Communication the Cleveland Clinic Way Read online

  Strategy and Myth

  Despite all the efforts made to drive Patients First, we still needed a strategy to engage physicians. Although the government had built a burning platform, physicians still struggled to see which pieces we could influence. Certainly, we could improve safety and quality, and we also control how we communicate, which is core to the patient experience. Not only does how well caregivers communicate drive overall patient satisfaction ratings, it also drives safety and quality and lowers the risk of being sued for malpractice.

  We spent over a year developing our content and a year piloting it, a process we detail in this book. One thing we learned, however, is that no matter how strong your content or how powerful your curriculum, significant vision and strategy is vital to bringing clinicians to the course itself. In fact, when we talk about the communication program nationally, people rarely ask about the content—they are most curious about how to get clinicians engaged. This brings up several important arguments we’ve heard about why communication skills aren’t important or why training won’t work and how you might respond to them (Table 1.1).

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  TABLE 1.1 Exploding Myths

  Five Myths about Communication Training and Approaches for Discussion

  Myth: Physicians don’t care.

  Acknowledge and listen to stress factors and causes of burnout.

  Ask physicians about what gives their work meaning—usually it’s time with patients.

  Discover what the physician does care about, and build from that.

  Myth: Basic communication skills aren’t needed.

  Explore real-world personal and professional challenges caused by basic skill deficits.

  Elicit the physicians’ own stories—the cases that haunt them.

  Link basic skills to leadership development.

  Promote lifelong learning and sharing of best practices for a given scenario or population.

  Myth: You can’t teach empathy.

  Know and share the decades of evidence that you can.

  Stay curious about prior learning experiences with empathy and communication.

  Demonstrate that empathic behaviors can be taught through innovative design.

  Myth: Residents, not staff, need the training.

  Learning is lifelong for staff and trainees.

  Residents watch staff closely and learn from their behaviors, including communication skills.

  By dedicating attention to communication skills, staff attendings message its importance and value.

  Caring for patients is a team sport, so everyone has a responsibility.

  Myth: Communication training is all about HCAHPS scores.

  Acknowledge that changes in healthcare are difficult.

  Expand the discussion to how communication skills training benefits the individual clinician.

  Show how effective communication impacts outcomes, satisfaction, safety, and efficiency.

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  1. Physicians don’t care

  By and large, this is simply not true. In our experience, the perception of apathetic physicians is much more likely a product of today’s healthcare environment. At times, we have all struggled with the sheer volume of information and tasks coming at us: electronic medical record messages, prescription refills, MyChart messages, alerts about open encounters, forms that need signing, physician metrics to document and complete, consent forms, e-mail messages, and our pagers, among many others. We must recognize that as we improve our electronic documentation, we seem to get better at generating it. Multiple studies have demonstrated physician dissatisfaction with feeling pulled away from our patients. That’s just our experience. If you are a community physician who rounds alone in the hospital before starting your own clinic, you may go back to the hospital at the end of the day and still have to finish your notes. We must appreciate that many of our providers are overwhelmed, disconnected, and unhappy about it. Expecting our community to simply sign up for a good course is wishful thinking. Physicians are making choices about their time, and communication courses fall low on the list of priorities. In designing and executing communication courses, we must acknowledge and address these physician concerns head on.

  2. Doctors don’t need foundational communication skills

  The irony of communication skills programs is that many among the target audience don’t think they need them. We’ve heard repeatedly, “I’m very good at this. I’ve been in practice a long time,” “You don’t really value communication. This is about the scores,” “If I just gave more narcotics, my scores would be better,” “My patients really like me,” or “So you want me to be soft and fluffy instead of doing my job?” As one participant put it, “I thought—being an empathic sort and thorough in history taking for over 25 years—I would have little to learn.” To be honest, we were a bit surprised by our fellow physicians’ lack of willingness to embrace foundational communication skills and the failure to recognize that if we are not willing to learn and practice relationship-centered communication skills, how can we be sure our patients are benefiting from them? Our students? Many told us that they studied communication skills in medical school, and then the skills were effectively squashed out during training. Then we unleash them as staff physicians and never provide them with any feedback on their communication skills, despite giving them ultimate responsibility for a patient’s clinical care and experience. We then promote our caregivers into leadership positions where they have challenging management conversations without training or preparation. If we do not open ourselves to the process of enhancing our skill sets, our performance will peak and remain stagnant. How can we as a healthcare community promote lifelong learning when we resist learning ourselves? Why is it that we believe that completing our fellowship means we have learned all there is to learn? In other fields, the idea that you already know everything you need to know is not an accepted norm, and yet in medicine it is.9 Why does Serena Williams have a tennis coach? Doesn’t she know what she is doing by now?

