Facilitating the Schwartz Center Rounds

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Read Interview #2


This is the third in a series of interviews with experienced facilitators of the Schwartz Center Rounds. The purpose is to give new facilitators insights and guidance on how to prepare for Rounds and facilitate discussions.

The interviewer is Kathryn Kaplan, PhD, Chief Learning Officer at Maimonides Medical Center in Brooklyn, New York. She facilitates the Rounds with the physician leader, Alan Astrow, MD, Director, Medical Oncology and Hematology. They began the Rounds in January of 2008.

Sally Mack, MSW, LICSW, the facilitator of the Rounds at Massachusetts General Hospital (MGH), was interviewed on September 15, 2009. Sally is a psychiatric social worker with expertise with Neonatal Intensive Care patients. She has the distinction of being the first facilitator of the Rounds, creating them with Dr. Tom Lynch, Kenneth Schwartz’s oncologist. Sally has facilitated about 130 Rounds at MGH over 13 years. As Dr. Lynch is now the Director of the Yale Cancer Center, the physician leader with whom Sally facilitates the Rounds is Dr. Lidia Schapira, a specialist in breast cancer.

Interview with Sally Mack, MSW, LICSW
Facilitator at Massachusetts General Hospital

K: Sally, you have so much experience facilitating Rounds, and I know you have done site visits and coached so many new facilitators. What do you most want to focus on?

S: Urging the people who are conducting the Rounds to encourage the attendees to make these their Rounds. I feel very strongly it shouldn’t be “here are the Rounds and here are the topics and here’s what you should be listening to.” I think people are very moved and inspired when they participate in the Rounds, and I think we should use that to encourage them to think of topics.

K: Do you mean to write it on the evaluation form?

S: Yes, and also if you are in the hospital, ask people “what did you think of last week’s Rounds?” Encourage them to understand that these are their Rounds, the program belongs to them, not the hospital. I feel that’s really important.

K: How many people in general come to your Rounds?

S: I’d say between 80 to 100 people. The room only holds that many with some standing. There is something about having helped create the Rounds and going through the anticipated resistance of the Rounds, that gives me perspective on it. I think I am much more concerned that people feel safe and willing to respect the confidentiality of the Rounds. I learned from another facilitator in the Boston area, I can’t remember her name now, something important. She said, “Just as we show compassion for our patients, we need to show compassion for our fellow caregivers and we do not reveal what they say about a particular person.” I think that is a beautiful way to phrase it.

K: How do you create the safe environment? For instance, someone said to me not to use that word when introducing the Rounds because it makes them feel, “oh, do we not have a safe environment?”

S: I don’t think I have ever said explicitly we are creating a safe environment. I don’t have a set statement because we have a lot of repeat people, after all these years. The two things I do always say are to put their phones on vibrate and that confidentiality is crucial to making the Rounds work. It is certainly okay to talk about the issues with colleagues, but it is very important not to quote anybody.

K: How do you start the Rounds?

S: The physician leader welcomes the group and introduces the panel. They know the case and the speakers, where as I, being external to the organization, do not. I tend to have a listening role. I sit at the end with those presenting the case.
I think it is definitely important to plan and have a rehearsal with the panel. Not word for word, but to realize what aspect each of them is talking about. It also helps the facilitator start thinking about the emotional issues and prepare to interact with them about it. For instance, knowing if it is the angry mother of the child or the screaming wife who needs attention. It’s important for the speakers to time themselves because when they talk too long we have no choice but to interrupt them.

K: What is your role during the Rounds?

S: I come as a non-hands-on caregiver. I call on people and ask questions that haven’t been asked. I find that I listen during the discussion to how people are following the rules and expectations they have for themselves that they learned in school. I am aware of being sensitive to their high expectations and when they are being hard on themselves, I raise things that haven’t been said. I might talk about the whole hospital or the community or whatever I think is needed. Especially at the end, when the physician leader asks me to summarize, I look at my notes and usually have about eight things starred that I could summarize. I try to share one or two things that seem significant. One point I make over and over to new facilitators is that the facilitator and physician leader should meet from time to time about how the Rounds are going. It’s important to explore how they felt about the interactions, did they understand where each other was coming from, and to build a collegial relationship.

