Communication the Cleveland Clinic Way

by Adrienne Boissy

  —CARDIAC SURGEON REFLECTING ON BEING

  AN INTERN DECADES EARLIER AND TELLING

  A FAMILY THEIR LOVED ONE HAD DIED

  I (Vicente J. Velez) stood outside the door of a family meeting room, hesitating to knock. Inside waited the wife and the mother of John, a patient who was admitted yet again to the hospital for pneumonia and respiratory distress. For years, John had suffered a rare and cruel neurodegenerative disorder that slowly but surely robbed him of his youth, vitality, and spirit. He was known and loved by many. He was a husband, a father, a son, and a friend. I stood there like I had many times before. This time, though, something about the scenario hit too close to home. I stood frozen, paralyzed by fear and sorrow; it was my job to deliver the news that John might have only a few months left to live. It would be necessary to facilitate a discussion about planning the last days of his life. The medical team knew that this was not a discussion that the family was ready to have. During past encounters, they had refused to believe he would die from this disorder.

  Empathy is a hardwired trait. When other individuals suffer, we can imagine what it might be like to be in that person’s shoes and our brains actually register the feeling. This capacity likely facilitated the growth of civil, structured societies based on justice, the common good, and shared goals. In some sense, we evolved to have the pain of an individual become the pain of the tribe. Medical training could not completely numb a very real neural mechanism that took millions of years to develop.1 In the case of John, I saw myself in him. Death can come to anyone at a moment’s notice. There was an undeniable possibility that one day I could very well leave my wife a widow at a young age, have my parents endure the agony of burying their child, and never give my young child the opportunity to play a game of catch with Dad.

  On that winter afternoon many years ago, I had to deliver news that would bring pain I would not wish on anyone. As I was in the midst of fulfilling this unwelcome responsibility, John’s family members, in deep pain that turned into rage, blamed me—for not having a cure, for not trying hard enough, for abandoning them at their darkest hour, and for his impending death. It was an afternoon that stays with me to this day.

  Medical practice is a minefield of encounters that haunt clinicians.2

  Doctors in popular culture have consistently been portrayed as poised, objective, and heroic,3 yet the reality is that they, too, suffer as a result of the care they provide.4 Moments like these can haunt them for a lifetime. When we don that immaculate white coat, we take on the expectation of being all-knowing and brilliant.5 We also personify hope, safety, predictability, and goodwill.6 Yet in reality, clinicians feel pain, resentment, conflict aversion, fear, vulnerability, and inadequacy.7 The white coat actually may represent a defense for us, our shield against people knowing that we have feelings and don’t always have the answers.

  Each of us brings our own stories and feelings to the patient encounter, and we also know that aspects of particular patient-clinician relationships often shape such feelings. The most challenging encounters involve demands for unnecessary or inappropriate treatment, patients who are unsatisfied with their care, and unrealistic expectations. Physicians report that one in six patient encounters is difficult.8 Physicians often find such encounters time-consuming and professionally dissatisfying and secretly hope that these patients will not return.9 Doctors reporting high numbers of difficult cases were more likely to be young and to feel burned out.10

  Difficult encounters become more stressful if clinicians fail to separate “what we do” from “who we are.”

  If “what we do” results in a patient’s negative outcome, lack of happiness, or lack of cooperation and we equate our job with our identity, this can adversely affect us at our core, no matter how confident we appear in our white coat.

  Medicine ranks among the most stressful occupations. Depression, disengagement, and professional burnout are harsh realities of the profession.11 Four hundred physicians committed suicide in 2013.12 Reflecting on the cases that haunt us can help us understand burnout. Being deeply invested in the care that we provide, feeling inadequate when tough conversations arise, and lacking a safe space to talk it through is a recipe for burnout. Here’s the big secret about haunting conversations: challenging communication scenarios haunt clinicians because the clinician feels like a failure. They experience shame, helplessness, and guilt. If someone is angry, lashing out at them, or crying uncontrollably, it must be their fault. They must have done something wrong, right? Of course not. These reactions are not about the clinician, but it is the clinician who bears the responsibility, the clinician who carries the emotional weight of his or her own feelings, as well as those of the patient and loved ones.

