Communication the Cleveland Clinic Way

by Adrienne Boissy

  Here are some dialogue quotes from skills practice sessions:

  DOCTOR: It sounds like this surgery was important to you. (reflective listening)

  PATIENT: You bet. Now you ruined my life!

  DOCTOR: I’m sorry (long pause). I do not want to ruin your life. Please help me understand why the operation is so important to you. (empathy with apology, open-ended question to explore impact, state difference between perception and intention)

  PATIENT: Prior to that emergency operation, I managed to get by and enjoy my trips to the senior center. My friends and social life at the senior center have given me a reason to live. Now, this colostomy is hideous, it irritates my skin, and it stinks when it leaks. I am embarrassed to be seen in this condition around my friends. I keep to myself now, and I’m much less active. I simply want my life back. I was hoping the reversal would do that.

  DOCTOR: Thank you for sharing that. I’m sorry that your colostomy is giving you so much trouble. It sounds like what’s important to you and what you miss are the social connections that have been interrupted ever since this happened. (reflective listening)

  PATIENT: Right!

  DOCTOR: OK, that helps me. Why do you believe we are reluctant to proceed with surgery? (asking for patient ideas, A.R.I.A.)

  PATIENT: Well, now that I think about it, I believe you think surgery is too risky since I’ve had a recent heart attack.

  DOCTOR: That’s right. I’d hate to see you have major complications or worse from undergoing more surgery. It doesn’t help you if you don’t survive or if you end up with a worse quality of life because the operation didn’t go well. (inform, A.R.I.A.)

  PATIENT: I guess.

  DOCTOR: Knowing your perspective helps. We can talk further about addressing the issues with the colostomy that concern you the most during these planned trips to the senior center. We can also work on reducing leakage, how to hide it, and managing the skin irritation. (align with goals, depart from point of conflict) How does this sound to you? (assess, A.R.I.A.)

  PATIENT: It sounds OK. Thanks for listening.

  Case 3: Strong emotion

  A 45-year-old man presents to your clinic for follow-up. He came in with weight loss and anemia. Workup shows an aggressive colon cancer. CT scans reveal multiple lesions in the lung and liver, consistent with metastatic disease. The physician reveals, “We have confirmed that you have colon cancer and it has spread to the lungs and liver.” The patient, although having come to expect such news, is in utter shock. Silent at first, he responds in rage: “This is your fault! You should have caught this sooner! What’s going to happen to my wife and kids? I have a death sentence, and you don’t care!”

  In this case, the physician has delivered devastating news without preparing the patient or assessing his readiness. The patient is shocked and becomes enraged, distraught, and emotionally hijacked. While bad news will sometimes be met with such reactions, there are communication skills that help keep us and our patients aligned. The foundational skills still apply. Keep in mind that many people go through specific stages of grief: anger, denial, bargaining, and acceptance. What is not constant, however, is the length of time it takes to go through all stages.15

  Strategies to practice: The learning point for giving bad news and responding to the predictable aftermath of strong emotion is to give the patient some control over the flow of information and to utilize what he already knows.16 We may inform the patient that we have his test results back and inquire whether he wants to review them or if now is a good time. We may ask if there is someone else whom he wishes to be present for support or other reasons. We may remind him what tests were done and ask what he understands the purpose of those tests was. Actively involving the patient in a conversation about what has been done, why, and what it revealed helps keep the patient in an active partnership with the clinician. After bad news is delivered clearly and concisely, we practice silence, and deliver support and empathy. We often see clinicians filling silent spaces with words. This space needs to remain empty for a while. It shouldn’t be filled with words born of our own discomfort.

  Here are some dialogue quotes from skills practice sessions:

  PATIENT: I have a death sentence, and you don’t care!

  DOCTOR: (silence, gives patient time to break silence)

  DOCTOR: I’ve delivered very painful news. I wish things were different. (emotion naming, “I wish” statement)

  PATIENT: (crying)

  DOCTOR: (offers tissue or touches shoulder if appropriate, other nonverbal cues that reflect the severity of the moment, such as mirroring body language and expression)

  Case 4: Somatoform disorders

  Patient is a 35-year-old male from out of town, plagued by years of fatigue, lack of energy, severe headaches, ringing in the ears, and inability to concentrate. He complains of an occasional skin rash that occurs at random times and has taken serial photographs of his skin. He has visited numerous specialists, including outside tertiary centers. He was told that there was “nothing they can do.” He comes in with a suitcase full of medical records and is in your office for a second opinion. He believes that there is an underlying systemic illness, possibly parasites, that no one has diagnosed yet. He is desperate for a cure and wishes for some form of exploratory surgery.