K: Do you have any examples of how you intervene in Rounds discussion that seem either too “flat” rather than a juicy conversation or the other extreme, kind of out of control with staff talking on and on about the case?

S: What do you mean?

K: Well, for instance, our last case was entitled: “Life in the ER: Whom Do You Trust?” The case was about suspicion of parental child abuse with a six-month-old, and the feelings the caregivers had about mandated reporting on the one hand and fear of judgment on the other. The panel was succinct, talked abut their emotions, and very professional. However, the audience tended to ask informational questions and not share their emotions. And at the beginning I asked how many of our 150 participants have had direct experience with abuse, and about 1/3 raised their hands. We were surprised then, when so few spoke about their experiences even when asked. I was wondering how you might make the discussion come alive.

S: I used to work in a child abuse clinic, so I know the issues. I might say with empathy, “This is a very uncomfortable topic for people in terms of thinking about our role and obligation.” I would acknowledge how the team worked with the patient. When I worked with parents, it was helpful to have compassion for them because they were struggling with their child. No one wants to be a bad parent.

K: Our case turned out not to be abuse; the child turned out to have a genetic disorder that causes bones to break easily, Osteogenesis Imperfecta. One of the issues addressed was caregivers feeling apologetic once the diagnosis was made. The family also was Orthodox and abusive behavior is kind of a taboo subject to discuss, especially in such a large setting.

S: It is tricky. These are painful issues and we’re not used to talking about them in public. I would ask if anyone understands why we don’t readily speak about it. I also would be tempted to have someone who is knowledgeable about the roles and practices of Orthodox Judaism educate the larger group; to take some time to explain how cultural differences relate to the theme and put them in perspective in some way. We will often have someone interpret non-medical aspects of a case. We brought in an Irish priest from the community and asked him to explain their mores. This would also be so helpful with people from the Asian culture who often will not tell anyone they are dying. It’s not pathological, it’s cultural. It’s very important to bring that aspect into the Rounds because it will help the staff be less judgmental and more exploring.

K: You have facilitated so many Rounds. What are the most memorable?

S: The most memorable are when the patient or the family has been present and they validated the staff. There is one I’ll never forget. We talked about a young man and the staff talked about how they dealt with him and the music he played. He was a rebellious teenager and also a dying patient. He had a drug history too. The parents were sitting in the front row. The mother was clutching her husband’s hand. I noticed her knuckles were white and I thought, “Oh why did you bring these poor parents here?” At the end when we were summing up, the mother said, “I just want to say how glad I am to be here. When my mother died 25 years ago, the physician who took care of her never talked to me after her death. The case was over. Now, sitting here listening to you and hearing how much you loved my son, and took care of him and respected him, has just healed 25 years of suffering.” I have to admit I cry every time I think of this.

K: Oh my, I have goose bumps. I’m choked up too.

S: I guess the ones that are most rewarding are the ones where there was tension that was resolved in a rewarding way. For example, when other staff members come through months or years of built up resentment and controlling their feelings, and then are able to share it with the group. Those are powerful.

K: Can you predict which ones these will be?

S: No. But when you invite patients and families, it is usually powerful.

K: We’ve never done that. How do you decide when and whom to invite?

