ICU Communication Skills:
Practicing the Conversations No One Taught You

Transforming Healthcare Coaching Podcast, Episode 129: ICU Communication Skills: The Conversations No One Taught You. Host Lillian Liang Emlet, MD MS CHSE CPC ELI-MP, in conversation with Tessie October, MD MPH, pediatric intensivist, palliative care physician, and VitalTalk Distinguished Faculty. Published October 5, 2026.

Lillian Liang Emlet: Communicating with patients and families is the most common procedure in critical care medicine, and most of us were never formally trained to do it. We log our central lines, we run our codes in the simulation lab, and the things we do 10 times a day, we actually just picked up by watching other people. And we're super happy today to have Dr. Tessie October here with us on the Transforming Healthcare Coaching Podcast, and she's going to talk with us about how much these conversations decide how clinicians get better at them, and how to do it on purpose. So Tessie, welcome to the show.

Tessie October, MD MPH: Thank you, Lillian. It's so good to be here.

Lillian Liang Emlet: You know, so I asked you here because you've spent your probably entire career studying what happens inside these family meetings. And because you are a pediatric critical care physician and a researcher, you have analyzed both in real life and also in the simulation lab how in the world we learn and grow as clinicians with the really, the highest stakes conversations that we have. I can't even imagine what it's like to have a child in the intensive care unit. And so I'm curious, from your perspective, why does communication matter so much?

Tessie October, MD MPH: I think it matters so much for exactly what you said at the beginning, is that especially in the ICU, it is the most common procedure that we do. And we're so intentional about every other procedure in the ICU. It's more than just a see one, do one, teach one. It's go to the simulab, have it be observed, do it in low-stakes environments first before you place that patient on ECMO, before you actually do it in real life. And yet we don't take that same intention with communication. And we are guiding families and patients through some of the most challenging, difficult experiences while they're most vulnerable, yet we don't take it as seriously as, as we should. And so there are real consequences when we don't do this well, and it's really important that we take ownership of our own professional development as clinicians to gain the skills that are necessary to master having these tough conversations.

Lillian Liang Emlet: So well said. There is so much at stake. I would say adult pediatrics, emergency departments, after complications, after good outcomes, bad outcomes, every moment that we spend with our families talking about what, and our patients in terms of what's happened and what is happening and what to expect, it's hard. It's hard because we don't even know sometimes, right? And so I think communicating uncertainty is even more scary.

Tessie October, MD MPH: Oh, absolutely. Especially because there's vulnerability. We have to be vulnerable, and we're meeting people when they cognitively may not be at their best. We're catching them where they have to process all this information in real time and make a decision for themselves or for their loved ones. It's really hard.

Lillian Liang Emlet: You know what happens for families and also what happens for us as the clinicians when these conversations go badly?

Tessie October, MD MPH: I guess I'll start with when they go well, right? Because in true VitalTalk way, we always think about what we do well. And I would say that when it goes well, do the hard work of understanding who they are as people, how they make decisions, what do they value most, and our job as clinicians is to turn those values into treatment recommendations. And when it goes well, we match the care to their values. When it doesn't go well, you see it. You see it in moral distress in the entire clinical team. We see it in the way that patients can sometimes linger in our ICU without a care plan. We see it when there's conflict with families and conflict even between the teams. And that all results from a breakdown in communication. And the consequences for families are that they are left stuck. They feel unheard, unseen, and they also don't know what to do, what comes next. Whether or not to cross that bridge and who's going to walk with them across that bridge is really unknown, and they feel afraid.

Lillian Liang Emlet: Yeah. I've also seen the, when conversations go badly, it lingers into the next encounter. A lot of times whenever I feel like we're spiraling, I'm going in circles with particular case in the family, and things aren't making any progress, it's mainly because there was a prior experience where it didn't go very well at all, and there were so many seared into that family or patient's memory of how poorly the conversation went, and then now it influences. I mean, it's lived, real experience. So this now influences every other conversation afterwards. And so I think a lot of times we often feel like, "Well, this is what it is, and I can't get around this." And yet, as we all know, the only way through these relationships is together, and to find some kind of way to reopen back up a possibility of healing those old bad conversations and moving forward in new ways. And I think a lot of people sometimes feel like, "There's nothing I can do." And I think we're on this show today to really expand people's minds to think about conversations and communication to be something that you can always develop. We're still learning. I'm trying to think. We've been teaching together for over 10 years at least at this point, and we're still always learning together.