  Somatoform disorders are a broad category of mental illness that includes somatization, hypochondriasis, Munchausen syndrome, and conversion disorders. Criteria for diagnosis include age, duration of symptoms, and multiple bodily symptoms in the absence of a causative medical diagnosis. The suffering of these patients is real, and most patients, like their doctors, feel very frustrated by the lack of a definitive diagnosis. The thoughts driving the beliefs may be strongly anchored, associated with personality disorders and/or abuse, and not easy to dispel. Thorough and reasonable differential diagnoses should always be considered first, with appropriate evaluations. Interestingly, even though clinicians can identify these patients, we don’t always tell them what we think they have.

  Strategies to practice: In addition to strategies we have already talked about, deemphasizing the focus on obtaining the correct diagnosis or making the symptoms go away may be helpful. Empathic statements should also be geared less toward the frustration around the diagnostic mystery or the symptoms. For the health professional, this can be challenging to do, because we were trained to figure out what is wrong with a patient. Instead, the leap we need to help the patient make is to focus on functional recovery, with an emphasis on a mutual commitment to focus on agreed-upon functional goals. Accomplishing this goal requires choosing the right words. Telling a patient that “this is all in your head” sounds like a value judgment and will alienate anyone. It also fails to validate the real suffering these patients endure. Instead, we suggest, “Our tests indicate that your hardwiring or anatomy is OK, but the functioning is not” or “What would it mean to you if there isn’t a medical diagnosis here?” or “Have you ever considered that the symptoms may be related to stress?”

  The most important step is to do no harm. Most harm that afflicts these patients is from us, due to complications from multiple tests, multiple surgeries, or increased anxiety if tests are equivocal. Instead of more testing, establishing and maintaining a trusting relationship can make the difference for these patients. In referring to mental health specialists, it helps to frame the referral as a general way to help with coping. “Given the impact these symptoms have had on your life, I’m wondering if we can support you more effectively. Most people wouldn’t be able to cope with all of this.”

  Here are some dialogue quotes from skills practice sessions:

  PATIENT: I need surgery now. I can sometimes feel the parasites crawl all over my skin. I swear some might be in my brain. I need a surgeon to explore my body, get samples.

  DOCTOR: I can’t even imagine. Tell me how this is affecting your life. (acknowledgment, assessing impact)

  PATIENT: I can’t concentrate, and I’ve been fired
from work as a marketing specialist for lack of productivity. So what about that surgery? It will help me, right?

  DOCTOR: Sounds like you’re hoping it will. Well, I looked through your records, and I’ve talked to other experts. Our tests do not show any structural abnormalities. (reflecting and informing in A.R.I.A.)

  PATIENT: I find that hard to believe. I swear something is wrong.

  DOCTOR: I know you do not feel well. I want to be honest with you and help you to get your life back. What I can offer is to work with you toward the things we can do to achieve that goal. (reflective listening, “I wish” statement, aligning goals, support in S.A.V.E.)

  PATIENT: I do not know what to believe. You’re the twenty-fifth doctor I’ve seen.

  If the patient says, “OK, I’ll give this a shot,” then you can offer the whole treatment plan based on functional recovery, cognitive behavioral therapy, and therapeutic visits while firmly deemphasizing symptoms and determination of diagnosis throughout the relationship.

  If the patient says, “No, this is bull. I’ve had it with all of you doctors. I’m seeking my twenty-sixth opinion,” then you can offer continued support should there be a subsequent change of heart: “I’m sorry to hear that. My door remains open if there is any way I can help in the future.” In our experience, most clinicians are uncomfortable with this approach, yet we view it as an essential skill. That is, knowing when to end a conversation so it doesn’t irrevocably damage the relationship is a skill like any other.

  Lessons Learned

  These four cases are a glimpse into some of the most common challenging cases for clinicians, this is by no means a comprehensive guide on how to navigate each of them. Other common challenges include interprofessional conflict, various varieties of intense emotion, verbal abuse, disclosing errors, or threats of lawsuits. The themes and approaches for such cases are somewhat similar to those discussed here: attending first and foremost to the relationship is generally the best strategy. In each of these challenging cases lies an opportunity to set aside the medical agenda for a moment and focus on the relationship with the patient. We should ask ourselves, “Who is this human being, and how can I be most helpful?” By focusing on building authentic connections based on genuine interest and caring, we bridge the disconnection, form partnerships, and align toward common goals. We must resist the urge to “fix” emotions and acknowledge our limited ability to fix medical problems.

  Perhaps more important, in facilitating challenging scenarios, we’ve learned that these cases leave a profound impact on the clinician. In the courses, clinicians often say, “I thought I was the only one having these conversations,” which speaks to the isolation that exists in real practice. These scenarios leave wounds that often don’t have a chance to heal fully. The clinician sees the next patient and has few opportunities to process traumatic encounters. Most clinicians are fiercely committed to doing the right thing for patients. Our hope is that by recognizing that suffering is at the core of the vast majority of challenging communications, clinicians can learn to decrease not only the patient’s suffering but also their own.

