Communication the Cleveland Clinic Way

by Adrienne Boissy

  I’m Just Trying to Remember My Address

  According to data from the American Association of Medical Colleges, the average U.S. resident graduates medical school and begins internship at the age of 28.4 In addition, the U.S. Census Bureau shows that the average age of marriage for a male is 28.5 and for a female is 26.5.5 The average college-educated woman is 28.2 years old when she has her first child, and the college-educated male is 30.8. The average age of first-time home buyers is 31. Thirty-four percent of medical students enter medical school in debt, and the median amount of those debts is $20,000. Eighty-four percent of medical students leave medical school in debt, with the median amount being $176,000.6 These statistics highlight the stage-of-life issues confronting residents.

  Let’s take a minute to envision this more fully. Jennifer is a 27-year-old woman who just graduated from medical school and is about to start residency. She completed medical school in the same city where she did her undergraduate training, so she had friends in the area during her medical school career. She was invited to various bridal showers and weddings of these friends. In the later years of medical school, baby showers started to trickle onto her social calendar. Because of the demands of medical school, she was not able to make all of these events. Some of her friends understood. Others did not. She had a boyfriend for some of this time, but he had to take a job in a different city and they both felt that the long-distance relationship wouldn’t work for them: he would be too busy establishing his career, and she would be too busy studying and doing hospital rotations.

  Jennifer was ready to go to residency training. She found a program that she really admired and that would further her professional development. The only drawback was that it was in a new city where she didn’t know anyone. She soon discovered that she was living in a nice area, but most of the other residents from the hospital lived in the other direction from her apartment. She worked weekends for the first two months, so she wasn’t able to travel away from the city. Her good friends from home couldn’t travel because they were either taking care of their kids, working weekends in their own residency positions, or couldn’t justify spending the money. Although the other residents in the program were nice, Jennifer didn’t know them well, and most of them had a significant other, fiancé, or spouse.

  As highlighted by Jennifer’s story, residents are dealing with tremendous personal adjustment and life changes while trying to master the content of medicine. Residency is a time when you are taking all of the facts that you learned in medical school and trying to make them fit into the context of the living patient in your care. With all of this happening at once, the skills of communication and building a relationship with the patient can be given a lower priority. With the collision of personal and professional events, residents are in a place where they need support and empathy of their own. After facilitating a resident course, one of our facilitators commented that the residents seemed to need more empathy throughout the day than any class that he had ever facilitated for attendings. Residents, like other clinicians, are often patients. Powerful stories have emerged in our sessions about cancer survival, loss, holding dying children, seeing death for the first time and no one discussing it, miscarriages, watching their parents die. Our trainees often enter medicine because they carry their own scars.

  The Reality of Relationships on Rounds

  When you think about the type of work that most residents are being asked to do and the way they are being asked to do it, you quickly realize that relationship building is not on their task list. Residents are asked to have quick communication on morning rounds, often seeing up to 10 patients an hour. They rarely, if ever, are congratulated for relationship building, especially if it means they didn’t get their other work done. Medical knowledge, diagnostic acumen, and safety are top priorities in training, and not without reason. On rounds, the clinical focus is often on vital signs, lab tests, imaging results—all of which will enhance their medical knowledge, diagnostic acumen, and recognition of patient safety. Yet medical students and trainees are expected to learn the art of medicine by observation. If they are not asked which communication skill will help lessen the patient’s anxiety or which empathic statement they can use after telling the patient she has cancer, these skills won’t be reinforced.

  There is a lot of discussion surrounding the hidden curriculum of medical training, which encompasses everything, often unflattering things, trainees learn that we didn’t intend to teach.7 In terms of communication skills, residents frequently shadow attendings who have not participated in formal communication skills training and who may not prioritize or value empathic, relationship-centered communication. Of course there are those who do value these skills. The students and residents who did receive this training were taught the skills and yet do not see these skills being used, valued, or recognized in everyday practice. The underlying message in the hidden curriculum, therefore, is that these communication skills are not important to be a successful physician. This is one of the reasons that residents were not included in the initial focus of our communication training. We didn’t want them to learn skills that subsequently were messaged to be unimportant. By the time the residents took the R.E.D.E. to Communicate: FHC course, at least one-third of their attendings had been trained in these skills.

