Communication the Cleveland Clinic Way
Page 9
Using relationship-centered care to improve patient and provider experience, we strove to offer opportunities in the course that might build resilience and offer respite for providers. We weren’t just providing knowledge and skill building. We were providing an experience to our deserving, highly respected colleagues. Of primary significance, we related to providers in the same way we were asking them to connect with patients, conveying empathy, listening attentively, eliciting their perspectives, and valuing their contributions in an authentic and genuine manner.
We rolled out our initial pilot to 1,000 fairly skeptical yet just as friendly clinicians and were grateful for responses such as “a valuable use of time,” “refreshing,” “not what I expected,” “helpful to know others experience similar challenges,” and “I can actually use this.” Still, we observed that when providers were practicing communication skills in our pilot course, many did not intuitively view “forming relationships” with patients as part of their role. Even those who wanted to connect with patients were often distracted by multitasking, information overload, and other challenges. This was concerning because we believed that providers and patients alike would not reap the full benefits of relationship-centered communication if they only applied the skills prescriptively or in a less than mindful way.17
Relationship as a Vital Change Agent
Several models have been developed to facilitate teaching and evaluation of healthcare communication.18 The skills themselves are well known, and people have been studying relationship-centered care for a long time. Some wondered why another model was needed. What we wanted to do, however, was explicitly and concretely align our relationship-centered values and mission with the communication skills themselves, and to nudge providers to think differently about their roles in medicine. We also wanted a model that would transcend the outpatient setting and apply to any environment. This led us to develop a conceptual framework for teaching relationship-centered communication that we labeled the R.E.D.E. (pronounced “ready”) model, which stands for Relationship Establishment, Development, and Engagement.
Based on the premise that a genuine relationship is a vital therapeutic agent, the R.E.D.E. model aims to improve the experience of both patient and provider. R.E.D.E. creates an intentional and reflective focus on the preeminence of relationship. As such, the R.E.D.E. model applies effective communication skills to optimize personal connections in three primary phases of Relationship: Establishment, Development, and Engagement (Table 4.1). R.E.D.E. harnesses the power of a relationship by using effective communication skills to focus on the essential features of each individual relationship.
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TABLE 4.1 R.E.D.E. to Communicate Model
RELATIONSHIP:
Establishment
Phase I
Development
Phase II
Engagement
Phase III
Convey value and respect with the welcome
Collaboratively set the agenda
Introduce the computer, if applicable
Demonstrate empathy using S.A.V.E. (Support, Acknowledge, Validate, Emotion naming)
Engage in reflective listening
Elicit the patient narrative
Explore the patient’s perspective using V.I.E.W. (Vital activities, Ideas, Expectations, Worries)
Share diagnosis and information
Collaboratively develop the plan
Provide closure
Dialogue throughout using A.R.I.A. (Assess, Reflect, Inform, Assess)
© 2013 The Cleveland Clinic Foundation. All Rights Reserved.
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One significant barrier had to be surmounted in developing and integrating R.E.D.E. into a new course called R.E.D.E. to Communicate: FHC. It pertained to the use of the word relationship, as it led to fears of being too touchy-feely for some or too presumptuous for others. Before clinicians were able to align with the principles of R.E.D.E., it was vital to define what a healthcare relationship was,19 as well as what it wasn’t (Table 4.2).
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TABLE 4.2 The Healthcare Relationship
REQUIRED
NOT REQUIRED
Emotional connection
Mutual respect
Genuine interest
Patient perspective and psychosocial context
Shared commitment to positive outcome
Friendship
Agreement on everything
Unlimited time
Tolerance of boundary violations
Practice outside your usual scope
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For instance, a healthcare relationship requires an emotional connection with patients, but it does not require friendship.20 Whereas friends might spend a few hours conversing over a cup of coffee, providers don’t have and are not expected to spend endless time developing healthcare relationships. We do not expect clinicians to always agree with patients nor to give them everything they want. Last, healthcare relationships don’t require clinicians to compromise personal or professional boundaries. Boundaries are an important element in all relationships, and there are very clear and important boundaries in the patient-clinician relationship. If someone is being contemptuous or verbally assaulting, he or she is violating boundaries and the provider does not have to stand there and take it.
