Alan Alda

Kate Bowler: This is Everything Happens. I’m Kate Bowler. Something you may have noticed if you’ve been listening for a while is that one of the most difficult things to get right in tough times is communication. How do you talk to someone who’s going through their own version of horrible? So I’m not just talking about skills or of family and friends who do, for the most part, gather ‘round with love and prayer and usually wine and cookies, and for that I am eternally grateful. But the communication skills of medical personnel or others can be, let’s just say, wanting — sometimes weak, sometimes wonderful. But what makes the difference?

I’m lucky enough today to talk to Alan Alda, who is just crazy famous. He is an actor and director, winner of seven Emmy Awards, and star of the classic TV show “M*A*S*H*” and many movies including “Crimes and Misdemeanors,” “Everyone Says I Love You” and “Bridge of Spies.” Alan Alda has spent a long time trying to train doctors and scientists how to communicate with their patients, their peers and the public. I’m hoping he’s got some real advice for us today.

Alan, I am so honored to speak with you.

Alan Alda: No, it’s great to talk to you, Kate. Thank you.

KB: Well, I was excited to learn that your dad was a vaudeville star, and you grew up in this world of theater. And you’ve said that you learned a lot about communication and empathy from acting, and in particular improv. I think some people might be really surprised by that. So what did improv teach you about empathy?

AA: You know, the essence of improv – what improv teaches you – is that you must focus on the other person, and the other person comes first. One of the principles is, you make your partner look good.

KB: I like that. I want to look good.

AA: You don’t look good at your partner’s expense. You don’t deny what your partner comes up with. You become partners. What I think is one of the most important elements in good communication is that you don’t have in the other person a target of your communication, you have a partner in communication. Which means you’re finding out if they are understanding what you’re saying. And you’re also finding out how they feel about it.

KB: Your book starts with this insane scene at the dentist’s office where you experience a terrific example of miscommunication. That seems like it was a really important moment for you. What happened, and what did it tell you?

AA: Well, what happened was, a dental surgeon had to take out my front tooth and said he had this great operation that he was going to do. He was going to pull down a bit of my gum over the socket and get a great blood supply to the socket, and everything was going to heal great, and I said okay. And he invented this procedure. And he had a white coat on, so I thought he knew what he was doing.

KB: Super authoritative!

AA: And then he’s standing in front of me with the knife, the scalpel, inches from my mouth and he says, “Now there’ll be some tethering.” And I said, “What? What?” And he said, “Tethering, there’ll be tethering.” I said, “Well, what’s that?” He said, “Tethering! Tethering! Tethering!” Starts screaming at me. And I let him operate. And I didn’t know what it meant. I never … I still don’t know what he meant by “tethering.”

And, as a result of that, he cut that little bit of tissue between your lip and your gums called the frenulum or the frenum depending on what dictionary you look in. And it turns out that I needed that to smile. So I was making a movie a couple of weeks later, and the cameraman came over to me and said, “I thought you were going to smile in that shot.” I said, “I did.” He said, “No, you were sneering.”

KB: Oh no!

AA: And I looked in the mirror, and I was sneering. So I went back to the dentist, and I said, “You know, I need my face to act with. And sometimes I have to smile.” And he said, “I told you there were two stages to this.” He had no sympathy, no sense of what I was going through. And I don’t think I ever went back for the so-called second stage. I don’t remember because I wasn’t going to let him in again. He had a thing for my frenum.

So, it really impressed on me the importance of thinking about the person you’re going to stick a knife into. You know? What are they feeling? What do they understand? I would imagine that’s a part of the healing process.

KB: Yeah.

AA: In fact, now that we teach doctors, essentially empathy, in the course of teaching them to communicate better, I’ve come across research that shows that when patients rate their doctors as empathic, they’re 19 percent more likely to follow the doctor’s orders. Which sounds to me like there’s a certain amount of life-saving in that.

KB: Yeah.

AA: I mean, if you take the medicine, if you follow the regimen, do the exercise, whatever the doctor recommends — if you’re 18 percent more likely to do it, you’re 18 percent more likely to get better.

KB: Yeah. Well, I mean I remember the first time the doctor said I had “lesions.” And I honestly had no idea he meant tumors.

AA: Oh.