S: A staff member who knows the patient and family and has a strong rapport does the inviting. Once we had a patient come and talk about mistakes the staff made, and we had a family talk about their experiences with the staff and what was helpful to them. Another time a wife complained bitterly about when her husband was a patient and how he was treated. I could tell she was getting out pent-up feelings. After the Rounds the social worker who had worked with the family came up to me privately and said, “Wow, she so misrepresented what happened.” I knew that wasn’t too comfortable for the staff to hear. But the wife felt good that she could turn to me as an ally in the room. People asked how I could keep talking to her. But I could. She was doing what she could with her grief in the way. I wouldn’t try to change her attitude. I’m not her therapist. I didn’t agree with her. But I was able to empathize and say, “That must have felt awful.”
Another powerful Rounds was when a physician came and talked who was terminally ill. His wife came too. The staff presented their feelings about taking care of him. So many people knew him. These experiences emphasize for those who come that these are interdisciplinary Rounds and everyone learns from them.

K: How do the staff respond, are they less talkative and polite when patients and families come?

S: Usually they listen and at the end, before they leave, the patients and family members and staff hug each other. The patients are so grateful to come back and say what a significant part of their life they shared. It is meaningful to hear what each other says to the audience; it intensifies their awareness of the healing relationships they had.

K: Have you ever had a bad Rounds?

S: The only one that was disappointing to me was when we our topic was about ethics. We could not get the physician to stop lecturing, it was too cerebral. The most valuable Rounds are when people speak from their heart and express their feelings. When someone on the panel shares their feelings, the audience can reflect on their own. Even though we gain a lot of insight and awareness and learning from aspects of the case, what’s unique about these Rounds is that chance for self reflection and getting that “ah-ha” about ourselves. It’s a chance to relive and heal a lot of old stuff.

K: I love it when I feel that resonance in our Rounds, but in general we are not getting to that level consistently yet. That’s why I’m interested in how you engage the group after the panel presents and it’s time to generalize from the case during the discussion.

S: Usually the physician leader opens the discussion, saying something like, “These were interesting Rounds, what are people struck by that are significant to them?” I might note that the case brought up a lot of thoughts and feelings and ask what the case opens up for them. I remember my very first Rounds and a doctor was standing in the back with his arms crossed and said something that sounded so cerebral. I asked him, “So how do you feel about that?” There was an awkward silence. Afterwards I found out he was a surgeon and never spoke about his feelings to anyone. Yet, we have to encourage people to speak about their own feelings. Over time, because people have heard each other and realize how much they have learned from sharing feelings, it’s more the norm. We have a lot of physicians who find this a valuable opportunity. “Forty years ago, when I was practicing, I held all these feelings in.” I remember one of them saying, “I realized how prejudiced I was against blacks.” We had a powerful topic on prejudice of obesity, and I think the most dynamic and well-attended Rounds were when we talked about racial issues.

K: So what I hear you emphasizing is having Rounds where patients and families can come and where you can address many difficult issues, such as racial and cultural differences. For someone new to the Rounds do you have a favorite resource you would recommend about facilitating?

S: The Schwartz Center Rounds guidelines are very effective and helpful for facilitators. I think it’s important for the facilitator to feel comfortable with groups. To not feel you have to be literal and cover every point for a topic. Be comfortable letting people open up about their feelings. I think for the most part, if you’ve been a therapist or minister or are used to sharing painful feelings with people, you are more likely to be a good facilitator.

K: Do you have any other reflections or advice?

S: Remember, it’s the medical community’s Rounds, not your Rounds. Especially when you’re starting Rounds, it’s very important that everyone feels welcomed. When you walk on to a medical unit, no one welcomes you. This is different. We’re here to set a different mood and special connection. We’re here to offer you food and nurture you; you can relax a little bit. It’s a special time to be together. Our physician leader used to have his assistant welcome people at the door and ask if they liked the lunch. Often people would put that on the evaluation, and they would comment that they appreciate that it’s their time to be a community.
I have worked on units where no one seemed to have the time to share feelings. The staff were so self-protective that when I would raise a question about the emotional intensity of what’s going on, they would just roll their eyes. So the Rounds are a time when no one has to roll their eyes. You can just talk about what you’re dealing with as it relates to the topic.

K: Thank you, you are inspiring to me and I’m sure other facilitators of the Rounds.