Communication the Cleveland Clinic Way

by Adrienne Boissy

  We have found that most observed communication behaviors that are less effective and relatively easy to improve fall into a relatively small number of areas: listening, explaining, and empathy.

  Take the example of the patient who is asking for narcotics that won’t help him or a terminal cancer patient who has exhausted all treatment options. We commonly see polarizing positions that play out as follows:

  PATIENT: Doc, I know I’m dying, but isn’t there something you can do? You’ve got to do something.

  DOCTOR: We are doing everything we can. I don’t want you to spend your last few weeks upset or worrying. (tells patient not to worry when he or she is worrying)

  PATIENT: Well, we can’t just give up.

  DOCTOR: I know. I just don’t have anything left to offer. (doesn’t provide any hope and isn’t true—palliative care is something valuable to offer)

  Compare that to:

  PATIENT: Doc, I know I’m dying, but isn’t there something you can do? You’ve got to do something.

  DOCTOR: You sound like you want to keep fighting. (reflective listening and emotion naming)

  PATIENT: Yeah, I guess I do. Doesn’t everybody?

  DOCTOR: Some people do. I wish I could fix all of this for you. In fact, I wish it wasn’t happening to you. Pause. (reflective statement, two “I wish” statements, and a pause)

  PATIENT: It’s just been so hard. You’ve been there all along. (crying)

  When we shadow clinicians, we are surprised by how much they talk when they are with patients. From a physician standpoint, they may feel they are conveying information about the disease state that is relevant to the patient and explaining things thoroughly. In most cases, from the patient perspective, it’s too much and is not focused on what they most want to know. Most patients do not need to pass a board exam or become a content expert on their disease. Rarely do we hear patients asked what their current understanding of their condition is or what it is that they want to know. Open-ended questions are rarely utilized. The result is that patients get to tell only an abbreviated version of their story before they are buried in a blizzard of medical information. These explanations are like watching the clinician pour a gallon of liquid into an eight-ounce cup—most of the effort is wasted. Looking at it this way, it’s easy to understand how physicians believe they are explaining a lot—which they are—but it’s not necessarily what the patient wants explained nor is it in terms the patient can understand.

  Our answer to this is more listening, less explaining, and targeting the explanation to what the patient wants to know or most needs to know. We recognize that the desire to give patients a detailed understanding of the pathophysiology of their condition is well intentioned, yet research shows that adults retain only a very small fraction of information that is provided in a lecture. It doesn’t work. And the clock ticks away.

  Regarding empathy, expressions of distress are often ignored or met with attempts to fix the distress. Rounding with a colleague one day, we entered the room of an elderly woman with advanced stage gastric cancer. She looked up from her bed and said, “Help me. Help me.”

  “What’s the matter?”

  “I’m in pain. I can’t move.”

  “We’re giving you medicine for pain. If you need more, you just need to ask for it.”

  So often we have seen this failure to express empathy for patient suffering and also a reflex to reach for a fix before fully understanding what is going on. What did this woman mean when she said she couldn’t move? Couldn’t move what? Why? Because of the pain? Had she suffered a neurological event? The weight of the responsibility to heal and fix patients seems to cause many of us to skip past empathy and understanding and reach instinctively for a solution. These reflexes can be unlearned. In the coaching context, we try to develop enhanced self-awareness and reflective competence on the one hand, and specific skills and tools that are helpful in building stronger relationships on the other.

  Accountability

  Coaching takes time and resources, and these investments must be accounted for. If coaching is to be utilized, then it is essential for it to provide demonstrable benefits. If a supervisor refers someone for coaching, it is with the hope and expectation that the coaching will result in improved performance. If someone self-refers, it is with the expectation that coaching will help achieve an outcome. Therefore, clearly defining the individual’s goals for coaching and how progress will be assessed is necessary.

  Similarly, it is the responsibility of the coachee to commit to participating wholeheartedly in the coaching process and working on the issues that led to coaching and to demonstrate implementation of the plan that is developed through the coaching process. If a coachee commits to videotaping three patient encounters and reviewing and assessing the resulting videos, then part of the coach’s role is to hold the individual accountable for completing this work. If the coachee is not completing the agreed-upon work, then it is important to assess why and to reassess whether he or she is committed to the coaching process. If the work is being done but performance is not improving, however that is assessed, then the effectiveness of and/or appropriateness of the coaching should be reevaluated. Some people are less amenable to coaching, some coaches are not very effective, sometimes the pairing of the coach and the person being coached is problematic, and sometimes coaching is not an effective strategy for the specific issue being addressed.

