Communication the Cleveland Clinic Way Read online

  What Works in Communication Skills Training?

  Our initial question when we started to build our program was, what was known about the effectiveness of different approaches to teaching communication skills? Numerous studies had been published over the preceding decades that tested a variety of strategies, some of which focused on clinicians, while others focused on patients.1 Most describe small numbers of physicians in general practice or oncology. Others focused on medical outcomes and demonstrated that communication skills training for either doctors or patients could improve measurable medical outcomes such as blood glucose levels and blood pressure.2 Communication skills and communication skills training have both been associated with higher patient satisfaction.3 Not surprisingly, some educational approaches have been shown to work better than others.4 Also noteworthy is the relatively small number of studies employing rigorous study design.5

  When we reviewed the published literature on communication skills training, several key themes emerged. The first was that experiential learning and skills practice were key.6 Studies of didactic interventions that relied on cognitive learning showed no impact on future communication behavior. The implication of the data was that communicating well was more about skill than understanding. Like any skill, whether it’s playing tennis or the violin or building a wooden cabinet, it was necessary to break down the larger process into key core elements and practice them with opportunities for skilled feedback. We learned the key distinction between understanding how to communicate and being able to communicate. Just as the test of violinists is how well they play rather than how much they know, so, too, the key communication skills question is how well someone communicates. In our early courses, we saw this in physicians who could define empathy and articulate its importance but struggled to make an empathic statement. In building our program, we therefore concentrated on providing the best opportunities for skill acquisition and practice and tried to minimize the time spent on cognitive learning. Our primary challenge was to change behaviors rather than to increase knowledge.

  While this insight came initially from reviewing published studies, it also had face validity. Many of the communication errors that clinicians make can hardly be attributed to lack of understanding. Take, for example, studies that have documented an absence of empathy from clinicians. One finding is that, when faced with an upset patient, physicians often change the subject to something less emotionally charged, such as the medication list or past medical history, a phenomena known as blocking.7 Is it really plausible that physicians have a thoughtfully constructed theory that what a crying patient needs is to be distracted by changing the subject? Or is it more likely that crying patients make physicians uncomfortable, we don’t like to feel uncomfortable, and we lack a skilled empathic response, so we try to make the crying stop? Is the problem that clinicians don’t know what to do or that they don’t know how to do it? The patient’s distress provokes not an idea but a feeling in the clinician. Being and staying with a patient who is displaying strong emotion and learning to feel competent responding to that distress requires practice for most people. We expect a surgeon to use well-honed techniques to skillfully manage a bleeding artery, and address it directly. Yet the same event would cause panic in a medical student. Practice can help clinicians overcome their own internal distress in the presence of strong patient emotions and learn to respond in a calm and caring manner.

  However, practice is not enough.

  Without skilled feedback from people they trust, most clinicians have a hard time refining their skills.

  Clinicians are practicing communication skills every time they interact with a patient, but they are not receiving feedback in a way that can help them to improve. They may know that some patients are highly satisfied while others are not, but they have little if any data about which specific behaviors are resulting in which outcomes.

  Adult Learning Theory and Small Group Facilitation Skills

  While reviewing evidence-based components of a successful program, a second key influence on us was adult learning theory. We planned to educate attending physicians first before moving on to nurse practitioners, physician assistants, and physicians in residency and fellowship training programs. We knew that we would be working with professionals who, in many instances, had been in practice for at least a decade and that there was a risk that they would perceive us as telling them how to do their jobs. For these and other reasons, we designed our program to respect Knowles’s six principles of adult learning.8 These principles are that adults:

  Are internally motivated and self-directed

  Bring life experiences and knowledge to learning experiences

  Are goal-oriented

  Are relevancy-oriented

  Are practical

  Like to be respected

  We anticipated that we would increase resistance if we made participants feel that we were imposing ideas or techniques on them or defining for them the key challenges that they faced. This led to an emphasis on developing a learner-centered approach in which participants would help set the agenda, decide what cases would be practiced, and develop solutions to the problems that were presented or that emerged in the course of the class. By asking them to identify the sorts of patient scenarios that represented communication challenges for them, we allowed them to be self-directed, we respected their life experience, we tied the work to their goals, we made it relevant to their work, and we showed them respect. By emphasizing skills practice rather than didactics, we made the course practical. By facilitating a process by which the group of participants developed their own solutions to challenges, we showed respect for their intelligence and their experience. And because most clinicians dislike role-playing, we specifically referred to it as “skills practice” to emphasize the purpose rather than the activity.

