Association for Academic Surgery (AAS)

by and

Crucial Conversations:  How to Improve the Quality of Your Discussions at Home and at Work

Introduction

Most of us like and naturally seek out encounters and discussions that are easy.  But in academic surgery, we frequently encounter difficult conversations.  These may be upward negotiations with a chair for salary or research support, delivering negative feedback to a mentee, or conflict with a team member in the OR.  In the book, Crucial Conversations, the authors define a crucial conversation as “A discussion between two or more people where the stakes are high, opinions vary and emotions run strong.”1  These tense situations may be unavoidable, but the authors lay out a number of tools to transform these experiences from negative to positive.  Growth in this area is a key component to success as a leader in academic surgery.

To begin, you need to understand when you are in a crucial conversation.  As stated above, there are three components to a crucial conversation: high stakes, differing views, and strong emotions.  While the issue at hand may not seem grand, the outcome of the talk can greatly affect the quality of your life.  Due to human nature, we are usually at our worst when we have these conversations.  Because the issues are important, emotions can replace logic and things can spiral downward.  We each bring a certain “pool of meaning” into every conversation that is derived from one’s beliefs, experiences, emotions, and perspectives.  Conflicts arise when people hold disparate opinions and pools of meaning.  When this happens, generally one of two outcomes can occur – people may become either silent and withdrawn or they might become violent and aggressive.  So how do we master crucial conversations?

7 Principles to Master Crucial Conversations

  1. Start with the heart

To avoid giving in to emotional impulses and making poor decisions, it is important to know and focus on what you truly want.  For example, assume a scenario where you are trying to book an urgent case and the OR board brings up the fact that you were late into the room three days ago.  You might feel offended by this challenge and tempted to become dismissive or angry.  This is a common problem in crucial conversations – you lose sight of your original goals (getting your case booked) and get distracted by less noble goals of winning an argument, punishing the other person or avoiding conflict.  It is important to break down you goals and stay on task to focus on what you actually want.

  1. Stay in dialogue

When dialog starts to break down, it is imperative to identify this as soon as possible.  Become aware of non-verbal cues (including your own) that signal a dialog is breaking down.  To get the conversation back on track, the key is to help people feel safe by listening to what they have to say.  This will make them feel that their opinions are respected and valued.  There are four steps you can take to really listen to someone, summarized in the acronym AMPP:

Ask – “I would love to hear your opinion about…”

Mirror – “You seem frustrated by…”

Paraphrase – “What I am hearing is…”,

Prime – “I understand that you think I am wrong about this…”

  1. Make it safe

Once you understand that you or others feel unsafe, it is time to hit the reset button, restore safety and then resume the conversation.  Often people have taken what has been said and created a negative meaning from it.  This needs to be addressed often by merely restating your positive intent.  For example, “Can we hit pause for a second?  My goal here is not to make you feel bad.  My intent is to help us both find a way through this together.”

  1. Don’t get hooked by emotion (or hook them)

To stay in meaningful dialog, you must manage your emotions.  When emotions start taking over from logic, then it is easy to get ‘hooked’.  To stop getting hooked there are three things we can do: 1) Stay focused on what you truly want 2) Don’t play the game (merely being aware that you are playing a game means you are less likely to get caught by it) 3) Avoid the Fool’s Choice, where we find ourselves in a situation where we think there are only two solutions.  Instead, consider how you can achieve both goals.

So how can we speak honestly without offending and risk the conversation shutting down?  There are five tools to help you STATE your path:

–Share the facts

–Tell your story (i.e the meaning you are making of these facts)

–Ask for the other person’s path/story

–Talk tentatively- State your story as a story, not as a fact.

–Encourage testing – The intent is to reach a shared meaning on the facts as a solid basis from which to agree next action steps

  1. Agree on a mutual purpose

The overall goal is to find a mutual objective that both sides can agree upon.  This requires give and take from both sides.  A useful acronym (CRIB) outlines the four skills to get back to a mutual purpose:

–  Commit to seek a Mutual Purpose

–  Recognize the purpose behind the strategy

–  Invent a mutual purpose

–  Brainstorm new strategies

  1. Separate facts from story

It is essential to separate facts from story.  Often, each party will have created a very different story from shared facts.  First, the facts need to be agreed upon.  If the conversation starts to drift off track, always bring it back to areas of common agreement (e.g. facts and/or shared purpose).  Next, get both parties to construct a bigger shared story.  It is only when we have a shared meaning that we can start to devise an action plan.

  1. Agree on a clear action plan

By this point, both parties have arrived at a shared consensus and can examine options for improving the issue.  Several different methods exist for decision making and it is essential that both parties are clear on how a decision is going to be made.  Once the decision is made, it is important to determine action plans and assign them to specific people.  Finally, there must be a planned follow-up where everyone is held accountable.

Summary

None of these steps are either intuitive or easy.  They must be learned and practiced.  In addition, we present merely an overview of the concept of crucial conversations and the seven principles to master them.  We highly encourage you to read the entire book and work to master your own crucial conversations in your personal and professional life.

References

1 Patterson, K., Grenny, J., McMillan, R., & Switzler, A. (2002). Crucial conversations. McGraw-Hill Contemporary.

Alexander Hawkins MD, MPH

Alexander Hawkins MD, MPH

Dr. Hawkins is an associate professor of surgery at Vanderbilt University Medical Center in Nashville, Tennessee, Director of the VUMC Colorectal Research Center, and Vice Chair for Clinical Research for the Section of Surgical Sciences. In addition to a busy colorectal clinical practice, he is a NIH funded scientist using mixed-methods and patient-reported outcomes to study the comparative effectiveness of colectomy for recurrent diverticulitis. Twitter: @alexhawkinsmd
Anne Hawkins

Anne Hawkins

Mrs. Hawkins is the Chief Operating Officer for Morningstar Properties, a vertically integrated real estate developer, owner and operator of specialty real estate products focused primarily on self-storage and marinas. She holds a B.A. in Economics and Political Science from the University of Georgia, where she was a Foundation Fellow Scholar, and an M.B.A from Harvard Business School.