  The Coaching Process

  Coaching is a process—a process that relies on the foundation of building a relationship of trust and mutual respect.

  Referrals. Individuals are referred for communication skills coaching by either themselves or their supervisors. If they are referred by supervisors, we try to review whatever information can be shared about the reason for the referral, which may consist of patient satisfaction scores and comments or complaints, as well as information from supervisors or colleagues. Although this may risk biasing the coach, we have found such data to be essential to understanding why coaching has been requested. The coach then has a responsibility to remain unbiased and to remember that such data represents only part of the story.

  Getting started. The initial meeting focuses on learning the individual’s goals for coaching or understanding of why coaching was offered or recommended. The coach provides a description of the coaching process and ground rules. Many people are unfamiliar with coaching, so a basic review is appropriate. Ground rules for coaching emphasize confidentiality and a clear delineation of what, if any, information will be shared with others. If, for example, a supervisor refers someone for coaching, then it must be clear to all parties what if any information about the coaching will be shared with the supervisor and, if so, by whom. Such communication is typically limited to confirming that the individual is participating actively and making a good-faith effort in the coaching process. Ground rules also include how often coaching sessions will take place and what the two parties will expect from each other. Ground rules support the coaching relationship by helping to construct a safe environment characterized by shared expectations.

  The second part of the initial meeting is getting to know the coachee. Curiosity is key. Good guiding questions for getting to know coachees include, What is it like to be them? What would it be like to go through a day as them? What makes them look forward to getting out of bed in the morning? What would they most like to change about their life? What are they most proud of? What experiences were key in their decision to enter into medicine? What is their family background, and how does it affect the way they behave in their current role?

  Eliciting self-assessment. Defensiveness, self-doubt, insecurity, discomfort with vulnerability, and an exaggerated sense of humility or narcissism can all interfere with our ability to take our own measure. This is especially important when working with staff physicians because the culture of medicine inhibits our ability to acknowledge weakness and imperfection. Creating a safe environment in which to candidly reflect on the areas w
here one is more and less effective is critical. It is hard to improve if we don’t have a reliable sense of what we need to work on. And it’s hard to continue our successes if we have trouble identifying what it is that we have done effectively. So it is fruitful to ask people to reflect on the following: What do they view as their strengths and assets? When have they been successful in the past? What did they do to make those successes possible? What would they like to be more effective at? What is their understanding of why they are undergoing coaching? Do they feel that they have been unfairly criticized or singled out? If a problem has been identified, what is their understanding of the problem? Do they feel that they have contributed to it in any way?

  Goal setting and making a plan. We have already raised the question of how coachees define success broadly. At this point, we are concerned with the goals for coaching. In the context of the issues that led to coaching, what are they hoping for? What would a successful outcome look like? We have already assessed their current reality, and now we want to consider what their ideal would look like. What is the gap between their reality and their ideal? What would it take to narrow that gap? How will we know whether the gap is closing? How will we measure progress?

  It is critical here to separate long-term goals (such as improved patient satisfaction scores) and short-term goals that can be implemented and measured more immediately (such as consistently sitting down at the bedside and beginning by asking patients about their understanding of their condition). Once we have goals, we need a very specific plan that includes accountability. What exactly are they going to do? When are they going to do it? What measures are they going to report back? What will they do if the plan does not work? Perhaps the first goal is to use at least three empathic statements in every patient encounter or to practice letting patients talk for a full minute without interrupting.

  The last time many clinicians got feedback on their communication probably was in medical school. It really isn’t fair that we are pushed out into a world as staff—a world with higher expectations, more complexity, and great responsibility—and expected to have all the skills we need. Our perspectives change over the course of our career as a clinician. What we may need or want from a coach will be different at different stages. Most of us providing care take great pride in it, and it hurts us in many ways when our patients don’t know how much we care. A coach can bridge the gap.

  Power Points

  Use coaching when clinicians want or need more individualized attention than can be provided in a small group class.

  Coaching builds on a foundation of a strong, trusting, appreciative, and candid relationship.

  Increasing personal awareness in clinicians through coaching allows them to come up with their own solutions.

  Don’t get stuck in definitions. Blend elements of professional coaching and mentoring for maximum impact.

  Chapter

  8

  Facilitating Staff Physicians Is Not the Same as Teaching Residents or Students . . . Or Is It?

  I’ll be lucky if I graduate with a kernel of empathy left.