We wanted to create an environment wherein we were not simply teaching people skills, we were also challenging the way they thought. We were driving for cultural evolution. Our perspective on how healthcare relationships are defined within R.E.D.E. challenges users of the model to explore their own assumptions and beliefs about patients, their role as clinicians, and the ways in which they interact with other human beings. In this way, R.E.D.E. has the transformative power to stimulate and inform a provider’s personal development and awareness. In addition, the model can be integrated with the traditional medical interview seamlessly (Table 4.3). Our teaching of R.E.D.E. acknowledges and engages a clinician’s expertise and encourages reflective competence, the notion that we are thinking about the words we speak and why we chose them, getting feedback on them, and revising our strategies accordingly.
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TABLE 4.3 R.E.D.E. Model and the Traditional Medical Interview
RELATIONSHIP:
Establishment
Phase I
Development
Phase II
Engagement
Phase III
Identify chief complaint
History of present illness
Past medical/social history
Meds and allergies
Family/social history, review of systems
Physical exam
Diagnosis
Education
Shared decision making
Close
EMPATHY
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The R.E.D.E. Model of Healthcare Communication
Phase I: Establish the relationship
Creating a safe and supportive atmosphere is essential for developing the trust necessary to establish a personal connection. The previous chapter details a significant amount of effort that went into making physicians feel safe; the same effort is required for patients.
The emotion bank account is a concept originally proposed by psychologist and author John Gottman, PhD. It refers to a mental system for tracking the frequency with which we emotionally connect with other people.21 Each time an emotional connection is made, it is equivalent to making a deposit in the emotion account with that person. Building up the emotion account is important to sustain a personal connection. This way, when a withdrawal inevitably occurs, such as when a patient is forced to wait to see a provider, the emotion account does not automatically go into the red.
Convey value and respect with the welcome. In doing so, we are essentially building the emotion bank account with our patients and families. Given that people form first impressions quickly and patients are discussing emotional and value-laden topics, how we set the stage for conver
sation matters, even if it feels irrelevant to the clinical problems at hand.22 The skills outlined in Phase I are intended to create a climate conducive to the development of trust by demonstrating that the provider is receptive and interested in the person first, patient second. For instance, while taking the time to review a patient’s chart before meeting him or her increases clinical efficiency, intentionally sharing that we took this time provides additional value by conveying to the patient that we value his or her time and experiences. And if we don’t tell patients we did it, then they don’t know. “Thank you for choosing me” or “I’m glad you came into the ER” can go a very long way in a very short period of time. Knocking on the examination room door and confirming the correct patient and his or her readiness before entering the room further demonstrates a respect for patients’ privacy and grants patients a small degree of control over their environment. Research has shown that a firm handshake and genuine smile help form a good first impression when culturally appropriate.23 Another step in valuing the patient, and any companions present, is to exchange introductions, clarify roles, and attend to the patient’s privacy. Positioning oneself at the patient’s eye level and maintaining comfortable direct eye contact can reduce the power differential between provider and patient.
Arriving for a medical visit is not an isolated event but rather the culmination of a number of events that started with recognition that a problem is occurring, searching out the right provider, and scheduling and ended with getting to the actual appointment. Thus, it is essential to recognize and respond to any immediate signs of physical or emotional distress upon greeting the patient. In the absence of signs of distress, making a brief social comment related to the patient can help put him or her at ease and further build rapport. Giving patients an opportunity to talk about themselves apart from their illness can also convey respect for the patient as a person. Platt et al. assert that initiating nonemergent visits with new patients with, “Tell me about yourself . . .” is an effective strategy for conveying value and respect and building rapport.24 Alternatively, we encourage messaging of what you value as a physician: “It’s really important to me to learn more about you before we get started.”
Collaboratively set the agenda. Many clinicians fear this practice will sacrifice time necessary for assessing or treating the primary concern. However, research has shown that sharing in agenda setting not only facilitates partnership but also improves visit efficiency, diagnostic accuracy, and patient satisfaction.25 Shared agenda setting helps minimize our tendency to presume what a patient’s concerns are and in what order of priority.
