Communication the Cleveland Clinic Way

by Adrienne Boissy

  We were not always successful in our attempts to avoid defense of the skills. One skill in particular was phrased in such a way as to leave very little room for alternative perspectives: Elicit all patient concerns early in the visit by using, “What else?” It was also the one skill most participants criticized. Generally, the criticism was that use of the phrase “What else?” sounded too disingenuous. Often as novice facilitators, we would respond to such criticism by arguing that there was literature that found “What else?” to be more effective than “Anything else?” We’d expound upon the multitude of videotaped encounters that the researchers had reviewed documenting a tendency for the interviewer to shake his or her head yes or no when asking, “Anything else?” that did not occur when asking, “What else?”9 With such an eloquent explanation, how could learners not agree that we were right and they were wrong? When put that way, we easily recognized that we’d fallen into the all-too-common trap of becoming more teacher-centered than learner-centered. Now not only do we acknowledge and validate participants who criticize this skill, we also have modified the skill to Ask patient to list all concerns for the visit or hospital stay up front. If participants are interested in different ways of achieving this skill, and the group is unable to come up with any ideas on their own, we are happy to outline the options including “Is there anything else?” “What else?” and even “Are there some other concerns you’d like to be sure we address?” Only after outlining all the options might we gently weigh in on what has been shown in a few studies. Often, our input isn’t necessary. This strategy has worked well to preserve the autonomy of each learner.

  If we have to prioritize our goals for the day, it is to value their perspective rather than prove how correct we are.

  Reflective Competence and Experiential Learning

  Most are familiar with the old adage that practice makes perfect. Still, we need only turn to our professional sports icons that have not one, but multiple coaches to suggest that feedback can be helpful no matter how expert or experienced we may become.10 Months and certainly years of practice can result in the formation of habits that allow physicians to communicate instinctively, focusing their attention instead on the more imminent needs of the patient. When physicians struggle to identify why they are performing a specific skill, this is aptly termed unconscious competence. Unfortunately, performing at an unconsciously competent level can also result in regression of skill or honing of less-than-perfect skills. Reflective competence, on the other hand, is characterized by the ability to be mindful of what, how, and why you are communicating in a particular way. Such awareness and reflection allow us to evaluate and refine our communication in an ongoing manner. It also enables us to tailor our communication to each patient, create opportunities to develop innovative communication techniques, and better share the skills with others. It is a vital component in achieving peak performance. Reflective competence resonates with clinicians who often feel belittled by being asked to simply remember a mnemonic or smile more in communication skills training. These efforts, albeit well intentioned, don’t honor how difficult communicating effectively can actually be. In a way, reflective competence gives physicians permission to use their clinical judgment and armamentarium of evidence-based skills to decide what language is needed when and where. And for most clinicians, having that control and deference to their expertise can go a long way.

  The dominant medical education theory proposes a stepwise progression from unconscious incompetence to conscious incompetence, conscious competence, and finally, unconscious competence.11 However, Will Taylor proposed that these stages might better be conceptualized as a series of overlapping circles that allow learners to cycle from one stage to the next and back again throughout life (Figure 5.1).12

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  FIGURE 5.1 Medical Education Learning Spiral

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  Such a spiral perspective on medical education normalizes and validates the concept of lifelong learning. By asking clinicians to move from unconscious to reflective competence, we are implicitly affirming their already high level of communication skill. Especially for those who expressed a high level of confidence in their communication prior to taking our course, we encourage a focus on the collective experience of all the staff and caregivers, and their pivotal role in modeling the skills for the purpose of being able to teach them to others. This is enormously important because only when you recognize that you have something to learn will you be interested in programs that have something to teach.

  The Johari window is a concept developed by psychologists Joseph Luft and Harry Ingham to improve personal development and self-awareness. The Johari window also illustrates the fact that what is known by oneself is more limited than that which can be made known by others.13 Note the practice and learning interventions that transition a learner from one phase to the next in Figures 5.1 and 5.2.

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  FIGURE 5.2 The Johari Window

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  Actively participating in the communication training through observing colleagues’ skills practice, exchanging stories, and having a dialogue about skills creates a third opportunity for shared discovery of that which was previously unknown to you or to those around you. The original exercise of the window asked people to choose from a list of adjectives what they thought best described themselves, and then asked the same question of people they knew well. The adjectives were then grouped into these four quadrants.

  We all have blind spots with respect to how we communicate, and we have to stay curious enough to learn what they are.