KB: And like, I’m a reasonably smart person.

AA: Yeah.

KB: I mean, at least I have a dictionary at home. So I went home, and I found that most of the translation of trying to understand my own illness happened by myself with the dictionary.

AA: Yeah that’s, you know, that’s called the “curse of knowledge.”

KB: Tell me more.

AA: Knowledge is not a curse. To have knowledge is a great blessing.

KB: Yeah.

AA: But when your knowledge is so deep and so complex that you forget what it’s like not to understand that language … That’s a curse. A curse for you, and it’s a curse for the person listening.

KB: Yeah.

AA: I had the same thing when my father had a stroke. I was standing by the bedside. He was unconscious, and I was trying to talk to him. And the doctor said, “He’s very deep.” I didn’t know what “deep” meant.

When my mother was ill, they said, “We’re going to have to intubate her.” I didn’t know what that meant.

KB: No.

AA: And it turned out it was this horrible experience where they choked her with this device, just ramming it down her throat. And there was a constant misunderstanding that I had to live through.

And you must have been through this many times too.

KB: Yeah. I mean, like, when you are the subject of translation, especially with the drugs I’m on, immunotherapy is this whole new frontier, and because of that, we often lack any language for it.

And so, like for instance, I have incurable cancer, which means I never get to be a “cancer survivor.” Because I’m not past it. And I’m also not “terminal”, which means we for sure know … I mean we’ll all die. Just, for anyone listening, as it turns out, we do not make it out alive.

AA: This is going to generate a lot of headlines. I have a friend who says, “I know we all have to die. But in our lifetime?”

KB: Yeah exactly. It does seem like when people are using the word “terminal” about me, like, they’ve isolated a special case of someone who’s not going to make it.

AA: Well, I think of it as just a bus station where you get off and get on another bus.

KB: Yeah, I like that. That terminal!

AA: For me, denial has been very helpful.

KB: I am a strong advocate of denial. Yeah, I go very cheerily into surgeries. I mean like, “Sure! Let’s give this a try.”

AA: I was on top of a mountain in Chile about 15 years ago, and I got this terrible pain in my gut. And it was the worst pain I had ever felt. And it turned out that about a yard of my intestine was dying.

KB: Oh my gosh.

AA: Lost its blood supply. And they carted me down a bumpy mountain road an hour and a half to this little town in Chile called La Serena. And a really wonderful surgeon figured out, almost immediately, what was wrong with me, and he communicated to me beautifully. He said, “Here’s what’s happened. Some of your intestine has gone bad, and we have to cut out the bad part and sew the two good ends together.” Isn’t that perfect?

KB: Yeah.

AA: The official name for that is end-to-end anastomosis. If he had said that to me … and if I didn’t know what it meant. Here I am woozy with pain and morphine. It wouldn’t have been comfortable for me. But instead, before they put that thing over my face and put me out, all I thought about was, “Well this may be it. I mean, I may not wake up from this.” So I went to get a message to my wife.

KB: Yeah.

AA: And that ease that he gave me was very important. I wasn’t struggling with what’s going to happen to me. It wasn’t in a panic.

But I had an experience in that situation that is so different from yours because I didn’t have to face it day after day. I wanted the pain to be over. It was so bad, and I never imagined such a situation like that, where the pain would be so bad. I wanted it to be over any way it could be over.

KB: Yeah.

AA: But, but are you currently in pain?

KB: I mean, I think that’s a funny thing about chronic pain, is you stop remembering that you’re having it. So yes, but it’s not as bad as it was.

AA: Yeah.

KB: Treatment gives you funny side effects, like, one time, because I was in an experimental trial – this is a great example of communication and miscommunication – you always think “Clinical trial equals cutting edge, first in line, coolest, in the door, I’m going to get the best stuff”. As opposed to, “We haven’t totally worked out the kinks on this one, but if you guys want to stand in line because you’re desperate, that’d be great.”

AA: Exactly. And you’re officially now a guinea pig.

KB: That’s right. Yeah, and someone even used the word “guinea pig” for me one time, and I was like, “Oh I don’t think this is going the way I thought it was.” But yeah they accidentally used a drug for too long that fried off most of the nerve endings on my feet. And then I would just fall over.

AA: Oh my god.