  In addition to dealing with the hidden curriculum, trainees are often criticized or berated for making any type of mistake during their medical training. Criticism can come after a resident missed an important lab value just as easily as it can come from that same resident arguing with a patient about a plan of care. Some attendings will actively undermine the relationship between the resident and the patient on rounds by saying to the patient, “You don’t have to listen to Dr. Youngin since I’m the one who has the final say. He’s just learning.” Another physician told us that when he rounded at a large academic hospital system as a resident, the attending would turn to him and say, “Now let’s hear from someone whose opinion doesn’t really matter.” Trainees may not have anyone offering encouragement when they catch important lab values or when they decide to use reflective listening and empathy to discuss a difference of opinion on a plan of care. Instead, we often focus on what went wrong.

  Consider this scenario: A patient comes into the emergency room with severe abdominal pain, suspected to be appendicitis. Josh, a second-year resident working in the emergency department, orders a CT scan of the patient’s abdomen to confirm appendicitis and to see if the patient needs surgery. The patient refuses to get into the CT scanner. Josh spends an extra 20 minutes getting to know the patient’s situation, listening to his biggest fears, and eliciting the main barriers to a plan of care. In doing so, Josh discovers that the patient’s grandfather was diagnosed with metastatic colon cancer after a CT scan, and the patient is terrified that the doctors think he has cancer, too. After Josh effectively uses communication skills to build a relationship, the patient agrees to a CT scan, appendicitis is confirmed, and the patient has surgery to prevent worsening complications from the appendicitis. In a busy emergency department or in your hospital, will Josh be celebrated for his efforts or told that ER wait times are increasing and to move it along?

  The communication challenges that both residents and attendings say they are facing are similar: dealing with an angry patient, managing unrealistic expectations, giving bad news, and so on. However, the details that lead to these encounters may be quite different. Again, because they are lower on the traditional medical hierarchy, residents are often tasked with communicating with families after something has gone wrong or wasn’t handled in the best way, situations that residents didn’t create and can’t control but that nonetheless expose them to the emotional torrent from patients and family members. Or it’s the middle of the night, and they are covering another team’s service and are called by the nurse to speak with an angry patient they have never met.

  The details surrounding unrealistic expectations also may highlight a re
sident’s plight. A patient may no longer have active issues keeping her in the hospital, yet the patient resists discharge. The attending is usually the one who makes the decision that the patient has to leave but often delegates to the resident the task of communicating to the patient that she is being discharged. When the resident tells the patient that she has to leave the hospital, the patient may get upset, cry, yell, or give a really good reason why she needs to stay. The resident, however, has been given orders that the patient has to leave the hospital and was not told that compromise is an option. That resident has to deal with either an unhappy patient or an unhappy attending. Neither situation feels like a job well done.

  Teaching While Being Taught

  Residents and fellows have teaching responsibilities as they go through training. As you facilitate this group, allow this fact to work to your advantage. Previous chapters have discussed our small group facilitation technique that ensures that we are spending time highlighting effective behaviors. With the resident group, one of the ways to combine positive reinforcement and their teaching responsibilities is to say, “I hope that when you have medical students with you, you are making sure to point out that it was your use of silence that allowed the patient to open up and tell his story” or “Has anyone told you before that your smile when greeting the patient, and summarizing his last few days in the hospital, really help the patient trust you in the first few seconds of an encounter? Think about how you might highlight this to other team members that are learning from you.”

  Given the amount of previous training that residents and fellows have had, we are very intentional in using the word facilitator, not teacher, when referring to those running the course. We do this partly to stay humble in our role, but mostly to recognize that every participant in our course has experiences from which we can learn, including the facilitator. There is an inherent power dynamic present in a class of trainees, and for some facilitators, humility and recognition of helpful experience can be difficult skills to model. Multiple types of power exist, and attendings may possess power because of their title or leadership role, as well as their content knowledge. This power may play itself out in a variety of ways with trainees, and awareness of it is critical to success.

  In the first few months training residents, one of the communication classes didn’t go so well and was frustrating for two very skilled facilitators. When I asked one of the facilitators about the course, her comments can be paraphrased as “Who do those residents think they are, being disrespectful to my cofacilitator and myself? We are attending physicians, and they should have given us at least that much respect and listened to what we have to say.” They went on to talk about how the residents don’t have the same amount of clinical experience or even life experience.

  It was extremely helpful to hear these comments because they highlighted the unconscious bias that facilitators can bring to trainee groups without knowing it. Often, facilitators will see an attending-level physician who challenges the data that we present as an expected yet reasonable “naysayer” or “forced marcher” who needs time, practice, and the opinion of a colleague to open himself up to the skills we are offering. Yet this same participant may be perceived as “insubordinate” in the resident group and someone who needs to be taught a lesson in respect.