  Relationships are therapeutic. Effective relationship-building skills can be leveraged not only to motivate and inspire patients to take an active role in their own health, but also to help weather the difficult parts that can haunt either party. What can the medical community learn from this? How can we establish and maintain functional, effective, and meaningful relationships with patients when things don’t go according to the script?

  I will explore key principles in tough scenarios, the cases that haunt us, and insights into how to approach them.

  Key Principles

  In our skills practice, we initially chose a challenging case based on a real patient and then had the clinician involved in the case play the patient. Unfortunately, this format often tapped into their defenses as the clinician in the case. We would often see the physician become increasingly adamant about how difficult the patient was. By making the patient impossible and unresponsive to any approach, the clinician would demonstrate that the challenge was entirely the patient’s fault, not because the clinician had used ineffective strategies. At times, it felt as if we were dance instructors who had students whose goal was to prove that dancing was impossible. It isn’t the purpose of the exercise—although it might be therapeutic for the clinician to be seen and heard—to show colleagues “see what I’m up against.” But we risk losing the rest of the group if they do not feel any ownership of the case being simulated.

  So we decided to have the group build a case rather than use a specific case supplied by one of the participants. We had each participant present a type of case he or she found challenging rather than a specific one. We listed the challenges and had the participants vote on which theme they wanted to practice. The group then built a specific case around that theme, and everyone contributed details about the case. This pivotal change not only encouraged group ownership of the case, but also avoided triggering the painful memories of a single participant.

  “Taking Care of the Hateful Patient” was a seminal article in the New England Journal of Medicine.13 It had broad appeal to physicians because it validated how difficult it can be to care for some patients—but it labeled patients as “dependent clingers,” “entitled demanders,” and other negative monikers. We avoided this at all costs. If physicians are accepting of patients being labeled, then we’d better be comfortable being labeled, too! It felt like the wrong direction for this work.

  The idea of relationship-centered care is to understand the goals, drivers, and perspectives of those we serve, not to label them because it makes us feel better.

  This labeling also implies that patients are the problem, and effectively shifts the locus of control away from us and anything we could possibly say or do.

  Given how sensitive this work can be for clinicians, they must be handled with care. The facilitator must be acutely aware of the sweet spots for maximal learning and avoid triggering deeply painful memories that may derail learning. Empathic curiosity is necessary to help participants feel supported before even approaching these conversations. Here are a few V.I.E.W. questions adapted for participants:

  What does your professional world look like?

  What are your common communication challenges, and how do they make you feel?

  How do challenging
encounters affect you?

  What would be most helpful for you?

  What have you tried?

  What are your ideas about what will be effective here?

  What obstacles do you see to improving communication in this scenario?

  In the past, have we taught clinicians how to say no to patients demanding inappropriate treatment while also making sure these patients have a good experience? Have we also taught clinicians how to tell family members that their loved one has died without feeling at fault? And in cases where it was their fault, how have we supported clinicians? We haven’t. We have acted as if these realities didn’t exist, and we have badgered clinicians about their HCAHPS scores. No wonder they have felt disengaged and isolated. We have an enormous opportunity to honor the sacredness of this work if we choose to. It’s a pivotal opportunity.

  Notes and Excerpts from the R.E.D.E. Practice Sessions

  Cases that participants identify as difficult communication scenarios fall into common categories (Table 6.1).