Tessie October, MD MPH: Absolutely. Absolutely. And I think that this is the investment that we all should put in ourselves for our own professional development. We rarely get time as busy clinicians to spend time thinking about honing your own craft and developing your own skill. And the only way we get better is deliberate practice. And one of the ways that, this is how you and I met, was teaching this material across the entire country to all clinicians who care for seriously ill patients. We're talking about chaplains and physicians and nurses, nurse practitioners, you name it. Anyone who comes in direct contact as a patient-facing can use these skills to their own practice. And what, VitalTalk for me has done is not only has it been a tool that I've used for research, but it's really taught me how to really lean in on these conversations, especially when I know there's going to be conflict, or especially when I know it's going to be difficult. How do I bring to the surface the important things and leave my baggage at the door, and my own opinions and my own biases so that I'm actually thinking about what is important for this patient and this family and how they make decisions?

Lillian Liang Emlet: And so I just want to put a plug in. This is why Tessie and I are both teaching together, along with many other faculty in San Diego at Society for Critical Care Medicine pre-Congress this March 2027 at a VitalTalk course before the actual big Congress. And so we'll talk about that more in a few minutes. I want to pivot and talk a little bit about your work. So you've recorded and studied real family meetings in the pediatric ICU, and what did you see that surprised you?

Tessie October, MD MPH: Well, one thing that didn't surprise me, I will say, is that we talk a lot and dominate the conversation. And I wasn't surprised that clinicians spoke about 80% of the time. What I was surprised at was that even when we did some really good work and we gave a strong empathic statement to support the patient or the family's emotions, we got in our own way. So sometimes we'll say things like, "Oh gosh, this must be so hard, what you're experiencing. But we do need to make a plan, and we need to figure out what comes next." And that but negated everything that you said beforehand. And I was surprised at how many times... Clinicians are such compassionate caregivers, and that they want to say and do the right things, but they don't always have the skills to do it. And I was surprised that sometimes they had the skills, but they got buried when they didn't know how to highlight what's really important. And it's building that relationship, that empathetic part that tells the patient and family, "I see you."

Lillian Liang Emlet: Yeah. A lot of times I also feel it's like we get so impatient. We're like, "Let's get it all done right now. Let's get it all done right now." And the reality is life doesn't happen that way, right? And process doesn't happen... Physiology doesn't even happen that way. That's what I think 20 years of practice has taught me. I have to be more patient with ARDS.

Tessie October, MD MPH: Yeah. I would say, Lillian, I also was surprised at when I saw it done well in these recordings, because I audio recorded family conferences around decision-making. So whenever the clinical team anticipated talking about prognosis or talking about a critical decision, I recorded those conversations. I was surprised at when it went well, it actually took a shorter amount of time.

Lillian Liang Emlet: Oh. Wow. So when you say it went well, what kinds of things do you notice that you as a third party watching the recordings or listening to the transcripts later, what made a great conversation?

Tessie October, MD MPH: That's a really good question. What made a great conversation was when it felt like they were walking the same journey at the same pace, the clinical team and the patient or family. It wasn't like I was leading them. You would hear the clinician walk in front, and the family is following behind, asking a lot of why, when, what, things. "Let's go backwards. I'm not really sure I got that." They weren't really walking the path together. And when it, when you saw them walking the path together, you saw the light bulbs go off in families' faces, and you saw the whole arc of emotion from families being shocked or sad from hearing some serious news that wasn't what they wanted to hear, to having significant gratitude towards the end of that conversation when they finally were told what exactly was going on. And they needed that information to make a treatment plan. And so when it went well, you had less conflict, but it wasn't void of emotion. There were lots of emotion, but there was a lot of support of that emotion from the clinical team. There was alignment where you saw the patient, family, and clinicians walking together.