KB: Which meant … I’m already clumsy so it looked really awkward.

AA: Did it come back?

KB: Yeah. As it turns out, nerves regrow a millimeter a day or a week or something.

AA: No kidding.

KB: So gradually, yeah, it’s been a year and I’m much less clumsy now. But it did mean that it took a while for me to realize, like, oh maybe what I’m getting is not the superhighway of medicine. Maybe it’s like the bumpy road on the side where you really need a Jeep. And I’m so grateful for the stuff that worked. And I try very hard not to regret the stuff that didn’t.

AA: And that’s the thing. I mean, I think that we’re all … most of us are glad to participate in a trial.

KB: Yeah. And it would help too, if usually when you get the very worst news, that the very best person is telling you.

AA: Yeah.

KB: Because like when I first heard the words “stage 4 cancer,” they gave me the intern. I mean, I was lying in a hospital bed. And this sweet little basically 12-year-old in medicine, with the shortest coat, came by, and he was like, “Hi …”. He was so nervous, and his nerves made me nervous, and it was 4 a.m. And I just remember thinking like, “Oh buddy, you drew the short straw, didn’t you? And they just sent you along to me.”

And it does make you wish that the person who knew how to give the talk is the one that sits you down at the right time with the right people.

AA: You know this reminds me of one of our success stories. We were we were working with a medical student who had done one of our basic exercises, a mirroring exercise, where you’re looking at your partner and you’re moving your body, and your partner has to be your exact mirror at the exact moment.

KB: Yeah.

AA: And this this does so many things. It teaches you the basis of communication, that you have to help the partner be the mirror.

KB: Yeah.

AA: You don’t trick them out. You don’t move too fast; you don’t move illogically. You’re staying with them, and you’re observing them, helping them be your mirror.

And he was on the floor with a supervising doctor who took him into a room to explain to a woman that she was going to die of cancer. And the doctor stood over her, told her, but used words like “metastasis.” And she wasn’t, she wasn’t responding. She wasn’t crying, she wasn’t asking questions. She just looked at him.

KB: Right.

AA: He finished saying what he had to say and let left the room. So the medical student said, “I don’t know if she got it, would you mind if I go back and talk to her again?”

KB: Wow, yeah.

AA: And he let them do it. So he goes in the room, he sits down.

KB: Yes.

AA: Right in front of her. Takes her hand in his hands. And tells her in absolutely plain language, not using words like “metastasis.”

KB: Yeah.

AA: And tears start to come down her face.

KB: Yeah.

AA: And she starts to really hear him. And he came back to our instructors and said, “You helped me do this. With that simple exercise of the mirror because I was mirroring her, she was mirroring me. And the two of us were mirrors of each other. I helped her face her death, and she helped me be a better doctor.”

It’s a nice example of how much ground you can cover by paying attention to the other person.

KB: Well, that was exactly what I said to that little 12-year-old, I said, “You better be holding my hand if you’re going to say things like this.”

AA: Oh, no kidding!

KB: I did.

AA: You were literally helping that person learn how to do it.

KB: Well, because like, you feel … I mean, I think I’m reasonably good at reading a room or understanding what’s going on, and it did really feel almost immediately like I was behind glass. And they were having one experience, and I was having another. And I wasn’t able to reach across and get them to …I know you’re not allowed to just run around touching everybody, but touch.

Like in that story where he holds her hand… I wanted people to get down on my level and to look at me, even just a hand on my arm, and say, “Look, this is what’s happening right now.”

Because mostly it was me looking up words like “metastasis,” or a tone that I like to call “hostage negotiator neutral,” where they’re like, “Ms. Bowler, we understand that you …” And it’s like this managing tone. And I’m on the other side being like, “You think I’m crazy. You think I’m going to jump.”

AA: Yeah. Right. I remember many times going to a hospital for one little thing or another and being spoken to in a general way. “This is how I talk to people coming in, and you’re just one of many.”

KB: Yeah!

AA: Doesn’t matter who you are. You’re the customer.

KB: Yeah. Welcome to Generic Tone.

AA: Yeah.

KB: It is very To Whom It May Concern, comma, or Are You Still Here?

AA: Yeah. To me it’s the same tone you get when you check into a hotel.

KB: Yes!

