Communication the Cleveland Clinic Way

by Adrienne Boissy

  Once a safe and supportive environment has been created, the relationship needs to evolve and grow. Getting to know who the patient is as a person and understanding her or his symptoms in a biopsychosocial context is the next step.

  Listen reflectively. Reflective listening is vital for developing the relationship and has been shown to enhance the therapeutic nature of a relationship, increase openness and the disclosure of feelings, and improve information recall.37 Yet listening in such a way as to understand and acknowledge what is being said without interrupting or derailing the patient’s train of thought can be challenging. Research has shown that physicians interrupt patients within 18 to 23 seconds of asking a question.38 Attention and awareness are necessary to restrain the interruption reflex to redirect the conversation to where we would like to see it go. By attending to the facts, feelings, and intentions conveyed by the patient, we can respond reflectively and empathically without disrupting the patient’s narrative.39 This enables the patient to provide the details necessary for us to hear all of their concerns and thoughts as well as to better differentiate diagnoses.40 Use of verbal continuers, such as “Mm-hmm” or “I see,” and nonverbal continuers such as head nodding convey interest and attention without interrupting the patient. Being able to reflect back the underlying meaning or emotion being conveyed without judgment or distraction is especially valuable in deepening a shared understanding of the patient’s perspective.

  Elicit the patient narrative. Obtaining the history of present illness (HPI) can quickly become a series of closed-ended questions that are of most interest to the provider.41 However, the goal of this skill is to use open-ended questions to better understand patients’ perspectives on their condition. This has been proven more efficient and effective than a provider-centered data-gathering approach.42 Examples include, “Now I’d like to get a bird’s-eye view of what has been going on with you” or “I’d like to learn as much as I can about your problem, from when it first began until now.” Open-ended questions and verbal and nonverbal continuers are effective in maintaining the patient’s narrative.

  Elicit the patient’s perspective. In healthcare, we tell patients things they don’t want to hear. We give them news that will alter the course of their lives and those of their loved ones. How they react to and absorb these pieces of information is not just about the news itself but about all of their prior experiences, beliefs, and values. This unique perspective or “explanatory model” is one that we frequently don’t know anything about.43 Being curious to explore and open to learn is key in knowing the person, the illness, which is a social response to disease, and the disease itself. R.E.D.E. suggests a simple mnemonic V.I.E.W. (for Vital activities, Ideas, Expectations, and Worries) to explore the patient’s perspective and tailor education and treatment planning. Vital activities refers to an individual’s occupational, interpersonal, and intrapersonal functioning. Questions might include, “How does it disrupt your daily activity?” or “How does it impact your functioning?” or “What made you decide to come in now?” Often people have a sense of what is happening to them. Asking what ideas someone has about his or her symptoms can be valuable in assuring that we have alleviated our patients’ concerns. Alternative questions that elicit patient ideas include, “Do you know others who have had similar symptoms?” and “What have others told you they think is going on?” Eliciting patient expectations also provides an important basis for alignment around the nature of a problem and possible solutions. Questions to elicit patient expectations include, “What are you hoping we can do for you today?” or “What outcome do you hope to achieve with treatment?” Worries are the final aspect of the V.I.E.W. mnemonic and are intended to elicit what worries or frightens the patient most. Asking directly, “What worries you most about it?” can elicit the patient’s perspective while also conveying that it is vital information.

  Phase III: Engaging the relationship

  The last step in relationship building aligns with the education and treatment stage of a patient encounter. Trust, rapport, and a shared understanding of the patient’s perspective all work together to set up the patient and clinician for success in Phase III. Research has demonstrated that patient-clinician agreement on the nature of a problem increases the likelihood of problem resolution.44 Having experienced success as a partner in his or her visit, a patient feels more motivated and confident in his or her capacity to learn health-related information and collaborate in making decisions and developing a realistic treatment plan. Relationship engagement enhances health outcomes by improving patient comprehension and recall,45 capacity to give informed consent,46 patient self-efficacy,47 treatment adherence, and self-management of chronic illness.48 Employing a more doctor-centered approach may feel easier and simpler in many ways, but it significantly impedes patient motivation and confidence to engage in behavior change and health maintenance that would otherwise lead to improved health outcomes.49

  Share diagnosis and information. Telling a patient the medical facts and what he or she needs to know is not sufficient for effective care. We must also be sure that the patient understands the information, which can only be assessed by asking. “What would you like to know about Y?” or “It would help me to know what you know about X.” Framing information in the context of the patient’s perspective and engaging in dialogue that allows the patient to register new information and ask clarifying questions facilitates patient understanding.50 It can be helpful to ask patients to reflect back their understanding of information shared. “I want to be sure that I’m explaining things clearly . . .” or “I’ve given you a lot of information . . .” are helpful ways to preface a request for patients to tell us what they’ve heard and understood.