Lillian Liang Emlet: That's really such a great teaching point. And I think a lot of times we, this often gets missed in many places, that we often feel like we're on different teams, even with different specialties, different professions and with us versus them being the family or the patient versus us. And there's a lot of binary black-and-white thinking in many linearly-minded individuals in healthcare. And I think you bring up a really great point, that what we have to all do is you had mentioned baggage that we leave at the door. It's also that we have to leave our baggage behind of thinking that we're the expert and know everything, even though that is our role in this conversation. But to really walk alongside people, and that's really about a we, not a us versus them.

Tessie October, MD MPH: Yeah, absolutely. I would say that my mentor, Bob Arnold, he loves to make music analogies, and one of his favorite is that in the ICU the team is huge and there are many players, and everyone has their own role, and yet the family can tell if it's the first time that the band has played together it becomes really obvious that we're not on the same page. And when we're not on the same page, they start losing trust in the whole system. So it's really important that we walk together.

Lillian Liang Emlet: Yeah. So such a great point. For anyone who's wondering at this point, this far into the conversation, Tessie is both a pediatric intensivist and a palliative care physician. She's built her research at Children's National by recording these real family meetings and learning for decades, and she still cares for critically ill children, and she's Distinguished Faculty and a board member at VitalTalk. Which brings me to my next question is for anyone who's never been to a VitalTalk course, what is this? What is this nonprofit? And what makes this method different from just going to a lecture or going to your local communication skills courses or listening to influencers on Instagram?

Tessie October, MD MPH: Yeah. So what is VitalTalk? So VitalTalk is a nonprofit organization that initially it was called Oncotalk before it became VitalTalk, and it was designed initially for having these hard conversations with patients with cancer, but we realized those skills are transferable to seriously ill patients. And so it has expanded to beyond just for patients with cancer. What it is, it's a nonprofit that their goal is about every patient and family should have a clinician who has core communication skills that can match the care to their values and help them make recommendations. What's fun about it is that it's experiential learning. It is not a lecture style. It is simulated with simulated actors in real time. You practice something, you say the words, you can play with it, you tinker it, you stretch it, and then you get a chance to play it, to say it again. We talk about all the things that might have gone well and the things that didn't go so well, and then we put you back into the scene to try again. And it's a safe place to really practice. And what I like to say is that if all it took was watching to develop a new skill, I'd be the most amazing tennis player because I watch a lot of tennis, right? But it actually takes deliberate practice. And that's the fun part of what we do at VitalTalk.

Lillian Liang Emlet: Yeah, and every time I tell people what VitalTalk, people who are non-medical about what VitalTalk is, they're like, "Oh, good Lord, you definitely need to do that," because there's so much bad communication that's out there in healthcare, and I would say probably everywhere. There's just a lot of insensitivities and unawareness to be able to meet people where they're at. And some little other fun tidbits about VitalTalk faculty now teach at more than 400 institutions, have trained over 9,000 clinicians last year, which is just a drop in the bucket of obviously the hundreds of thousands of clinicians between nurse practitioners, physician assistants, physicians, chaplains, nurses, social workers. And so I guess we have grown over the last decade, but what does this growth tell you about what clinicians and healthcare systems and hospitals are asking for?

Tessie October, MD MPH: What it tells me is that people and relationships matter, right? We are in an environment in hospitals and clinical settings, and sometimes the patient and the relationship gets lost. People are asking for us to spend a little bit more time thinking about what that is, how do we develop, how do we see each other as humans, and how do we walk those paths together? I think as AI develops and becomes integrated into our systems, as it already has, what can't get lost is the relationship that you have one-on-one with your patient and family. And people are asking for, "How do I do this better?" It's not just about, oh, this person has good bedside manner and this person doesn't. It's really about how can I learn to deeply have these conversations when the stakes are really high?

Lillian Liang Emlet: So good. And as you said when it's done well, it's actually more time-efficient for you as the clinician. And so can you imagine that having conversations that are more values-aligned, meet people where they're at, more time-efficient? And I would argue that for a lot of people, it's these conversations when they go really poorly, it just eats at you and noodles on you for days, weeks. Sometimes it really changes how a clinician even practices. When you have negative feedback from a family or negative feedback from a patient, you just wonder and question yourself for years often afterwards. And so I guess my question for you is why is practice with feedback and that deliberate practice you were mentioning in these moments with simulated actors, how does that actually translate to what we do at the bedside?

