Communication the Cleveland Clinic Way Read online

  Finally, time is precious in the healthcare environment and must be addressed by the organization. Hospitals and practices are running on ever-tighter budgets, and clinicians and administrators face increasing pressure to maximize revenue by seeing as many patients as possible. Pulling clinicians out of clinical work for communication skills training means lost revenue in the short run with no guarantee that it will be made up in the long run. A frequent response to this problem is to propose that clinicians have an early morning or lunchtime lecture on how to communicate effectively, an approach that has been shown not to work. Just as people cannot learn to ski or play tennis by attending a one-hour lecture or a long series of lectures, nor can people learn to communicate more effectively with such an approach.9 Learning new skills requires opportunities to practice. We designed our course to last a full day because we discovered that we needed at least that much time to include meaningful skills practice and because we could not realistically ask for more. It also took time for the small groups to coalesce into a coherent and trusting team in which participants felt safe enough to participate effectively in role-plays. It’s hard for that to happen in an hour. Anyone preparing a communication skills course needs to be prepared to ask for sufficient course time to accomplish meaningful work. Changing human behavior is difficult and cannot be done quickly and cheaply. Outcomes studies of communication skills training initiatives report that in order to be effective, programs should last at least one day.10

  Overcoming Resistance to Skills Practice

  If you walk into a room of physicians and ask them for volunteers to participate in a communication skills training course, you will find few raised hands. If you mention that the course will include role-playing, most people will leave the room as quickly as possible. And yet our experience has been that many of our participants have requested additional opportunities to continue practicing their skills using role-play exercises. Why do role-play exercises have such a bad reputation? How does one make them fun and productive?

  When role-plays go wrong, the etiology can usually be tracked to a facilitator who is not prepared, skilled, and fully comfortable working with physicians. We are not saying that people don’t have the best of intentions; we are saying that teaching communication skills is complex, high-risk work, and it should be thoughtfully planned and meticulously executed. Role-playing is a vulnerable place for most people to be; participants should be handled with appropriate care.

  For example, leaders of one major hospital system that invited us to work with them reported that when they sent a faculty member to their simulation center for remedial training in communication skills, she walked out of the session in tears because she felt so humiliated. Trainees who participated in communication skills training role-plays at the same center rebelled and refused to continue their participation. And yet when we ran sessions for them, we found that, by the end, the trainees were volunteering to participate in our “skills practice.” Similarly, attending national conferences throughout our careers, we have seen that the typical role-play scenario involves pairing up with someone who happens to be sitting next to you and practicing specific scenarios with no skilled observer present to provide feedback. No structure is provided to help people identify what they are doing effectively and what they should consider doing differently. It’s like playing the piano without being able to hear anything.

  Other scenarios involve bringing people up in front of a group to play a role without preparing participants to succeed in their assigned roles. Sometimes it’s not clear which skills they are supposed to practice or demonstrate. Sometimes they’ve been given inadequate preparation to assume the assigned role. Often the agenda is set entirely by the teacher with no input from the learner about what he wants to work on. Feedback often is provided in the typical deficit-based manner where shortcomings are highlighted and less attention is given to what was done effectively. The experience of participants is that they are placed in an exposed position, asked to perform a task not of their choosing and for which they feel inadequately prepared, and then criticized for anything that they do ineffectively in front of an audience. Who would volunteer for such an experience? We wouldn’t, and we’re pretty sure you wouldn’t either.

  What we realized was that we could only succeed with skills practice if we were highly conscientious about establishing a process that was safe, constructive, and relevant to the participants’ goals and work. And we wanted to make it fun. A key element here is working hard to prepare participants to succeed so that feedback can focus on reinforcing their success. Setting people up to fail and then giving them feedback on their failure is mean and counterproductive, not to mention the kiss of death for your program.

  Making skills practice safe requires very specific steps. First, there need to be ground rules so that participants know what to expect. We allow the participant practicing a skill to pause at any time if he or she feels stuck or wants to talk through what is happening or what to do next. We ask the participant to tell us what he or she wants to work on and get feedback about and then focus on those issues. We clearly define the skill that we want participants to practice and make sure that they have a plan for what to do before they begin. We take careful notes so that we can give feedback on specific behaviors and word choices, and we avoid evaluative language. Telling a participant, “The patient seemed to start to calm down when you said, ‘I know your time is valuable, and I can understand why you would be angry about having to wait so long,’ ” is more helpful than “You did a great job calming the patient down.” We work hard to eliminate language such as “good/bad,” “liked/didn’t like,” and “great” and replace it with “effective/less effective”—the former has a value judgment, while the latter does not. In addition, we always start feedback by having the participants in the role-play reflect on their own performance, beginning with what they did effectively. When observers give feedback, they also must start with what was done effectively. This creates, as noted previously, a culture in which people feel confident that others are looking for the best in them and giving them credit for their successes. Ninety-eight percent of physicians are challenged by this and usually start phrases with “I did well at ____, but I didn’t do ____ and ____ and ____.” This pervasive tendency requires active facilitation. In such a supportive environment, people become more willing to take risks, try new things, and be open about where they think they can improve.