  3. Physicians can’t be taught to be empathic—you have it or you don’t

  There’s been about 30 years of research in the field of communication skills training and its impact on the individual clinician. Multiple meta-analyses have been completed. Through the work of Wendy Levinson and others, we know that effective communication impacts malpractice claims. We know that it also impacts patient safety and quality, physician experience, patient experience, and there is an emerging body of literature on its impact on health outcomes.10

  We are hardwired for empathy, and the concept matures with the growing brain. Functional MRI studies have expanded our understanding.11 Although a personality and habits may be firmly rooted, the use and acquisition of new relationship-centered communication skills is a choice, as is any meaningful behavior change. In our experience, physicians must be receptive to learning new things and then choose to do a few things differently in order for communication skills training to have an impact. By simply saying it is an innate skill, clinicians excuse themselves from having to acquire and master it.

  Rather than create a checklist of all communication skills that a clinician should learn, we promote the concept of reflective competence. With respect to communication skills, this is the ability to reflect on the words that come out of our mouths, get feedback on them, and then practice new language deliberately and intentionally.

  4. The residents (or consultants) need this training more than I do

  Today, more than ever, we are providing care in teams. Sometimes hospital patients see a single clinician; other times, they see a rotating, dynamic team. From our standpoint, this simply raises the bar. If your score is reliant on 30 other people, then you should be working hard to get those 30 other people on the same page. When we have the option of who to choose for a consult, we should exercise that option. If we don’t, we should communicate directly with patients that as the attending staff in charge, all final decisions regarding their care will be
the result of a discussion of the issue between us and them.

  Residents are watching the staff. It’s how they learn the art of medicine. If the staff don’t model these skills, or can’t identify what they are or why they were used, the team won’t learn them. This latter part is critical. On multiple occasions, I’ve been told that Dr. X is really well liked by patients. “What does he say or do that makes him effective?” we would ask. “What do you mean?” is usually the response. If we push harder and ask for specific words or phrases that resonated with the patient, we sometimes hear, “He really listened” or “He sat down.” What is fascinating about these exchanges is that if we cannot identify effective language that has the most impact on our patients, we lose the opportunity to teach it to others. Oftentimes, effective practitioners are simply identified as “nice” or “friendly.” This undermines the complexity and intricacy of effective communication. A doctor can be nice without using reflective listening, the skill of reflecting back to the patient the content or emotion of what was just said to reinforce that it was heard. He can be nice without empathizing. She can be friendly without shared decision making. Our goal is not simply to be nice; we aim to form strong, authentic, caring, and mutually respectful relationships with effective skills.

  If there are multiple people on your team, as there often are, then many of the medical details are already known. You may even have heard them before you walk into the room. If that’s the case, then you have the luxury of being able to fully engage with the person. The patient is already known.12 The human being is not.

  5. This is just about the scores

  When we hear the comment “This is just about the scores” during the communication course, we typically respond, “Of course we live in a new healthcare environment. We all recognize that. However, for me as your colleague, this work means much more and has transformed my practice. I keep doing it so that I can inspire the same in my colleagues.”

  We rolled out our Foundations of Healthcare Communication course (FHC) shortly after the communication scores became transparent. As an institution, Cleveland Clinic wanted to hold people accountable for their scores, while also providing them with the educational resources to improve and developing communication skills training that took into account how difficult it is to be an effective communicator in today’s practice.

  Although the origins predate the current emphasis on HCAHPS scores, the course contents could not have been more timely. I am going to try some of the techniques that I learned tomorrow. I really appreciate your willingness to do this. I imagine that it is not easy to deal with a bunch of doctors.

  —COURSE PARTICIPANT

  Caregivers are having high-stakes conversations with patients and families daily without any feedback about how to do it or what might be more effective next time. This goes beyond service excellence or customer service. Some doctors are very frustrated by challenging conversations with patients for which they don’t feel well prepared. If the conversation doesn’t go well, there is an emotional impact on the provider that increases his or her sense of helplessness. In addition, we know that communication gaps are at the root of ethics consultations,13 calls to the ombudsman’s office, and safety issues. As an organization committed to the success of our caregivers and the care of our patients, Cleveland Clinic provided the skills and tools our people need.