Tessie October, MD MPH: It translates because the first thing is the feedback that comes from in real time in the session is first and foremost is positive, right? We want you to know what you did well, so you can continue doing that every day in your practice. Then we start to ask you about what do you wish could have gone better? And instead of me as the facilitator telling you feedback of, "This is what you should do," all of that feedback comes from the learner, right? So what is it that you want to learn? What is it that you want to take away? What was so hard for you about that interaction? How did you get stuck? And then we practice on how to get unstuck. We do it in small group settings, so you get to practice, but you also get to practice even if you are observing. And so you think about, ooh, when was that last situation that I had where I got stuck similarly? I might use those tools the next time I'm at the bedside.

Lillian Liang Emlet: So what you're saying is you really get customized ways to figure out what you want to work on, get intentional feedback directly from the group and also from the actors and the people who've been teaching VitalTalk for quite some time and watch all kinds of conversational practice, and then decide for yourself what you want to bring to your own practice. So it's really customized to you. So here's where you can practice with us. On Saturday, March 13th, the day before the Critical Care Congress opens in San Diego, Tessie and I are teaching, along with many other faculty, a full-day course on communication skills training just for critical care practitioners. This is VitalTalk at the Society of Critical Care Medicine. You'll work with realistic ICU cases. We'll have trained actors. We'll be practicing a range of serious news cases responding to emotion, and also getting into how do we determine goals of our treatment plans and care. It's built for physicians, advanced practice providers, nurses, respiratory therapists, pharmacists, social workers, chaplains, and people in training. So registration is at sccm.org, and the link is in the show notes below. And so Tessie, why is it so important to keep looking for chances to sharpen these skills even after we've been in practice for almost 20 years now?

Tessie October, MD MPH: Yeah. I would say I think about it like every other skill. Because we've been in practice for over 20 years, we were doing lines without ultrasound, and so eventually you realize, huh, there's this new technology that can help to not only improve my own skills but also can help me in teaching. And so just like the adoption of ultrasound to the eyeball, you name it, I think we have to do the same with our communication skills. Adult learning is an iterative process. It is something that we always should be trying to improve because at the end of the day, what matters most is our patients and families, and they deserve us to show up as our best versions of ourselves, the ones that are most skilled, that have focused on learning your own professional development so that you can come with the best skills to the table.

Lillian Liang Emlet: Yeah. I think obviously for any of us, a lot of times you often outsource this to trainees or people on your team, and then you become the teacher and the coach for the team to be able to have these conversations. And if you don't have intention, and if you don't have the skills to role model, then it becomes really challenging to lift everybody up and to have these debriefings and to think about how we might do things differently or even strategize how the week is going to go. And so I think having all of these skills, even 20 years later, trying to continue to refine it, continue to get more efficient, and begin to notice, I think so much of the opportunities, we don't notice the opportunity to try something that we actually learned in one of the courses. I guess I'm curious, what's one thing a clinician could practice in their very next family meeting? Why don't we give people a little sneak peek for some of the stuff that we talk about in our courses?

Tessie October, MD MPH: There are so many tools. Okay, you said just one, so I'm going to just give one. I would say my favorite question to ask is, "What else?" And what else does is that if you're asking somebody about their fears, like, "What matters most to you? What are you most worried about? What are you hoping for, given that we've said that his kidneys are unlikely to recover? What's most important knowing that information?" What you often get is a very surface-level answer for that first question, but the deeper fear, the deeper worry, the deeper hope lies below the surface, and it's often unroofed with something as simple as, "What else?" I would say even as a clinician who sometimes I'm not sure what I want to say next, I'll just say, "What else?" to give myself some time to figure out where I want to go in the conversation, because you're processing the data in real time of the information they gave you, and how do I turn that value into a treatment decision? How am I linking it? And sometimes my, my brain doesn't process it fast enough, and what else helps me to give me some time, but it also almost always gives me new information.