  A related issue is the defensiveness that arises when clinicians perceive criticism that they are poor or unskilled communicators. This is not to be taken lightly or underestimated. Because all caregivers are deeply invested in the care they provide, phrases such as “your scores are low” or “I wouldn’t have said . . .” can be interpreted as a criticism of them as a person and caregiver, which puts them at high risk for being emotionally hijacked. They then worry more about protecting themselves than about learning.

  One agenda that participants often suspect is that communication skills training is designed to improve patient satisfaction scores and that participants are selected if they are considered poor communicators. The implied agenda is that we are there to fix them. The key problem here is that it is very hard for people to learn when they feel defensive. If they feel criticized and overly stressed, they are more inclined to show you how much they already know rather than to learn new things. Defensive participants also tend to focus on all the shortcomings of any alternative way of communicating because they are invested in justifying their current practices. Actively displaying abundant respect for and appreciation of the skills and experience of participants was essential in our work. When the participants perceived that we admired them and were not there to remediate, their need to defend themselves diminished and they became more open to experimenting and learning.

  Some communication skills programs focus exclusively on reinforcing feedback. We chose to give both reinforcing and modifying feedback to enhance credibility and authenticity
with physicians. No one is perfect; there is always something that could be more effective. Our goal is not to hide from this reality but rather to create an environment in which carefully chosen opportunities for improvement can be explored safely. By the same token, we reject the feedback sandwich in which criticism is surrounded before and after with praise; everyone knows that a sandwich is primarily defined by what’s in the middle, and the praise can come across as perfunctory. This raises a key point: reinforcing feedback must be sincere and specific, and facilitators must therefore develop finely tuned observational skills so that they notice and can identify effective behaviors upon which they can comment. Many of us have tuned our eyes and ears to focus on mistakes and imperfections, and this bias must be conscientiously unlearned.

  The notion that role-plays can be fun may sound naive, but our experience indicates otherwise. The word “play” in role-play is often overlooked, yet making role-plays playful is key to their success. An important issue here that extends well beyond the issue of role-plays is agenda setting. One of the reasons we think that communication skills training in general and role-play exercises in particular generate so much resistance is that the participants experience someone else’s agenda being imposed upon them. The teacher has drawn a path and now expects the students to walk it. Adult learners resist being controlled in this manner. We did not want to be salespeople pushing a product. We wanted to invite people into a fun and productive environment where they could try some new things to help them with challenges in their work lives.

  One alternative to walking a predefined path is going on an adventure. If a communication skills course can be viewed as a learning laboratory, then the task is to experiment with new things and discover what happens. As with a scientific laboratory, the key question isn’t so much who’s right and who’s wrong but what did we learn from the last experiment and what would be a logical next step. Approaching such work with a sense of curiosity and wonder, an openness to the many different approaches that can be applied to any given communication challenge, feels very different from arriving with a set of hoops through which participants are expected to jump.

  Similarly, although we had defined what we viewed to be a key set of core communication skills, we strove to present these skills as options to be tried and tested so that participants could decide for themselves what worked for them. And if they wanted to experiment with their own alternative approaches, we encouraged them to do so. We believe that their own experience and feedback from other participants would be far more persuasive than anything we could say. This turned out to be quite true. Physicians most valued the feedback from the patient, followed by their peers and then the facilitator.

  Power Points

  Credibility and validity will be issues when creating communication skills programs. Anticipate skepticism and resistance and be prepared to meet them with empathic curiosity.

  Communication skills programs must include experiential learning (as opposed to passive didactics), be rooted in adult learning theory, and last one day or more.

  Do facilitate; don’t lecture. Create opportunities for participants to make their own discoveries rather than spoon-feeding them yours. Leverage the expertise of your group for maximal engagement.

  Invest in faculty development for facilitators. Feedback skills are critical.

  Be on the lookout for emotionally hijacked learners. Show participants the same empathy you hope they will show patients.

  Start by knowing your culture, securing leadership endorsement and resources for facilitator training, and clarifying time coverage.

  Begin small, and do not try to grow the program until it is working effectively. Test and develop the initial offering with friendly, known participants before opening it to others.

  Appreciation, safety, fun, and setting participants up for success are critical to optimal learning in skills practice.

  Chapter

  4

  Birth of the R.E.D.E.TM Model

  Whatever the nature of our wounds, we heal to be healed.

  —ANTHONY SUCHMAN AND DALE MATTHEWS1

  Healthcare providers go into medicine to help alleviate human suffering. Though medical training quickly zeroes in on building biomedical knowledge and expertise, relationships are essential to our health and well-being as well as to our basic survival. Cozolino asserts that we are all social beings, developing relationships on multiple levels “from neurons to neighborhoods.”2 We are shaped from birth by our dependency on others to meet our basic physical and psychological needs. We quickly adapt—learning how to interact with our environment and develop meaningful relationships that activate development of brain structure and biochemistry.3 Should it be surprising then that these personal connections play a vital role in our physical and emotional development and well-being? Meaningful relationships have been shown to be therapeutic, in and of themselves, resulting in improved health outcomes such as lower blood pressure, better pain management, and weight loss.4 Mindful awareness and intentional practice of empirically validated and efficacious communication skills have the power to deepen our connections with others.