AA: And they say, “How’s your day been so far?” Well up until this moment, it’s been fair.

KB: Yeah exactly.

AA: And now I’m a robot.

KB: You don’t care.

AA: Yeah, right!

KB: It’s true though, and I try so hard not to be uncharitable. I’ve been grateful to get to know more doctors as humans. But the relationships I have with doctors as humans and the relationships I have as a patient seem totally different.

AA: That’s interesting. Do you run across doctors who are apparently naturally empathic, warm, thoughtful, considerate?

KB: Yeah. Yeah.

AA: I do too. I can think of a couple who are really extraordinary in their ability to be direct, frank, open, plain.

KB: Yes.

AA: And totally caring about you, really wanting to know what’s what.

KB: Yeah.

AA: But the difference is, if you don’t have that naturally, you can be trained into it.

KB: So how did you teach doctors empathy?

AA: Well, we start with improvising. The first thing we do is put them through basic improvising exercises. And they’re calibrated so that one leads to the next. And that leads to the next. And then we go into roleplaying, where they make use of what they’ve learned about the basis of intimacy, the basis of connection.

And that sense of relating, is really, I think, the most important thing you can learn. If you can really make connection with another person and make a connection in such a way that you listen so that you’re willing to let the other person change you, that’s a kind of radical thing to say. Because you don’t know what the person’s going to say.

KB: Yeah.

AA: Why should you let, especially a stranger, why should you let them change you?

KB: Yeah.

AA: But that’s the essence of relating. Relating is, you do something, say something, you have a look on your face. It does something to me. If I let it in, it changes me. And now we’re connected. We’re dancing, and if we don’t do that, it’s just me spraying stuff at you, and then you wait ‘til I finish, and then you spray stuff at me.

It seems so interesting to me, that it feels so good to connect to another person. And yet there’s a tendency for most of us not to do it. Some kind of avoidance.

KB: Yeah.

AA: It’s so much easier to be in our church, in our castle. And not let anybody come across the moat.

KB: But I can say as a patient, it makes me feel crazy sometimes. Like I notice myself trying to add little details so that they know I’m a person.

AA: But that’s good.

KB: Like “You know I have a kid, right?” Not in a weird way, but like, “Oh my son’s doing this.” I’m not bringing out pictures, but I’m close.

Or, like, I literally get out of class that I’m teaching as a human professor and then walk over and then put on a rough cotton gown, and then all of a sudden I’m a patient. And I feel like I’m trying to refer back to the world I was living in 10 minutes ago to be like, “I promise if you saw me in another setting, you’d think I was a colleague or someone you want to connect with.” But I guess what I’m saying over and over again is, “I’m human.” Right?

AA: You know, I think every time I’m in a hospital setting, it seemed like it always boiled down to that gown they gave you, that exposes your rear end.

KB: Yes.

AA: There’s a message in that, that you’re no longer the person you were when you came in with your clothes on. You’re this patient thing.

KB: Yeah.

AA: At least that’s the message I get wearing the gown. They probably don’t intend that message, but the transaction builds out from there. And there’s a bridge that has to be crossed all over again.

I’m lying on the gurney; the doctor comes in and stands over me. It’s a task for the doctor to make contact with this person who’s already been diminished by just changing clothes.

KB: Yeah. I think mostly out of love, people offer me a lot of advice or have a lot of suggestions of how I might just personally overcome death through sheer will. I was wondering if you had any advice for me about how to successfully communicate better with people who are trying but failing to help me. Because I do feel empathy for them. I do. But sometimes I struggle to describe what it’s like to be on my side.

AA: Yeah. My guess is, based on everything we’ve been talking about, a lot of it depends on how much of a channel you have opened between you. I feel that somebody who’s just lecturing me,

I listen and respond in a similar way, but if somebody really is connecting to me then I open up more.

It seems like an easier thing to do, but I think it depends on where your heart is at the moment. And I think your technique is really good of bringing up your child, bringing that into the conversation.

It’s interesting, that one of the things that I don’t think doctors may do — many doctors, not all, because some are very good at this — of finding out about the whole life of the patients and not just the symptoms they come in with. Because sometimes they have other things that they need to take care of, too. And they don’t become apparent until you hear the whole story.

KB: Yeah.

AA: And it also reinforces this open channel.

