that biofeedback that helps us understand what somebody saying. You know, we use… we get the tone of voice, but we use that body movement, which is restricted because you and I are both sitting in chairs staring at a computer screen. Another reason is that we often don’t have only that that Zoom or Microsoft Teams tab open. Right. We have other tabs open all of our screens and our brains are focusing on those other tabs all the time.

Right. Will you, Celeste, have a conversation with anyone? I mean, someone you deeply disagree with. You know, I’ve tried to reach out to talk to people who I knew did not share my thinking on some scientific issue. I thought, okay, I’m going to show up with data and logic and evidence and facts. Here we go! This should be a layup, you know, maybe a slam dunk, but it’s not.

Yeah. And the only thing that would change people’s mind, this is an empathic bond anyway. So if you haven’t made an authentic connection with them. Mm hmm. None of your data or statistics are going to matter at all. They have to feel heard, which means you have to come from this place of either deep curiosity or deep understanding.

The logic, the data, the evidence. It’s not going to hit the mark unless you’ve made that connection.

And, you know, I’ve done a lot of workshops for different medical organizations, and there are two things come to mind for me. Number one is that we know that doctors in particular begin to lose empathy in their first year of medical school. Like it’s not after years. Yeah. It’s not after years of treating patients, first year of medical school, which means that’s being taught to them, something in the teaching itself is training them to harden themselves, to become resilient by losing empathy. That’s the first data point. The second one is that listening skills among doctors is abysmal. Doctors and lawyers are among the worst at assuming they know what someone’s going to say and as soon as they know what someone’s going to say, they can do performative listening. They can continue nodding their heads and looking at the patient. But they’re not listening anymore. They’re just waiting for the person to stop talking so they can tell them what the diagnosis is or whatever they think is going wrong. We are not training our medical professionals in how to continue to be resilient in a job that can really test your empathy without losing empathy. How do you maintain this job without losing that connection with other people, and how do you really listen?

As Dr. Rana Awdish’s story revealed at the beginning of the episode, a lack of connection in conversation can have a profound effect on the patient experience. After the break, we return to Rana to find out how her near-death experience transformed the way she communicates with patients and inspired her to train other physicians to do the same. But first, a quick favor. We’re working on an upcoming episode about grief, losing a loved one, a home, anything that you cared for? If this is something you’ve ever struggled with or overcome, we’d love to hear your story. Record a voice memo, email it to asksanjay@CNN.com or give us a call at 470-396-0832 and leave a message. We might even include your story on the podcast.

And now back to Chasing Life.

For me, having the opportunity to go from critical care physician to critically ill patient really exposed some of our communication patterns. The number of times I’ve sort of rounded on a patient through their chart, through their imaging, through their labs, through the story that the team is giving me and come up with a plan without actually knowing their values or what a good day looks like or what their hopes for recovery are. It’s shameful, and yet it’s embedded in our culture.

Today, Dr. Rana Awdish has made a full recovery from the burst tumor that sent her to the hospital and she’s now the director of the Pulmonary Hypertension Program at Henry Ford Hospital in Detroit. She’s also one of the founders of a new training program for doctors called CLEAR.

We chose the name CLEAR because it was really the values that we sought to embody for ourselves and for our patients. So it was connect, listen, empathize, align and respect.

The CLEAR training program is unusual in that it pairs doctors with improvizational actors. Together, they act out different medical scenarios that challenge the doctor to relay information with clarity and empathy.

The actor could go from being very, you know, easy and compliant to the skills to being like Al Pacino, and like, you were going to have to talk them down.

It’s easiest to get a sense of this program by listening in on one. So, Rana sent us a recording.

Carl Donaldson? Hi, I’m Dr. Buic. I’m one of the ICU doctors that’s taking care of your mom.

All right.

So I wonder if this is a good time for an update?

Yeah it’s as good a time as any.

In this recording, the doctor you’re hearing is a real trainee and the patient is a trained actor. The doctor’s job here is to explain to the patient that his mother may not survive a serious infection.

The infection is in her lungs. She’s receiving antibiotics for that. However, there’s another part of this that’s more serious. The infection spread from her lungs to her bloodstream and when that happens, sometimes other organs are damaged. What your mom’s body is showing us signs of now is that the damage happened in her lungs. While the antibiotics are reversing the infection. They cannot reverse the damage that’s been done in the lungs. So over the next few days, we’re hoping to see signs of recovery but, there is a possibility that she may not survive this.