Lillian Liang Emlet: I love that. I also, with the what else it's always about what else is going on? Because we often only get a snapshot of what they're like at the bedside when they're in the ICU, but the reality is there's so much else going on outside their life. Well, actually, there's issues with your boss, there's issues with the kids, there's actually, there's what else is, also what, what else is going on with you? Because each person is not just focused only on this treatment plan that we obviously are highly focused on, but there's also so many things going on in any person's lives that they often don't want to admit to us. They don't think they're supposed to. And so I think it gives permission, that what else? There's so many things going on. Obviously there are things going on with us. We have all these other patients to take care of. But also acknowledging just that it's normal to have other things going on. I'm curious, what do you want clinicians who are listening to this and they're like, "I dread these conversations. I've been given some pretty bad feedback. I actually don't like getting feedback, and I am sweating just even thinking about doing this in a group with other people, much less my national peers." What do you say to a clinician who's listening to our podcast this far and has that in the back of their mind?

Tessie October, MD MPH: I guess I'll say that at the end of the day, this really is our job. It is so important that we don't leave families hanging and burden them with making the hard decisions. They rely on our expertise, our knowledge, our relationship with them to make a recommendation based on all the information that they've given us. So I would say that it can sometimes be scary and just like any other thing that might be scary, like writing, like trying a new skill, you got to try one thing and try one thing at a time. And I will say that families and patients are forgiving. We might not say the right thing or it might come out a little clunky. If you come from a place of curiosity and a place of truly caring about learning about who they are and what's important to them, you just can't go wrong and they will forgive you if it doesn't come out quite right as long as the meaning is there. And you really want to know, you're not asking a question about what are you hoping for just because it's a checklist. You're asking because you really want to know what are they hoping for given what I just told you about how your loved one is doing.

Lillian Liang Emlet: I love that. I also just always think about, I'm also nervous thinking about okay, if you have to reopen someone's chest or you have to do ECMO, I'm nervous about these really high, highly important and high acuity, but very low-frequency occurrence type of procedures. And yet conversations and things we do with our families and our colleagues and our peers happens every day and is so casual, yet it can really hurt somebody. And so I think it's really important to think about a little bit of willingness to just be in a safe place. Simulation is pretend at the end of the day. It is not, it is actually not real. And yet you will have tangible takeaways you can use in real life because you'll be able to recognize the patterns and see the things, and just having that safe place just to have a playground. We're really lucky and happy that so many places are adopting this, because at the end of the day, you can't talk to the chatbot. You can't just talk to the bot and think that even if the bot talks back in a very beautiful ElevenLabs designed voice, it's not the same as a real human with all the lived experiences. And so your lived experience matters in these conversations. And so having a place to practice and play is really important. And so I guess as we come to a close, I'm curious what, if there's any last things that I didn't ask you about that you're hoping to share with the audience about communications or life in the ICU or what it means to be a leader in conversations and communication in high-stakes environments?

Tessie October, MD MPH: I guess I want to leave with a message for all clinicians, is to give yourself some grace, that this is hard. This is hard on our patients and families, and it's also hard on us because we have been walking these paths with these patients, and we had hoped that the outcome was going to be different. And we had hoped that we would get to a place where you get to walk out of the ICU. And if we can't give you that, at least we can make sure that the experience is coming from a place of empathy and caring and compassion. And I want you to give yourself grace as well. This is not easy for us to do, but it does get easier the more you practice.

Lillian Liang Emlet: So well said. And I think everyone, every leader and every person in the team is leading from below, above, beyond. And so everything that you do say matters. And it's really important to be able to support each other through that and also give each other grace. So thank you so much, Tessie, for being here. How can people find out more about VitalTalk, what you do for your work? How can people stay in touch with you?

Tessie October, MD MPH: So I'd first say that VitalTalk, you can find them at vitaltalk.org. They also have an app that is on all the platforms that's free called VitalTips, and it has a lot of the core teaching materials like talking maps and some tools and tips that you can use right before you go into a family conference. It's called VitalTips, and you can find it anywhere you download your apps.

Lillian Liang Emlet: And so Tessie, thank you so much for being here. None of us finishes learning. We are always practicing, and it helps to have someone practice alongside us, and that's what we do at Transforming. And we'll leave all the show notes below with VitalTalk and Tessie's bio and a bit more about the link to the San Diego course in conjunction with VitalTalk and Society of Critical Care Medicine. Until next time, thanks everybody. Please contact us at podcast@transforminghealthcarecoaching.com and tell us what you want to listen to, what we should talk about next.