  Lessons Learned

  Early on, we often heard comments like, “I’ve practiced for over 20 years. What exactly do you think you can teach me?” and “Regardless of what you may say, of course this is about HCAHPS.” Once we removed the slide about HCAHPS, discussing HCAHPS scores became the exception to the rule. Instead of focusing on what the course was not, we shifted our focus to what the course objective was. In so doing, facilitators were able to speak from a place of passion and authenticity as opposed to the fear they often experienced when trying to convince colleagues that it wasn’t about the HCAHPS survey.14

  The use of standardized patients (SPs) was another opportunity for us to be reminded that what may enhance learning for some might disrupt learning for others. When we developed the course, we decided to use SPs to reduce the artificiality of skills practice in the second and third phases of R.E.D.E. We asked participants to practice Phase I skills with a colleague playing the patient role to establish a degree of safety within each group and familiarity with the feedback process. Then, for Phases II and III, SPs presented for the small group skills practice. We developed a standardized case that we thought most clinicians would be comfortable with and were careful to craft interviewer instructions to provide sufficient context and direction for developing a treatment plan with the patient (Figure 5.3).

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  FIGURE 5.3 Phase II Skills Practice: Patient Encounter Form

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  The patient was Mrs. Sandy Dilhum, a middle-aged woman presenting for follow-up after having had a heart attack while out of town with her daughters. There is no doubt that participants took their clinician role more seriously when SPs entered the room. After an initial introduction of the concept of SPs, we asked everyone to refer to them only as patients for the rest of the day. After the interview was complete and the interviewer had reflected on his or her practice, the facilitator would ask, “How did you feel, Mrs. Dilhum?” SPs were trained to respond only to how they felt and what they appreciated or would have preferred in a visit. We also realized early on that many clinicians have become so specialized that they are very uncomfortable with cases that fall outside their particular specialty. They easily became anxious about not knowing anything about that particular diagnosis or what questions they should be asking. Even when directed not to focus on the medical facts, they struggled to untrain their brains. To address this, facilitators an
d standardized patients tailored the Dilhum case to an individual’s specialty. For example, if a participant’s specialty was dermatology, we’d adapt the case so that Mrs. Dilhum was presenting for a rash that she suspects is associated with medication she started following her recent heart attack. Guidelines were developed around how best to adapt the case so that standardized patients felt comfortable with these last-minute changes. These changes put the focus back on the communication skill, not solving the medical case.

  Ultimately, we reevaluated the use of SPs when we began training advanced care providers (ACPs). Within one class, we might have a speech pathologist, a nurse practitioner, a general bedside nurse, an administrator, and a social worker. Crafting a case that was adaptable to all of these disciplines was time-consuming, challenging, and often resulted in more anxiety for participants. Recognizing the importance of balancing task competency and task difficulty to maintain participants’ learning edge, we decided to remove this added complication to the skills practice. We piloted advanced care provider courses without SP cases. This pilot was met with significantly reduced anxiety from participants and facilitators and eventually was rolled out to the physician courses as well. Given that there are usually costs associated with using SPs, balancing where and when they have the most impact is worth considering.

  Facilitating an integrative skills practice presented a third learning opportunity. After didactic, demonstration, and skill practice sessions for each phase of R.E.D.E., we asked everyone in the group to share a specific case they’d encountered that posed a communication challenge. From those, one or two cases were selected by the group to practice. While this allowed for an opportunity to apply all the R.E.D.E. skills in one encounter and often rejuvenated the group’s energy, it was not without its challenges. First and foremost, facilitators were facing what felt like the most challenging part of their facilitation at the end of the day. Many also did not feel confident in their ability to facilitate the integrative skills practice effectively. When facilitators were asked what they wanted to work on in faculty development, facilitation of the integrative skills practice was repeatedly the response. In addition, there was an ever-present risk of getting bogged down in the minutiae of the case itself. For instance, if the communication challenge pertained to a patient who was angry about being rejected for a surgical procedure, the group might become focused on the ethics or technicalities of surgical evaluation. Or the group might ask the participant who proposed the case to explain the reasoning behind a particular decision. Not only did this result in conversation irrelevant to communication skills practice, it also posed the risk of an unsafe atmosphere in which others less familiar with the case might cast judgment on the clinicians’s medical decisions. Needless to say, facilitating the integrative cases felt like navigating dangerous terrain.