  The ability of facilitators to maintain self-awareness about how they are feeling about the reaction of participants, what that is triggering in them, and their ability to register these feelings and put them aside so that they can meet the residents where they are is paramount. Regardless of our titles or years of experience, we all want to be respected and valued. In fact, it is a beautiful parallel between what patients want from us. Just because they don’t know all the medicine and are in a gown doesn’t mean they are deserving of any less respect. It is important to find a way to communicate respect for the resident or trainee experience early when facilitating with this group. We often ask residents to help make sure the class is relevant for future participants, requesting that they point out similarities and differences in our courses to their prior communication skills training.

  Key Strategic Approaches to Trainees

  We identified a subgroup of facilitators who enjoy working with the residents preferentially. This group may be earlier in their training or may work closely with residents in other settings. We sent a checklist to the facilitators before their first three resident courses to remind them of some of the facilitation skills that will help them connect with the resident group. These key strategic approaches will be discussed in the following section. Comments from our facilitators after working with the resident group reveal that with the right attitude and approach by the facilitator, the resident classes are invigorating, energizing, and a whole lot of fun. One facilitator told me, “A bit of off-color humor probably went a long way, but banter and humility were probably worth more.”

  The communication curriculum for most medical schools is introduced in the first year and is built upon over time. If Jennifer, from the previous story, was asked how to get to the grocery store in her new town or to remember the mnemonic on how to elicit a patient narrative, it is easy to imagine that directions to the grocery store will take a higher priority. It is for this reason that we currently teach R.E.D.E. to Communicate to new residents starting in September of their first year rather than during their orientation. The time from July to September allows residents to adjust to their new life and their new role. It also gives them more clinical time with patients. In this way, they are able to come to class having experienced the pressure of these conversations as a new doctor.

  Trainees are used to being in the role of learner, and they are hungry to master their specialty. As such, they are often more engaged and more willing to practice techniques differently. Facilitators need to make sure that they come prepared for anything. In the class of nine resident participants who all had very robust prior training in communication skills, we found the learning edge (the place between boredom and feeling overwhelmed) of each participant and made sure we were challenging that edge. One of the small group scenarios that day was breaking bad news to a patient. Another involved talking to a patient when a disruptive family member was present. These are scenarios that would be too advanced for first-time learners in another setting.

  In some other classes, the resident participant who had been videotaped in medical school may be sitting next to someone who has only received lectures on communication skills. As facilitators, one of our roles is to create safety while making the session meaningful. We wouldn’t want the resident who received only lectures to be worried that his or her small group skills practice session will involve breaking bad news to a patient and the patient’s hostile spouse just because the previous resident identified that as his or her learning edge. One of the ways to engage a group with different skill levels is to ask the very skilled participants to help you pay attention to those communication skills they have learned previously; invite them to help you cofacilitate in a sense.

  There is benefit in having these classes be a mix of years of experience and specialty, just as with the attending-level classes. Early in the expansion of these skills to the resident group, we had a class that consisted of 12 residents all from the same specialty. Instead of being an experience in which the communication skills could be adapted to that single specialty, it became a matter of “You don’t know what it’s like in our world,” and the residents highlighted all the reasons why the skills wouldn’t work for them. The facilitators were not from the same specialty and were seen as lacking in credibility. When friends are sitting next to each other, instead of new acquaintances, there is less filtering of unprofessional comments. This seemed to be the situation that we were facing in training a small group of residents who all knew each other. When the classes contain a mix of specialties, you are less likely to have an entire group feel suspicious and mistrustful and intrepid enough to be vocal about it.

  To make
sure that mixing resident specialties and postgraduate year (PGY) levels is acceptable to trainees, we asked them their preference after taking the course. On the questionnaire, residents were given the option of having the course with the same specialty and same PGY level; the same specialty and a mix of PGY levels; a mix of specialties and same PGY level; a mix of specialties and mix of PGY levels; and no preference. Our results found that 53 percent of residents preferred taking the course with a mix of specialties and PGY levels, while 32 percent had no preference.

  Nostalgic

  At the end of every class, we ask participants for a word or a phrase to describe how they are feeling as a result of the day. Our favorite word came from a surgical resident. His word was “nostalgic.” In describing this more fully, the resident said that a day spent focused on building relationships with our patients through communication made him remember all of the great reasons that he went into the medical field in the first place.

  Another neurology resident shared that spending time on hospital service with one of our facilitators had gotten him thinking. “I’ve started identifying patients by their room number. I used to have a dream. I was going to provide medical care, and my wife, a music therapist, was going to join me in providing meaningful, healing care for those less fortunate. I haven’t thought about that dream in a long time.”