  * * *

  TABLE 6.1 Most Common Communication Scenarios that Haunt Clinicians

  Theme

  Typical Reported Example

  Chronic pain in setting of opiate use or abuse

  Patient demanding opiates early, by specific type and/or dose in emergency room or from a covering provider

  Unrealistic expectations

  Patient thinks that a fourth redo back surgery will fix her lower back pain and came to you because you are the best doc

  Strong emotion, usually as a result of bad news

  After being given a cancer diagnosis, the patient or family becomes angry and lashes out at the clinician

  Multiple symptoms without cohesive medical diagnosis (somatoform disorders)

  Patient presents with a thick, color-coded binder of symptoms and believes that his symptoms are related to mold exposure

  * * *

  Case 1: Chronic pain

  The patient is a 40-year-old man who was injured in a motor vehicle accident six years ago. Since then, he has continually suffered from severe back, leg, and rib pain at the sites of injury. He has been on the oral opioid oxycodone 5 mg as needed every eight hours for pain. He is here for his follow-up visit one week earlier than scheduled because he was recently hospitalized. He shows up at your clinic rating pain at an “11 out of 10” and asking for resumption of opioid prescriptions, with an additional request for increased dosage and frequency.

  The dilemma for the caregiver here is balancing the need to provide sound medical care with the impulse to relieve suffering. The clinician’s experience may be that denying a patient pain relief with a quick opioid fix is cruel and uncomfortable, or the practitioner may feel so manipulated that he or she becomes angry. A typical dialogue might fail to set boundaries, avoid discussion of areas of conflict, or involve stonewalling, simply giving in, or agreeing to an inappropriate compromise. Any of these can result in enabling the same vicious cycle that will invariably perpetuate or worsen the pain condition or even lead to a fatal overdose or complication such as respiratory failure. Despite the fact that patients suffering from chronic pain and opioid dependency generate strong feelings in providers, there is no reason a chronic pain patient should be denied the opportunity to form an authentic relationship with a healthcare provider, one that includes rapport and an exploration of the patient’s concerns, agenda, and perspective. Unfortunately, the clinician’s own reaction to these patients or the stigmatization of this group of patients can prevent the practitioner from responding with empathy.

  Strategies to practice: Understanding and acknowledging that chronic pain is an incurable condition represents a key first step that has to be the foundation of any honest conversation. The goal for management strategies is to improve quality of life, function, and coping skills in the patient without compromising the patient’s health, well-being, and safety. Pain symptoms and the quest for more tests and procedures should be deemphasized. Psychological wounds and damage often perpetuate chronic pain, and avenues to address these wounds should be provided. Given that these are the goals in mind, how do we get there? What words and actions are effective?

  Effective statements that we have heard from our physician participants are:

  “Help me understand how the pain affects you.” (explore impact)

  “It must be hard to feel judged.” (emotion naming)

  “I wish to be honest about what we can do.” “I wish there was a quick fix here, but there just isn’t.” (“I wish” statements)14

  “This is also frustrating for me as someone who wants to see you feeling better.” (limited self-disclosure)

  Key elements include determining the patient’s agenda, eliciting the patient’s narrative of his or her illness, and using empathy to demonstrate a genuine interest in and concern for the patient’s experience and suffering. The S.A.V.E. mnemonic also provides some possibilities:

  S:

  Support—“I am here to work on this pain with you.”

  A:

  Acknowledge—“Chronic pain is a terrible thing to live with. It’s a credit to you that you have been working hard to maintain a job and keep your life together.”

  V:

  Validate—“I think anyone who has struggled with pain for as long as you have might feel the same way.”

  E:

  Emotion naming—“You really seem incredibly frustrated.”

  Another helpful acronym is V.I.E.W.:

  V:

  Vital activities—“Tell me more about how this pain has affected you. What has been the impact of using pain medication on the rest of your life? How do others feel about your opioid use?”

  I:

  Ideas—“What are your ideas about how we might manage your pain from here? What benefits do you get from Percocet? What are the downsides to using pain medication for the rest of your life? Other than more Percocet, what are you willing to consider to help your pain?”

  E:

  Expectations—“What are you hoping I can do? Tell me more about your goals.”