You said yourself over the next couple of days, you know, you’re going to check things out, but maybe she’s just on the wrong drugs. Maybe you guys are screwing up your care. I’m trying to handle things the best that I can. I trusted that you guys would… and now… Just give her different antibiotics or maybe more of the ones that you have right now! Like, would that help the problem at all?

It sounds like it’s really hard to trust that the doctors are doing the best thing for your mom.

When, she ends up like this, yes!

We’re going to be with you each day to help walk you through what to expect and what comes next.

Well, I’ll tell you what we are… Thank you. We’re definitely going to need that.

One of the interesting things about this recording is the way the doctor chooses to respond to the actor with an empathic statement rather than with more medical information. Here’s Rana again.

I think what you’re seeing there and what what is so often the case in the ICU is that there is mistrust or anger that’s directed at the physician or the team, a sense that maybe we’re not doing everything that we could. And it’s so easy to respond to that defensively. And you know, you can’t bludgeon fear with data. The patient’s family is scared and the fear is what needed to be decoded there. And if you can listen for not just what’s being said, but how it’s being said, the words he’s using, you start to be able to say, “it sounds like it’s really hard to trust that we’re doing the right thing.” And you saw his level of anger kind of de-escalate there because it is hard to trust and he’s letting us take care of the most important thing in his life and acknowledging that helps to rebalance the power a little bit.

Rana says that trainings like this one have had a profound effect on the way medical staff engage with patients at her hospital.

I did not have a clear line of sight into how much our physicians needed this, and the kind of skill set that we’re buttressing them with is really it’s protective against the kind of moral injury and burnout that comes from trying to be this robotic technician that never has the reward that comes from the hard work.

Maybe most impressive of all, the impact of this training has potential to extend beyond the hospital.

You know, just recently my husband came in on a cell phone, like having this conversation, ignoring everyone around him and I found myself getting irritated that he was still sort of at work, even though he was home. And when he got off the phone, I said, it sounds like it was really hard to disengage from that conversation. And he said, “Oh, yes! And I just wanted to be home and I was so frustrated that I couldn’t end it.” So instead of having a fight, it was a shared understanding that we were both in a situation that we wouldn’t have wanted to be in but found ourselves in in that moment.

As Rana and Celeste’s experience reveal, becoming an effective conversationalist requires real work and self-awareness. So I asked them for some tips that we can all apply to our daily lives. The first tip comes from Rana. Don’t assume you know the answer.

I most often not being called into that conversation to solve anyone’s problem. That usually I am there to be a container to listen and reflect back to the person what they already know. That that person is whole and has all of the skills that they need to navigate this situation and that if I approach it with curiosity and support, that they’ll leave it feeling better than when they started. And isn’t that the goal?

Tip two is from Celeste Headlee. Ask the right questions.

Who, what, where, when, why and how? Try to stick to those, because those are going to be open ended questions. Right. And the more open ended your question is, the more freedom you’re giving to the other person to tell their own story, to answer in the way that they want.

Tip three: try to learn something.

If instead, you go into the conversation saying, You know what? I want to learn where they’re coming from on this. If that’s your goal, you’ll always be able to achieve it. And for me, that’s all that since I made that shift in my perspective and stopped trying to convince anybody of anything, it has totally changed my ability to talk. I can talk to pretty much anybody.

Tip four is simple. Stay concise.

Don’t pontificate. Try not to repeat yourself. Stay out of the weeds and be brief.

Being good at conversation isn’t as easy as it seems. It does take practice, awareness, and a really good ear for listening. But as Celeste and Rana have pointed out, it’s worth the effort to achieve that deeper connection. If you have found some good conversation strategies of your own, I’d love to hear from you. What did you learn from today’s episode and how are you planning on putting it into action? If you’ve tried some of these tips, let us know how they worked for you. Record your thoughts as a voice memo and email them to askanjay@CNN.com or give us a call at 470-396-0832 and leave a message. We might even include them on an upcoming episode of the podcast.

Next week, we’ll take a look at the harmful effects of racism on our health. We talk to Asian Americans about the trauma the past two years and what it’s going to take to heal and build a safer community. Thanks for listening. Chasing Life is a production of CNN audio. Megan Marcus is our executive producer. Our podcast is produced by Emily Liu, Andrea Kane, Rachel Cohn, Xavier Lopez, Isoke Samuel, Grace Walker and Allison Park. Tommy Bazarian is our engineer and a special thanks to Ben Tinker, Amanda Sealy, Carolyn Sung and Nadia Kounang of CNN Health, as well as Rafeena Ahmad, Lindsay Abrams and Courtney Coupe from CNN Audio.