Since patients are generally not accustomed to this level of participation, it is important first to orient them to the goal of obtaining a complete list of presenting concerns in order to prioritize his or her needs. For example, “I’d like to get a list of all the things you’d like to address today so we can manage our time effectively” or “I know you came into the ER with leg pain. What other concerns do you have?” Open-ended questions, such as, “What can I do for you?” followed by, “What else?” or “Is there something else?” are often necessary to elicit an exhaustive list.26 Eliciting all of a patient’s concerns early in the visit can be unsettling—more like terrifying—for clinicians who feel pressured for time. Despite the fears it often conjures, collaborative agenda setting has been shown to save time in the office visit.27 Since a patient’s outline of individual concerns might actually represent symptoms of an overarching diagnosis, having the list up front can increase efficiency and diagnostic accuracy. Last, although most physicians find mentioning time distasteful, it doesn’t go away because we don’t mention it. Time framing—“We have twenty minutes today . . .”—is a useful approach.
Collaborative agenda setting has been shown to save time in the office visit.
In addition, patients do not always share the most important concern first, especially if it is very sensitive to the person.28 Eliciting the full range of a patient’s concerns early in the visit can reduce the potential for “doorknob questions,”29 which adds time. Answering such questions can make the clinician late for subsequent patients, whereas failing to address them can result in patient harm or dissatisfaction; preventing them by eliciting all concerns early is a more effective strategy. Finally, if a patient raises an issue that is outside one’s scope of practice, we are not, of course, expected to treat it. However, it is important to address the concern by referring the person to someone who can help and to message a willingness to hear it. The final skill is in adding your own agenda items, asking patients to prioritize their concerns, and then agreeing on what will be covered. For example, “So you came into the emergency department with chest pain. You said that the chest pain is your biggest concern, and you’re also worried about your back pain. We can discuss both. I’d like to go over your test results, too. How does that sound?” If a patient identifies too many concerns to address in the time allotted, an example of an alternative is, “You have a number of concerns you’d like to address in our time together: chest pain, arthritis, and asthma. I agree that we should start with the chest pain. I want to do a thorough assessment, so if we don’t cover everything we may need to find some more time in the near future. How does that sound?”
Introduce the computer. The electronic health record is a reality for most clinicians, and forming a relationship with a person who is staring at a screen, be it a computer, television, or smartphone, is challenging. To the extent possible, we should introduce and utilize the computer in a manner that enhances patient care rather than detracting from it.30 Involving the patient in reviewing lab results or scans in his or her record, angling the screen to maximize direct eye contact, and a willingness to stop typing as soon as any hint of distress arises are important in minimizing the potential of the computer to cause disruption and alienation in the patient-clinician relationship.31
Empathy is the ability to imagine oneself in another’s place and to express that imagining to the other person through communication.
Demonstrate empathy. Academic definitions of empathy emphasize cognitive (detached concern), affective (emotional), moral (impulse to try to understand), and behavioral underpinnings (response through communication), which differentiate it from sympathy or compassion.32
Most clinicians care about their patients, but not all recognize emotional cues or respond to them.33 Research shows that physicians respond to only one in 10 opportunities to express empathy.34 Yet, verbal statements of empathy reduce the length of both an outpatient surgery and a primary care visit.35 This makes sense. When someone is upset and receives an empathic response, he or she feels acknowledged and valued as a person. Empathy has also been shown to result in improved health outcomes such as improved control of low-density lipoprotein cholesterol and hemoglobin A1c in diabetic patients, shorter and less severe symptoms of the common cold, better pain management, and weight loss.36 In R.E.D.E., every opportunity to convey empathy is encouraged, and the mnemonic S.A.V.E. (for Support, Acknowledge, Validate, and Emotion naming) is introduced for outlining different types of empathic statements a provider can use. Oftentimes clinicians have one or two ways of expressing empathy, and their arsenal can be expanded with S.A.V.E. Nonverbal behavior—such as a softer, lower tone of voice, a tilt of the head, or a hand over one’s heart—are also powerful in communicating empathy. Having more options for conveying empathy verbally and nonverbally can allow us to tailor our response to the individual in an authentic and meaningful way.
Phase II: Develop the relationship