  Power Points

  Recognize that caring for patients can be difficult and that most clinicians are deeply invested in the care they provide. Because of this, communication that goes poorly can cause tremendous suffering for patients and clinicians alike, suffering that may not have an outlet.

  Align your facilitation approach to support the clinician and enable the clinician to share these experiences.

  Be ready. The most haunting conversations fall into predictable buckets: chronic pain with opiate requests, unrealistic expectations, strong emotion from bad news, and somatization disorders.

  No new models are needed to navigate these conversations. Reinforce foundational skills.

  Chapter

  7

  Individual Peer Coaching

  What to Do About Dr. Jones?

  “Do you know why we never see my husband’s urologist anymore?” A patient’s wife asked one day.

  “No, tell me.”

  “After Frank (her husband) had his biopsies done, the urologist called on the phone and I answered. He said to me, ‘Would you please do me a favor and tell your husband that he has prostate cancer?’ ”

  The story reminded me of a time when I (Timothy Gilligan) was a fellow and was rounding on the patient of a famous oncologist. The oncologist wasn’t with me that day, and the patient asked me, “Where’s Dr. Doubt It?”

  I was puzzled. “Who is Dr. Doubt It?” I asked. “You know,” the patient replied, “Dr. _______,” and he named the famous oncologist.

  “Why do you call him Dr. Doubt It?” I asked.

  “Because,” the patient replied, “when I asked him if he thought I’d still be alive in a year, he said, ‘I doubt it.’ ”

  And then there was the day my wife, a cardiologist, called very upset because of the way a surgeon had spoken to her. He had asked her to perform a study on a patient to confirm a finding that radiology had reported and that he doubted. It took a couple of hours to get the test done, and it revealed that the radiology report was incorrect and that, therefore, the patient could undergo an operation that had been planned for earlier that morning.

  “You f*#@ing f*#@,” the surgeon screamed, “Why did it take so f*#@ing long? Now I’m going to be stuck in the f*#@ing O.R. until midnight!”

  In the prior chapter, you read about how difficult caregiving can be for patients in their darkest moments and the impact that can have on clinicians. Sometimes, physicians respond to these challenges by building resilience and effective coping skills. Other times, it brings out the worst in us. One of the challenges we faced teaching a standardized full-day communication skills course was to be responsive to the needs and skill levels of individual clinicians. By making the course highly learner-centered, we could meet the vast majority of learners at a level that was relevant and challenging for them. For some clinicians, however, a full-day course conducted away from the setting in which they practiced was inadequate. With our team leading a new push to train clinicians to communicate more effectively, it was natural that colleagues would ask how we could help with physicians and others who needed more individualized attention. These clinicians were outliers with regard to communication skills or were getting into trouble because of recurrent problems related to interpersonal interactions. What, we were asked, could be done about clinicians who:

  Told a patient sitting on an exam table in her underwear that she was fat

  Antagonized colleagues to the point that they wanted to leave their job

  Treated patients in such a manner that colleagues would no longer refer patients to them because of complaints

  Had multiple patients in a six-month period report that they would refuse to see that clinician ever again

  Got into a shouting argument with a hospitalized patient

  For these sorts of individuals and for others who simply wanted more help, we started offering one-on-one coaching. We thought that by providing more sustained and focused attention on individuals, we could intervene in a more effective manner. Moreover, in the sorts of challenges described above, there was typically an unusually large deficit in self-awareness, one that required more sustained attention and work to correct. At the same time, such work was highly labor-intensive and thus could only be offered to a limited number of individuals. In this chapter, we will describe our approach to coaching, which others might describe as a blend of coaching and mentoring.

  What Is Coaching?

  As noted by Atul Gawande in an essay in the New Yorker magazine, it seems strange that, unlike professional athletes and opera singers, physicians do not generally have anyone coaching them to help them improve their performance once their training ends.1 LeBron James, Tom Brady, and the stars who perform at La Scala are at the top of their fields and yet have coaches helping them maintain and grow their skills. They aim to continually improve and recognize that they can bene
fit from help and from working on their skills in the context of a relationship. Why is the same not true of physicians? Although the examples presented at the beginning of this chapter describe situations where remediation was needed, coaching does not imply remediation. Instead, it implies an interest in and commitment to improving. In fact, there are substantial numbers of physicians who have approached us about wanting more personalized coaching and observation of their ability to communicate because, despite their best efforts, their patient satisfaction scores don’t reflect their commitment to helping their patients. Should we be satisfied with our current level of performance, or should we as a profession always strive for a higher level? If I have mastered the clinical content of my field, can I then challenge myself to develop stronger communication skills with my patients and fellow clinicians?