KB: Yeah.

AA: Then when whatever I have to say, if I’m a doctor, is directed at you as a person, not you as a patient, you as a liver.

KB: Me as a half a liver now. Yeah, I’ve got the rest. It’s okay.

AA: Is the liver the thing that grows back?

KB: You know what’s funny. It doesn’t grow back, it hypertrophies.

AA: What? I don’t even know what that means.

KB: Yes, that was the problem. I couldn’t figure out if they were cutting it and it would grow back like a lizard tail or if they were cutting out half my liver and then it would just like… do what? So it took me forever to realize they were going to cut out half, that it would puff up to create more mass, and it would regenerate in function a lot. But like …

AA: So how is that different from growing back? It just gets puffy, or what?

KB: I don’t know. So, like, this is the thing.

AA: Here we are talking about what you ought to know about …

KB: Yeah, I don’t know the answer! This is a great example of, I asked a million questions just like that, and I only a little bit know the answer

AA: It’s that “curse of knowledge” thing again. One of the problems is that they spent years or decades learning this stuff. We rely on them to know it in great detail. It’s very important that they do.

KB: Yeah.

AA: They haven’t been spending decades on learning how to explain it to you. And you have not spent decades learning it. So it’s like coming into a room and somebody speaking Chinese, and the best you can do in Chinese is say “moo goo gai pan.” And there’s this gulf.

KB: Yeah.

AA: That’s why I spend most of my time now trying to help doctors and scientists and people in business, women in business. Many, many different kinds of situations where we can break down that barrier, and people learn early on that it’s not just good enough to know it. You have to be able to say it to people who don’t know it.

KB: Yeah. All this has kind of made me realize, I think one of the main hopes I had for writing my book was that I want more language that is a little less certain and a little more generous. And I think mostly what I was trying to describe is exactly what you’ve been describing, which is that little space between people where something a little more magical and generative can happen.

AA: Yeah, I think generosity is a really interesting and tricky subject because there’s so much behavior that is intended as generosity but is really an imposition. I think of this moment. Arlene and I were walking across the street on Broadway and there was a woman who seemed to be 10 or 20 years older than us, next to us, and one of us said, “Can we help you across the street? And she said, “No! Can I help you?”

And I think it’s kind of indicative of the idea that it’s not helping unless you are actually helping, the person wants you to help, you’re providing help that the person can use.

KB: I’m usually on the receiving end of a lot of people’s generosity that I often receive as kind of a tiring certainty.

AA: Talk about certainty. I love that notion because I talk in the book about the sound of certainty in the voice.

KB: Oh really? Because to me it’s… so I was thinking about people who approach me as teachers, they’ve recently seen a documentary, and they very much want me to understand the content, and it’s really meant to help. Like there is a tone of voice to it. And I can tell when it’s, like, on the approach. It’s like, “Oh, I’ve got to be in a learning place because someone is in a teaching place.”

AA: Yeah. I know. There’s a particular thing about that that gets me, because it’s not the words themselves.

KB: No.

AA: It’s the tone, and so many things can be subverted by a tone that says, “I’m up here, and you’re down there.”

KB: Well it’s the same with the minimizers that I get, where they really want me to have more perspective about my cancer. And I think that’s a tone thing too, because the words “at least” always sound the same. “At least you …”

AA: At least. Any sentence that begins with “at least” …

KB: It’s like …

AA: I was shooting for more than “at least.”

KB: Your book begins with a great quote attributed to George Bernard (Bernard?) Shaw. Which, as it turns out, he may never have said. But it’s, “The single biggest problem in communication is the illusion that it is taking place.” And I hope that’s not true right now because it’s been so great getting to know you.

AA: Oh I had a great time. Thank you. You’re a great communicator.

KB: Thank you.

After we’d had that conversation, we traded places, and Alan wanted to ask me about my book and my family and what it’s been like going through this tough season. Here’s a bit of that conversation.

AA: You were iagnosed with stage 4 cancer and then at a certain point, you found out that there was a trial you could take part in?

KB: Yeah. That’s right.

AA: And you’re in that trial now?

KB: I was in that trial for a little over a year, and then I stayed on that drug out of the trial, and I get scans every three months that let me know if the tumors are still in check. And so it’s just like purgatory, I guess.