  The solution came in the form of action methods and completely redefined our notion of active learning. The distinction between active and passive learning is often characterized by the degree to which learners are able to direct their own learning. For instance, in passive learning, students are viewed as empty vessels in need of filling. Active learning, on the other hand, recognizes the ability of learners to ask questions and generate possible answers. Originally derived from sociodrama and psychodrama, action methods refer to a set of techniques that allows a group of learners to engage mind and body in examining interpersonal conflict along with potential resolution or management strategies and skills. The first step is warming up participants through the use of exercises that reduce participant anxiety and increase their openness to being spontaneous and honest with one another. Warm-ups are most effective when designed to move from fun and lighthearted to focus on the more serious and yet transparent issues that participants may be facing. For instance, when we were first learning action methods, we all met on a weekend, so one of the warm-ups consisted of asking participants to stand in various parts of the room that represented what we were giving up to be there (e.g., family time, exercise, other work obligations, etc.). We were able to recognize the commitment that everyone made to being there on a weekend to learn new facilitation tools, and this helped us to move past it and get down to business.

  The second step is similar to the more traditional integrative case method in which we elicited a challenging communication from each participant. However, instead of summarizing the details of each scenario, we only summarized the specific communication challenge (e.g., breaking bad news, managing mismatched expectations). Participants then vote to achieve group consensus on the one case they want to practice. The third step entails development of a new case around the agreed-upon challenge by interviewing for role. Interviewing for role requires participants to take turns suggesting the characteristics of the patient and provider. This alone has proven energizing and therapeutic as participants recognize common themes and acknowledge the complexity that patients often present with. Doubling, or asking participants to share from the patient or clinician’s perspective feelings they might be experiencing but are too professional to say, is another strategy used to help participants better understand the perspectives of both parties. In one case involving narcotic-seeking behaviors, doubling was applied to the physician as well, which creatively highlights to everyone the depth and range of emotions and impact our patients can have on us. The method ensures that the clinician is also seen. To best ensure the success of the learner in the designated hot seat, a fourth step involves asking the group to brainstorm strategies or skills that might assist in resolving the conflict. The skills practice is started, and the facilitator continues to look for opportunities in which one party or the other may not be responding from a place of genuine empathy, interest, or curiosity. When this occurs, doubling or other techniques can be further employed to deepen understanding. A fifth and final step is debriefing the skills practice by appreciating the participants, shaking off the roles, and eliciting learning points.

  Not only did facilitators demonstrate greater confidence in having a step-by-step process to follow, but also in seeing the energy and enthusiasm from start to finish with action methods. Participants commonly shared aha moments stemming from speaking as the patient or provider in doubling or watching a particular communication skill work effectively. Thus, action methods engaged facilitators and learners in a powerful way to explore and develop skills collaboratively to address challenging communication scenarios in the healthcare setting.

  Sustaining Facilitator Engagement

  Relationships require tending. Facilitators taught once a month to maintain their facilitation skill set and contribute to maintaining good access for participants. However, midway through the mandated rollout, facilitators were often teaching three or more times a month to meet the high volume of participants. This created a new challenge of facilitator fatigue. We employed a number of strategies to minimize facilitator fatigue. First, we continued to refine the curriculum based on facilitator contributions so that they had ownership of the course while continuously improving it. We worked hard to balance our desire for a standardized course and method with facilitators’ needs to be authentic and creative and to apply their personal styles. Second, facilitators needed protected time. Often a call or letter from leadership was sufficient, but when we were asked to roll out the course to all physicians, it became necessary to buy out facilitators’ time.

  Furthermore, we found that giving presentations locally and nationally about the work we were doing served to renew feelings of purpose and meaning in facilitating the course. The skills taught are empirically validated and work! We encouraged facilitators to speak within their specialty audience about their skills and the subsequent impact on their clinical and professional efficacy. In addition, our homegrown Train the Trainer program was recognized for its value in training prospective leaders. This recognition resulted in facilitators being offered additional professional growth opportunities in and out of the center (e.g., advanced peer coaching, professionalism i
nitiatives, etc.).

  Ongoing faculty development was held quarterly, and social engagements for group relationship formation and ongoing development were key to sustaining the engagement of facilitators. We were always looking to add new facilitation tools to their toolbox. One facilitator described these activities as an oasis that she hoped we would preserve forever.

  Power Points

  Attend to the basic needs of your participants to convey value and respect, which can foster an openness to learn.

  You don’t have to be an expert in educational theory, but ground your program in its key components so your curriculum is solid.

  HCAHPS doesn’t inspire most clinicians, so leave it out of the discussion.

  If something isn’t working or is too costly, such as SPs, work around it.

  Use action methods, which are highly effective means of engaging participants in unexpected ways.

  Plan from the outset how you will continue facilitator engagement and skill development.

  Chapter

  6

  Conversations That Haunt Clinicians

  I still have nightmares.