  Working in this way, however, required learning many skills related to small group facilitation. Historically, most medical education has been based on a model of the expert disseminating knowledge to the less expert. Lectures and highly hierarchical apprenticeship experiences predominated. The learners watched the expert and tried to model their own behavior on what they observed. In communication skills training of attending physicians, we did not think such a model was appropriate, nor was it likely to be accepted by participants. Our participants had extensive experience and their own wisdom. They had developed practical, if not optimal, approaches to the challenges that they faced. Providing a context in which they could reflect upon their challenges with a group of experienced colleagues and consider alternative approaches seemed more promising than telling them to do things differently: we aimed to facilitate learning rather than teach. In our judgment, our having expertise in how to communicate effectively was less important than having expertise in how to facilitate small groups so that an effective learning environment could be created. Our primary goal became fostering the formation of an effective group that could teach itself. In that way, we envisioned the communication skills course that we were developing not so much as a classroom but rather as a tumor board where different perspectives could be heard and a collective wisdom could emerge. One benefit of this approach was that it eliminated many sources of pushback: if we weren’t setting the agenda and we weren’t providing solutions, there was less to resist. By asking participants to come up with their own solutions, we were respecting them as professionals and encouraging them to take responsibility for their own learning and for the development of as high a level of competency as they were capable of achieving.

  Keys to Small Group Communication Skills Training Facilitation

  Express curiosity about and interest in participants.

  Use facilitators who have credibility with participants.

  Attend to group formation by making everyone feel welcome and using icebreakers and check-ins.

  Use participants’ past experience when building the agenda.

  Establish ground rules (e.g., confidentiality, respec
t all opinions, silence, and put away all electronic devices).

  Assess learners’ goals.

  Foster an appreciative environment focused on reinforcing feedback relevant to learners’ goals.

  Allow participants to make their own discoveries, draw their own conclusions, and come up with their own answers.

  Creating an effective small group learning environment required several specific steps (see box). First, we didn’t want to be told that we didn’t understand the challenges that clinicians faced, so we only recruited facilitators who were busy clinicians themselves. Second, we were not focused on patient satisfaction scores in developing the course and were wary of being perceived as agents assigned to improve scores, so we emphasized the relevance of communication skills to quality medical care and to physician experience. We asked participants to reflect on their own positive experiences with the healthcare system when they were patients or family members of patients. Third, we established ground rules that were reviewed at the beginning of each course that encouraged active participation, confidentiality, openness to different opinions, and silencing of electronic devices. The last item is important: having people on their smartphones during the course would have been distracting and prevented full engagement by the group as a whole, so participants were asked if they were expecting any urgent calls or e-mails that couldn’t wait until the next break time. If they said no, then we established an expectation that phones and other devices would be put away. Fourth, we developed warm-ups and check-ins to facilitate the formation of relationships among the different participants. Warm-ups involve a series of crafted questions and exercises to gradually move people to a more creative and playful space, from left brain to right brain, which is essential to immersion in this training experience. Rest assured, they can go back across the corpus callosum in a little while.

  Keys to Making Skills Practice Fun and Effective

  Set clear ground rules: The person in the driver’s seat can take a time-out to reflect or ask for help.

  The facilitator can take a time-out to make teaching points.

  Feedback, including self-assessment, starts with what was done effectively before addressing opportunities for improvement.

  Feedback starts with self-assessment by the person in the driver’s seat before others provide feedback.

  Experimentation is encouraged and imperfection is expected.

  Skills practice has a time limit.

  Bring an attitude of exploration, experimentation, and adventure.

  Make it relevant to the learners’ goals.

  Do warm-up activities to help loosen up participants so that they can enter a more playful space and get into character.

  At a broader level, we worked to foster an effective learning environment by creating a strongly positive and appreciative climate within the course. Much of the medical world is defined by deficit-based thinking. When a medical imaging study shows nothing bad, we say that the study is negative. When it shows a cancer, we say the test is positive. When no disease or abnormalities are found on a history or examination, we call it “unremarkable.” We often only start filling in details when we find markers that herald disease. In some senses we stay quiet when all is healthy and only speak up when we find pathology. This culture carries over into the educational and interprofessional environments. People associate feedback with criticism, which isn’t what effective feedback really is. When everyone is doing his or her job well, we are quiet. When people know what they are supposed to know, we take it for granted. We speak up when there is a mistake, a complication, or when someone answers a question incorrectly. This creates an environment where the priority becomes avoiding looking ignorant or foolish, and this can stifle creativity and experiential learning.

  Our prioritization of overcoming the hypercritical environment of the hospital led to specific feedback strategies.

  Structure feedback to be primarily supportive and reinforcing, aiming to give four times as much reinforcing feedback as corrective feedback.