  Collaboratively develop a plan. Relationship engagement is designed to support patient understanding, decision making, and consideration of potential treatment barriers, such as financial difficulties or limited support. Treatment adherence and behavior change are more likely when the patient is an integral part of the planning process and agrees with the recommendations.51

  It is the patient’s responsibility to make an informed decision about how to proceed, if at all. To do so, it is important to describe the treatment goals and options including risks, benefits, and alternatives. This is when a clinician’s experience in diagnosis and treatment planning, as well as knowledge about the efficacy of various treatment options, is of major value to the patient. Sometimes we can have strong convictions about a particular direction to take. Rather than conveying judgment or imposing our perspective, the patient may ultimately be better served by our seeking to better understand what contributes to his or her preference. For instance, “Help me understand what makes this the best option for you.” This may facilitate compromise or further negotiation. Other times, you may agree to disagree, but at least you’ll have a better understanding of why the patient feels the way he or she does. Once you have a plan, checking for comprehension and any potential barriers to the plan helps to solidify recall, understanding, and adherence.52

  Provide closure. Ending a visit can easily be taken for granted. However, reviewing the time spent and demonstrating respect and appreciation for the patient provides closure and also engenders continued partnership. Often a misassumption is made that the patient knows when a visit is ending and what to do next. However, it is necessary to alert the patient when a visit is ending and affirm his or her contributions and collaboration. For instance, “We’re about out of time. I’m glad you came in today and appreciate your willingness to share what you’ve been going through. It helps me get a better sense of what’s going on and for us to work together to address it.” Providing a handshake and personal goodbye along with next steps continues to help the patient navigate his or her medical visit with ease.

  Dialogue throughout. Patients are unable to comprehend and accurately recall most of the information presented during a typical medical visit.53 In our experience, shared decision making can be the m
ost challenging for clinicians because we’ve created nice, informative monologues on X, Y, and Z. Specialists and primary care physicians alike typically have a three- to five-minute educational monologue about a disease, and don’t pause to check whether the patient wants or needs all the information provided. This can be a time sink for clinicians and is easily avoidable with A.R.I.A., a mnemonic representing a sequence for engaging in dialogue throughout the education and treatment stage of a patient visit. A.R.I.A. stands for Assess, Reflect, Inform, Assess (see Figure 4.1). Dialogue as opposed to a monologue keeps the patient involved in the learning process54 and can improve understanding and recollection.

  Power Points

  Change the goal of communication skills training to develop meaningful relationships with patients. Relationships have the power to heal.

  By using relationship-centered rather than purely patient-centered communication, your program values and honors the expertise of all stakeholders.

  Consistently model relationship-centered communication to reinforce a parallel process: the skills required to facilitate participants and the skills we are advocating for with patients are the same.

  Implement reflective competence as a learning goal to have clinicians actively reflect on why they say what they say.

  Chapter

  5

  Making Communication Skills Resonate with Experienced Clinicians

  Motivating physicians to attend and actively engage in communication skills training is often perceived as an enormous feat. We knew if we put a program in front of experienced clinicians, it had to be rock solid. In addition, we wanted to provide participants with an experience equivalent to, if not exceeding, that of a patient. This strategy entailed modeling the skills we teach with one another and with participants in an authentic and meaningful way, recognizing their expertise and valuing their contributions.

  Basic Principles of Engagement

  We were mindful of Maslow’s hierarchy of needs in creating a climate conducive to learning. Maslow proposed that certain needs (biological/physiological, safety, belongingness/love, and esteem) be met in order to reach self-actualization or a state of personal growth and fulfillment.1 We considered many of Maslow’s hierarchy of needs to be absolute prerequisites for an optimal learning environment. Before participants attended the course, they received a detailed e-mail outlining the course, the location, where to park, the number of breaks, meals, and even suggesting a comfortable, layered type of dress to accommodate fluctuating temperatures. If participants had specific requests, such as dietary needs, they were invited to contact our program manager who addressed each and every request. Upon arrival, participants were greeted warmly with a smile and handshake. Rather than rushing into the course content, participants were invited to hang up their coats, get comfortable, and have breakfast.

  We also thought about the size of the group and how this would impact learning, safety, connection, and active participation.2 Groups were maxed at 12 with two facilitators and divided into two smaller groups for skills practice. Groups larger than this can make it easy for some participants to fade into the background, allowing others to dominate the conversation and focus the learning in personal areas of interest that might not be the consensus of the group at large.

  To foster a sense of connection and belonging, facilitators were mindful to connect with participants and/or connect participants with each other in a personal manner. Each of these steps was also included to convey value and respect, an important ingredient in establishing a personal relationship and a relationship as part of the group.3 For those of us facilitating, it was really important to provide colleagues who are hardworking experts in their fields, working under incredible time and task pressure, with an experience that rejuvenated the clinician while improving patient care.