AA: That’s interesting. None of us want to believe that we’re going to die.

KB: Yeah.

AA: And you’re, in a way, put in a position where you have to think of that.

KB: Yeah. But even I can’t think of it, like, I really, it’s an impossible thought. How could you possibly imagine your heart not beating, and you know, all the things that make up who you are?

AA: What do you think about … This is really interesting. When you think about what….I imagine you think about it more than most of us do because it is what you’re struggling with. What do you think it would be like? Do you think that you do have a vision of what it would be like to not be here?

KB: It’s funny. The second I got sick I started to think of my mental processes as “double brain.” Like one part of my brain is exactly the way I was before, where I always imagined everything’s going to work out. And I’m making plans to, you know, run a marathon, or at least try 5K again. And then the other part of my brain is always making plans that I will come to the end of myself, and that I will have to be making plans for a life for my family beyond me. And they’re always running concurrently, which is exhausting. It’s like I’ve got two decision trees to make for any major decision, like saving money, or do you get a house?

AA: Yeah.

KB: Or, you know, any decision has two very complicated decision trees associated with it. And the one that pictures life without me, I never think of myself. I only know how to press this despair into hope for my family.

AA: Yeah.

KB: And so you just … any plans you make is like emotional triage. You cut off all the terrible parts of that fear, and then you transform them into beautiful ideas for other people. And so, weirdly, picturing death can only feel like love for someone else.

AA: I think you make a real contribution just on that point alone with your book and other things you’ve written, where you really allow us to think about death and dying and what other people are going through as they have various responses to that fact that — it’s the one universal fact we all face.

KB: Yeah. Yeah.

AA: Why did you write the book? And why are you doing your podcast?

KB: I wrote the book as a love letter to my family and to other people I knew who were in pain, to try to ask the question, “What is it like to live after you give up on some of your most deeply cherished lies, like that everything’s going to work out? Are there still true and beautiful things that we can still learn in the dark?”

And so I wrote the book to kind of dig down deep and try to find new language to live in this new way. And it’s the same reason I’m doing this podcast, is hopefully to thicken up that language for all of us so that we can communicate better about what it means to grapple with the beginning and the end.

AA: That’s great. Well thank you for writing it, and thank you for talking about it that way. That’s a beautiful way to express it.

KB: Aw, well I’m grateful.

AA: Thanks for talking with me.

KB: Look, in my wildest dreams, I never thought I’d utter the phrase, “Here’s what I learned from Alan Alda.” But here’s what I learned from Alan Alda. We need to surrender the idea that just because we’re talking, we’re communicating. In Alan’s book, “If I Understood You, Would I Have This Look On My Face?”he makes the point that we could miss each other in a zillion different ways.

And here’s the thing, he didn’t come in with a script, lines fully rehearsed and ready to deliver. He was there to engage, to ask questions, and to keep reflecting my own thoughts back to me until guess what? Our words made a little magic. They danced a little. And what a thrill, even in the darkness, to bump into some great dance partners.

And so here we are at the end of Season One. And yes, if we’re talking about Season One, then there’s got to be a Season Two, right? Right! There’s just so much more to say, to figure out, don’t you think?

So, I’m working with my team to bring you more amazing guests and their amazing stories. So we’ll be back soon. And in the meantime, send us your ideas for people you’d like to hear from. E-mail me at everythinghappenspodcast@duke.edu. Look for updates from me @katecbowler on Twitter and Facebook and Instagram, and of course, if you subscribe to Everything Happens, the first episode of the new season will magically pop up in your feed as soon as it’s ready. I can’t wait. And look, in the meantime, I’m so grateful to know that there are so many people like me who wish that the world was a little gentler for delicate hearts like mine. So thank you, my dears.

Everything Happens is produced by Duke University in association with North Carolina Public Radio/WUNC. Support comes from Faith and Leadership, an online learning resource. And so many thanks goes to my awesome team! Beverly Abel, Alison Jones, Amanda Hite and the Be The Change Revolutions team, Ivan Panarusky and Random House.

If you’re enjoying these conversations, please go to Apple {odcasts and post a review, and come find me on Facebook, Twitter, and Instagram @katecbowler.

This is Everything Happens with me, Kate Bowler.