  Healthcare providers feel deep responsibility in caring for people. Reversing a diagnosis that someone has had for years is delicate work. Getting patients to take medication when they don’t believe it will be helpful is challenging. Rather than explore the patients’ goals and motivations through meaningful dialogue, clinicians often try to convince patients to do what they want them to do. Perhaps as biomedical advances led providers to become increasingly specialized, the focus of the individual also narrowed. The inability to view the patient in his or her entirety has led many to feel disenfranchised and disengaged from their own care.5

  At the same time, with increasing consumerism in healthcare, patient-centered care is commonly championed in today’s healthcare environment. It has permeated the atmosphere of medicine. Patient-centered care and the inclusion of psychosocial elements in the biomedical framework have been valued increasingly as research unfolds to support a more holistic and humanistic view of disease, illness, and patient care.6 One of our challenges in teaching communication skills is to address the disconnect between the doctor-centered, pathophysiology-based perspective and the more holistic, patient-centered perspective. As part of the R.E.D.E. to Communicate: FHC course, we ask providers to recall a positive healthcare interaction they’ve had as a patient. We then ask them to identify what it was that made the encounter powerful and memorable. Commonly, the stories speak of feeling cared for and valued. They express gratitude that the clinician took the time to get to know them as a person and to listen to and understand their concerns. When they find themselves in the role of patient, physicians value the experience of being seen as a human being. This should not be surprising. As healthcare providers, we have the power to connect and be present with patients in that dark, lonely space so often filled with fear, pain, and loss. Our willingness to meet patients in this space and walk alongside them can be therapeutic for all concerned.

  Unfortunately, in the current climate of economic uncertainty, tightening budgets, and demands for increased productivity, the focus on patient-centered care has resulted in many clinicians themselves feeling disengaged. Pressure to make up for deficiencies in the current healthcare system, to improve access, efficiency, safety, and quality while completing extensive documentation that often seems irrelevant to improving their patients’ outcomes or experience, with less time and fewer resources for the things they believe to be important, all contribute to dissatisfaction among providers. Providers also suffer from information overload with requests arriving via mail, e-mail, pager, smartphone, fax, and electronic medical record. The number of medical journals has exploded such that a new medical article is now published every 26 seconds; keeping up with a specialty requires increasing time and effort.7 Consequently, we have learned to juggle many balls and to filter much of what comes at us. Unfortunately, this multitasking and select
ive attention clouds awareness and prevents us from being fully present in any moment, much less in one with a patient. A certain degree of stress can be healthy to motivate and achieve peak performance.8 Too much stress, however, can lead to distress and burnout, and can render clinicians incapable of being mindfully present with patients, much less communicating effectively. When overburdened clinicians are asked to be more patient-centered and to attend more to patient experience, they may say, “Well, what about my experience?”

  A Solution That Resonates with Clinicians and Patients

  Relationship-centered care, and relationship-centered communication as the primary vehicle, bridges this dichotomy by shifting the focus and power to the relationship or personal connection between provider and patient.9

  Relationships in healthcare extend far beyond that of patient-provider. Today, healthcare occurs among interdisciplinary teams and within the community at large. The Pew-Fetzer Task Force on Advancing Psychosocial Health Education established relationship-centered care to better recognize the value of these multilevel relationships and the unique perspective of each participant in caring for individual patients.10 Building upon this formulation, Beach, Inui, and the Relationship-Centered Care Research Network outlined four major principles of relationship-centered care (RCC).11

  The first principle is mutual respect. Both provider and patient are recognized and appreciated for their unique perspectives, experiences, and expertise.12 As a provider, this is a blend of personal and professional culture, socialization, education, and practice. Patients present with personal expertise characterized by their experience of their illness, preexisting knowledge, life experience, and sociocultural upbringing. Tempering the historical power differential through mutual respect improves a patient’s sense of efficacy.13 Self-efficacy is a key component in one’s readiness to change behavior whether it be taking insulin for diabetic management or acting on a referral for additional testing to rule out a malignancy.14 A second characteristic of RCC is eliciting and understanding the psychosocial context in which the patient is experiencing a particular biomedical issue.15 We must possess and convey genuine interest in the patient as a human being with individual thoughts, behaviors, and emotions. Without intentionality, such sentiments can easily go unvoiced due to time and task demands. Through exploration of the patient’s perspective and psychosocial context, we can be more mindful of and attentive to the patient’s needs and thus evolve our healthcare relationship. A third characteristic of RCC is acknowledgement of reciprocal influence. Though patients are the focus of healthcare relationships, both parties influence one another. Thus, as providers, we, too, can and often do derive benefit from relationships with our patients. Acknowledging how patients inspire, teach, and even care for us through respect and relationship can go a long way in a proactive and collaborative partnership to manage a patient’s health. A fourth characteristic of RCC is the affirmation of genuine relationships as inherently valuable. The more care and connection providers feel toward patients, the more invested we are in their health and well-being. Similarly, patients who partner with a provider are more likely to feel efficacious in caring for themselves and yield greater levels of self-management and treatment adherence.16