  As with any educational intervention, designing a curriculum that can meet all learners “where they are” is a rigorous and critical process. I will highlight the core principles and methods that have made communication skills training effective for our experienced, and sometimes reluctant, learners. Of course, we could not learn what strategies worked without also stumbling upon a few that did not.

  Creating Solid Curriculum Grounded in Learning Objectives and Measurement

  In his taxonomy of learning,4 Benjamin Bloom originally identified three domains of learning: knowledge, attitudes, and skills. He proposed that each domain must be mastered prior to proceeding to the next. Nowadays, these domains are often identified as the goals of learning. In curriculum design, it is important to identify what you want to change. In our course, we wanted to focus primarily on the acquisition of specific communication skills, such as collaboratively setting an agenda. However, we also included empirical research to challenge participants’ preconceived notions about communication and provide a rationale for change. Clinicians may identify, and certainly respect, a well-designed curriculum that is grounded in educational theory, and strong curricular design gives them another reason to engage fully. We wanted a solid design that would motivate all staff to engage and participate.”

  In 1959, Donald Kirkpatrick developed and revised a process for evaluating training programs that incorporated Bloom’s taxonomy and continues to be widely used today.5 The process consists of four levels of assessing (1) participant reaction to the program; (2) the specific learning of knowledge, attitudes, or skills; (3) comparison of actual performance before and after the program; and (4) outcomes that result from the integration of newly learned knowledge, attitudes, or skills. We found it helpful to identify specific goals and hypothetically answer Kirkpatrick’s questions when designing the curriculum. From there, we sought empirically validated methods whenever possible to increase the likelihood of a positive learning outcome. We also designed pre-, post-, and three-months post surveys to assess each level qualitatively and quantitatively. No matter how much rationale is provided during the pilot phase, a program is only as strong as its evaluation. If we weren’t achieving the results we anticipated, we were determined to revamp it until we did.

  Engaging Physicians: “What’s in It for Me?”

  Malcolm Knowles’s theory of andragogy, or adult education, posits that for adults to learn new skills, the skills need to be relevant to their personal or professional goals.6 When choosing continuing education courses, people select courses that appeal to them—a topic relevant to “what I do” or “my specialty,” with the hope that it might provide some “knowledge or skill helpful to my practice” and “that I could implement relatively easily.” Not only must the skills be useful, they must be feasible to implement. This is certainly true of staff physicians. Coincidentally, the timing of transparency of communication scores created a real need for providers to seek out resources to improve their communication with patients. Once at the course, we worked to foster more internal motivation by appealing to participants’ desire to improve patient outcomes and become more efficient, effective, and satisfied with their jobs. Who wouldn’t want that?

  People are more engaged and more interested in what has perceived meaning or value to them.

  Andragogic theory also asserts that adults are more receptive and tend to learn more when education is self-directed or learner-centered.7 It’s worth noting that learner-centeredness also includes respecting the decision of a participant not to learn. We recognized that if we tried to sell clinicians on participating, we might increase resistance to practicing the skills. There were only two occasions during our training of thousands of physicians internally in which individuals had to be pulled outside of the room for a discussion about their decision not to learn. Even then, their perspectives were explored and their behavior addressed because it was disruptive to others’ learning efforts. In one case, the learner recognized that he was being disruptive and that this was due primarily to “antibodies” he had developed to prior training. He sent a note of apology after the course, which demonstrated more reflection than one might have typica
lly given him credit for:

  Thanks for all the time you both put into this. I hope I was not the “participant from hell” for you. I did enjoy the conference and did benefit from it. I think all Docs think they are doing a better job of communicating than they really are.

  In the other case, the participant made comments about how the course was “stupid” and that he was being “picked on.” Recognizing his discomfort, the facilitator pulled him aside, explored his perspective, and highlighted that the course was about the group learning, not his individual behavior. The participant was invited to leave, but he chose to stay. In the end, his take-home word for the day was empathy. He mentioned that he had had a tough week prior and he hoped these skills could help in the future. Maintaining appropriate boundaries while modeling empathy and curiosity applies equally to facilitation and clinical work and is just as critical.

  The use of reflective listening and empathy were additional skills that facilitators employed to foster self-discovery and insight among participants. Facilitators were invited to share any initial reservations they experienced when learning the skills for the first time. This self-disclosure was usually followed by personal testimony of how the skill was found to be quite helpful later and, in effect, legitimized learners who were grappling with new concepts.

  Miller and Rollnick, who developed motivational interviewing as a powerful intervention for behavior change, recommend another technique called rolling with resistance.8 Sometimes this includes acknowledgment or validation statements, such as, “Sounds like a lot of people feel that getting the patient perspective takes time” or “I’ve felt the same way at times. It can be frustrating to feel you are doing your best, but it still isn’t enough.” Yet another response we used was to elicit input from other participants by asking, “How many others feel that way?” Such a question encourages dialogue and self-discovery rather than spoon-feeding a particular answer.