  W:

  Worries—“What worries you most about your pain and your use of pain medications?”

  Setting boundaries does not mean withholding empathy. Setting boundaries is an expression of care and a commitment to having an authentic relationship. As parents, if we refuse to cave in to a child’s demand for chocolate cake as a main course for dinner, our standing firm is an expression of concern for our child’s well-being. He will be upset because we said no, but he will be better off in the long run eating a healthy diet. The boundary statement should be firm, surefooted, and followed by silence. Here are a few examples:

  “I will not be prescribing the Percocet today. I hope we can work on a different approach.”

  “I do not think that your continued use of oxycodone is a good idea.”

  “Opioids are not a good option for you.”

  When a boundary is set, patients may or may not be at a phase of change where they will accept counseling. Preaching the dangers of opioids does not help. We do not want to engage in a debate about the pros and cons of opioids for chronic pain. Debates have winners and losers—and no one wants to lose. Instead, invite self-discovery from the patient. The A.R.I.A. (Ask, Reflect, Inform, and Assess) cycle can be an effective tool for this. Using A.R.I.A. in this instance can help assess insight, health literacy, the phase of change the patient is in, the patient’s level of interest in change, and ideas and strategies that may help.

  Here are some dialogue quotes from skills practice:

  DOCTOR: Why do you think I am reluctant to prescribe additional oxycodone? (explore impact)

  PATIENT: Maybe you think I am addicted. But I am in real pain, Doc.

  DOCTOR: I believe it is real. I want to work together to find a way to get your quality of life back. (validate, partner with patient, focus on goals)

  PATIENT: I hope so. Why are you so worried about this, Doc? What’s the big deal? Ju
st give me the prescription, and I promise I won’t be any trouble.

  DOCTOR: I really am worried about your condition and even more so because what we have been doing doesn’t seem to be working. I can explain if you are interested. (self-disclosure of worry)

  PATIENT: Go ahead.

  Case 2: Unrealistic expectations

  The patient is a 70-year-old woman who underwent emergency colectomy two months ago for massive hemorrhage from extensive diverticulosis. She is a dialysis patient and has COPD, insulin-dependent diabetes poorly controlled, and a recent massive heart attack. She is on anticoagulation and dual antiplatelet therapy. A cardiologist told her she was a very high-risk surgical candidate and recommended no surgery, including colostomy reversal. She is very angry when told that surgery is not advised and demands that it be done anyway.

  There are many variations of this case, wherein a physician’s recommendations do not match the patient’s expectations. When we are uncomfortable in a difficult conversation, we often default to attempting to persuade emotional patients by using data. (“You have multiple stents, and coming off the platelet therapy is dangerous.”) We may well be correct about the medical facts, but overpowering patients with our superior medical knowledge does not help our relationship with them. Moreover, when patients are upset, a cognitive approach generally has no impact, except for, sometimes, making them more upset. The key learning here is this: the emotional brain does not respond to data. It responds to recognition of the emotion.

  Strategies to practice: In cases where there is conflict, “competing” with the patient at the point of disagreement is generally not helpful. In this case, the point of disagreement is whether or not to go through with colostomy reversal. This argument could go on forever. What we invite our learners to do is to address the conflict from the point of the patient’s goals (vital activities), ideas, expectations, and worries (V.I.E.W.). The next step is to find a way to align with the patient and his or her goals. If done right, it will not be a conflict between the practitioner and the patient, but rather a partnership that will tackle whatever is standing in the way of the patient’s goals. If we assume that neither party wants the patient to die in the perioperative period and that both parties want to improve the patient’s quality of life, then a partnership with common goals is possible. The initial medical recommendation may stand or change, boundaries may have to be set, and the patient may still be unsatisfied. Whatever the outcome, an alignment of perspectives does wonders to help patient and clinician see eye to eye, or at least view a disagreement from a position of mutual respect. Reflective listening, S.A.V.E., V.I.E.W., and A.R.I.A. can all help here.