  —NEUROSURGERY CHIEF RESIDENT

  We hope you’ve started to envision how the facilitation techniques we’ve presented can enhance the facilitation that you are already doing, or will hopefully be doing soon. Although there has been a lot of research on the training of medical students and residents, it is less certain whether these strategies and approaches translate into the world of practicing clinicians, attending physicians in particular. Often, we assume they do. In our experience, we developed different approaches for them that helped us tailor our training to their needs. In this chapter, we will discuss communication training for residents and fellows and highlight areas of consideration when facilitating for this group.

  The Case for Similarity

  Medical students and residents become staff physicians, so the internal motivations and training framework are similar. Resident and fellow (trainee) training in communication appears to be the same as teaching attending physicians in the following ways:

  The foundational skills for relationship building are the same.

  The themes for communication challenges are the same.

  Both often think they do a pretty good job of communicating with patients already.

  Both are scientists who critically evaluate evidence.

  Their time is valuable.

  They bring their own values and experiences to bear.

  Both feel vulnerable when their communication skills are criticized.

  Neither group becomes better communicators by listening to lectures on how to communicate.

  Both frequently evolve in a deficit-based culture.

  The Case for Differences

  We already know that empathy declines in medical school and residency as pressures escalate during training. Not only does it decline, it doesn’t recover until late in one’s medical career. Efforts to better understand the environment of our medical students and residents offer several reflections about what is different for these populations:

  Trainees are much more likely to have had communication skills training in medical school than faculty.

  Trainees have had less clinical time and experience with patients.

  Trainees have basic needs that aren’t necessarily met (sleep, food, etc.).

  Trainees are at a different stage of life, both personally and professionally.

  Attendings have the final say in the plan of care; trainees don’t.

  Trainees are expected to teach each other.

  Because they are lower on the medical hierarchy (with less power), trainees may be made to feel as though their opinions will not be taken into consideration.

  An attending facilitator may be perceived as an adversary rather than a peer.

  Trainees are still in learning mode and therefore seem excited to be challenged intellectually.

  Resident and Fellow Communication Training: Current State

  While recently facilitating a group of nine residents, we noted that all of the residents had had some form of communication training; at least half had participated in role-play, and four said they had been videotaped during patient encounters and were given feedback. When the same question is posed to attendings, few mention prior training.

  Many medical students today are being educated in institutions that give time and importance to communication skills and to the relationships that are essential to a productive medical career. Medical students today are likely not only to have been trained with skills practice regularly incorporated into their learning, but also to have had more of this formal training than any physician that has been in practice for 25 years.1 In a 2011 survey of medical schools in the United States, 97 percent of schools surveyed reported that they use simulation to give feedback on interpersonal communication skills, and 78 percent use simulation as an assessment tool. In residency, these numbers are 85 and 47 percent respectively.2

  Understanding the Most Basic Needs

  Maslow postulated that before a person is able to reach a level of higher learning, his or her basic physiologic needs such as food, water, and rest must be met.3 Meeting these needs provides the platform essential to creating safety, belonging, confidence, and reflection. This may seem like common sense; however, residents and fellows come to the communication class having put their needs last on the list, in lieu of the needs of their patients and their clinical services. This was borne out in our observations of resident classes: much of the meet-and-greet time was spent eating. Yes, eating. It would be a simple conclusion to say they just eat more, but a more thoughtful theory would be that trainees are taught to “eat when you can” or that the eating is a stress response to their environments and pressures. Subsequently, we increased the amount of food served for a resident class as compared to the attending class—and it almost always is eaten. Understanding, anticipating, and addressing the stressors sets everyone up for success.

  People cannot learn un
til their basic needs are met.

  Attending to the basic physiologic needs of participants is a cornerstone of our program and relationship-centered approach. Recognizing that residents and students have different needs than attendings may make all the difference in their engagement. Like attending physicians, trainees may have had to round on patients in the morning prior to the communication class, may have been on call the night before, or may have to return to the hospital to check on patients immediately after the class. This deserves attention and adaptation. Remembering that the person with the heavy eyelids at 2 p.m. is the person who has had little sleep, and not someone who considers you a boring facilitator, is the facilitation skill of simply meeting people where they are without judgment. Many residents, especially those in surgical specialties, have to get to the hospital at 4 a.m. to start seeing patients. Senior residents often go back to the hospital to check on the medical students, interns, and residents on their team to see if there is anything left undone. Although it seems more common among trainee groups, any clinician in any class may have been on call the night before, had early and late rounding, or something else. We often call these issues out during our warm-up questions so we can understand participants’ readiness to learn and adapt our approach and expectations for them.