  Ask for learners’ goals and focus feedback on areas they have identified as being of interest to them.

  Have the participants reflect on their own performance, starting with what has been done effectively, followed by reinforcing feedback from others, before moving to self-reflection on what could have been done more effectively and modifying feedback from others.

  Be careful not to overload participants with excessive feedback by asking them “How is this landing on you?” or “How are you feeling about the amount of feedback at this point?”

  In this manner, we aimed to create an environment in which learners felt supported and felt that the group was looking for the best in them. Additional steps designed to create an appreciative environment included warmly welcoming participants at the beginning of the day and getting to know them over breakfast prior to the start of the class; warm-up exercises at the beginning of the class so that the participants could learn about each other; ample food and beverages so that participants felt cared for; and an eagerness to hear their opinions and solutions before or instead of offering our own.

  Organizational Strategies for Success

  Many of the steps described above seemed critically important to enhancing buy-in through effective facilitation: working in a learner-centered way on challenges that they identified, attention to group formation, creating a safe learning environment, respecting their experience as clinicians, and fostering an appreciative climate. However, there were other key elements more related to organizational strategy, which was more about leveraging communication skills training as a means to engage physicians. In many ways, Cleveland Clinic’s history and Patients First laid the groundwork for us.

  One was maintaining sensitivity to local culture and expectations. Cleveland Clinic grew out of a multispecialty group practice and is still in many ways a physician-run healthcare organization. Unlike some academic medical centers, high-quality clinical care is the highest priority of the institution, and busy clinicians with expertise are highly respected regardless of whether they publish a lot of papers or bring in external grant money. Our decision to recruit only busy clinicians as communication skills training facilitators was partly a reflection of our culture in which clinicians are highly esteemed. We believed that participants would be most open to reflecting on communication challenges with colleagues who also spent a significant amount of time seeing patients and confronting the hassles, annoyances, and inefficiencies that often exist in patient care settings. In a different hospital, it’s entirely possible that clinicians would be more interested in working with people with a doctoral degree in education or psychology who brought specific academic credentials certifying them as qualified to teach communication skills. Sensitivity and responsiveness to local culture increases the likelihood of buy-in.

  Second, we sought as much voluntary participation in the course as possible and knew that busy clinicians were unlikely to decide spontaneously that they wanted to spend a day in a communication skills training course. We knew that when we first started teaching the course, our skill level as facilitators would not yet be well developed. Yet when a new program is rolled out, it typically gets the most attention in the early days, when kinks are being worked out and new faculty are getting up to speed and developing their expertise. The first sessions will not go as smoothly as desired. Unexpected challenges arise, and facilitators learn to adjust to the variations that occur from group to group. If the first few sessions go badly and word gets out that the course is not a good product, support and participation can evaporate quickly. Just as theatrical productions on Broadway often start with runs in smaller cities where the kinks can be ironed out away from the limelight, so too did we think it important to start our work in an environment in which it was safe to have a few failures while we figured out what we were doing. We addressed these challenges by asking friends and colleagues whom we knew to be effective communicators and to have a strong interest in com
munication skills to participate in the early sessions of the course. We asked them to give us feedback so that we could improve. By doing so, we earned constructive criticism and support rather than word-of-mouth sabotage. The result was a kind of stealth marketing campaign whereby the friendly early participants went back to their various departments and divisions and told their colleagues what a wonderful course it was. This led to rapid escalation of participation in the course, and by the time that happened, we had had substantial practice and had developed confidence and poise as facilitators. When the course was made mandatory for all physicians, it had a strong reputation as being a high-quality and relevant experience.

  A third critical element enhancing buy-in was strong commitment from the highest levels of leadership at Cleveland Clinic. There were strong endorsements of the course at staff meetings, and generous resources (i.e., time) were provided to support the work. The leadership support occurred in the context of a broader and more comprehensive effort to improve patient experience and to make all hospital employees see patient experience as a priority. This made the emphasis on communication skills training more credible and positioned it as a key element of the larger institutional mission. Hospital leaders further signaled their belief in the importance of communication skills training by having the entire executive leadership team take the course, including colleagues in financial, human relations, and operational leadership roles.

  A fourth organizational strategy was investing in our facilitators to make them effective, as well as to build a strong cadre, which we believed would reward us in the long term. Preparing trainers to work in this manner where they are facilitating learning rather than teaching, reflecting questions and resistance back to the group, and creating an appreciative and safe environment requires substantial time and training. Facilitators need practice to achieve competency. There is a steep learning curve, and we invested time and effort in observing our facilitators in action and holding regular faculty development sessions.