  Fueled by a changing healthcare landscape that is driving transparency and individual physician accountability, the burning platform for communication skills training across the health system was created. Because we began our journey developing a communication skills program for physicians, we will focus on them. We know full well that all caregivers impact the patient experience, and we also know that many clinicians have unique communication needs given the complexity of their work. We’ve included the perspectives of advanced care providers to date and have much more to learn about this group, as well as nursing. We’ve grown and expanded since then, but this is the story of the beginning of a lifelong journey.

  The answer is yes, we teach empathy at Cleveland Clinic.

  Chapter

  2

  Leveraging Your Burning Platform

  Our Story

  My invitation to develop a communication skills program for Cleveland Clinic was entirely unglamorous. Merlino took me for coffee and, as we were catching up, asked if I would take on such a role. Without thinking, I said, “Yes.” As I (Adrienne Boissy) walked out of that meeting, I had the distinct feeling that I had accepted an enormous job that I felt unqualified to do. I’m a neurologist, not an educator or communications guru. By the time I made it back to my own office, I had started wondering about my colleagues and friends. How would I ever be able to deliver something to them that would matter? By the time I made it home, I had successfully talked myself out of the job. No way could we engage seasoned clinicians in communication skills training. But as I considered how I would want to learn communication skills, I decided that this was the kind of chance I needed to grab and run with. When was the last time someone helped me understand how to have the tough conversations? What if we could actually build something that would help all of us feel more comfortable having the difficult talks? The challenge was enticing. To his credit, Merlino gave me a blank slate to work on and told me to figure it out. So off I went.

  Caregivers in healthcare are compassionate, dedicated, and hardworking. Physicians are also data-driven, outcome-focused, and default thinkers. When we tell patients we teach communication skills to physicians, they say, “Thank goodness!” When we tell educators, they say, “Good luck!” And when we tell physicians, they typically say, “What for?” When I was swapping ideas one day with Ananth Raman from Harvard Business School, he highlighted that we might learn something from the seat belt industry. How do you convince people that they need something they don’t think they need?

  Task Force Assembly

  The path was totally uncertain, so it seemed best to gather a team of like-minded believers in the concept of relationship-centered communication who could help define it. The core group included Dr. David Vogt (senior hepatobiliary surgeon), Dr. Amy Windover (psychologist and director of Cleveland Clinic Lerner College of Medicine communication skills training), Shirin Rastgoufard (project manager), Paula Timco (experience improvement), Dr. Tim Gilligan (oncologist), Dr. Vicente J. Velez (hospitalist), and me. We met monthly to survey the current institutional environment and to formulate an approach. What programs already existed and in what areas? Who led them, and what tools or models were they using? Areas we surveyed included the Office of Professional Learning and Development, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic Academy (Education Institute), ACGME competencies, national communication organizations (American Academy of Communication in Healthcare [AACH], Institute for Healthcare Communication [IHC]), and comparable organizations. This inventory took a year. Yes, an entire year.

  An important benefit to this approach was that we learned about what efforts were underway in our own house, which presented the opportunity to unite these efforts. This served us well. We learned that we were using outside consultants to teach communication skills, small departments were working with other institutions because they had previously worked there, and others had started their own programs for their own populations. After surveying what we had, we worked to unify the language and model we wanted to use. If you are hoping communication skills will stick, the effort can’t be fragmented by diverse models taught throughout the organization. It has to be one unified program. We spent significant time learning about existing resources and rallying them.

  Dr. Windover had a key role in leading communication skills training at the medical school, and she brought a depth of experience and credibility to the program. She was mapping to competencies and making sure we understood our objectives and built content to those. You’ll notice that we didn’t have a lot of faculty from the medical school initially, and as we look back on our
ability to roll out a program that resonated with providers, this was a key—albeit accidental—decision. Because we didn’t have a road map, we really were able to design a curriculum that was creative and adapted to our local culture. We were not a group of seasoned educators, and although we felt like fish out of water, we also felt unconstrained by philosophies of “that’s the way it’s done.” At the same time, we were intentional about being guided by published evidence of what works.

  We consulted with several groups in the initial evolution of the work. At the time, one of the most evidence-based models that existed was the Four Habit Model©, which had been created at Kaiser long before the patient satisfaction surveys of today. The habits are (1) creating rapport and collaboratively setting an agenda, (2) eliciting the patient perspective, (3) demonstrating empathy, and (4) delivering diagnostic information in a manner that the patient can understand. With gracious permission, we used this for our initial internal training for about a year before we developed our own for reasons that you will learn more about in Chapter 5. Several other models of communication exist. What is important to note about models is that they give providers a clear framework for approaching a given conversation rather than just seeing how it goes or winging it. When conversations are complex, emotions run high, and the risk of failure is great, why would we think that winging it is an effective strategy?