Communication the Cleveland Clinic Way

  Getting our physicians to dream again just may be our greatest outcome.

  Power Points

  Appreciate that residents and attending physicians are at different life stages, which is relevant to how and what they learn.

  Seize the moment! One significant advantage for residents, fellows, and medical students is that they are already in learning mode.

  Celebrating micromoments of effective relationship building and communication on rounds represents an enormous opportunity.

  Customize. When developing programs for trainees, consider timing, selection of interested facilitators, and responsiveness to their real-world challenges.

  Engage with humor, humility, and self-awareness, and be mindful of any power differentials in the group.

  Chapter

  9

  Who Facilitates Whom?

  Advanced Care Provider Training

  Thank goodness you didn’t have a nonphysician teach this course.

  This comment came from a participant in one of our sessions for doctors within the first year of the rollout. It’s not a comment that any program or organization wants to hear, yet it wasn’t uncommon. It’s interesting that the term nonphysician was used, as few of us define ourselves by what they are not. How many Asian male physicians call themselves nonwhite, nonfemale non-nurses? Beyond the issue of language, it’s easy to come to the conclusion that physicians think that no other professionals have the same knowledge base and experience that they do. Some physicians do feel this way, and programs that focus on relationship-centered communication rather than just physician-patient communication have a role in helping this thinking evolve. However, if we stay in a place of empathic curiosity, there are other options to explore. In an era when there is increasing emphasis on teams and interprofessional communication, the attitude that doctors are “different” feels outdated. Comments like the one above opened up a critical dialogue about how training or profession can affect perception of the course’s benefits.

  We’ve described much of our work with staff physicians because we targeted that group early on. As the program evolved, however, we made a concerted effort to integrate our training and our facilitators with advanced care providers (ACPs) and physicians. This chapter will explore our experience training ACPs in separate courses from physicians and our decision to move to more integrated courses.

  The Who and Why

  Our communication skills courses were initially taught separately to physicians, on the one hand, and physician assistants (PAs), nurse practitioners (NPs), and additional ACPs on the other. The physician group included MD/DOs and was taught by their peers, MD/DO facilitators. Likewise, the ACP group was also taught by their peers. The decision to group the courses in this way was an intentional one. The rationale for differentiating physician training from ACP training was based on several considerations: physicians and ACPs would feel safer practicing communication skills in front of their peers. Physicians might feel embarrassed looking less than competent in front of ACPs, and ACPs might fear disrespectful behavior from physicians. Safety is paramount, and we value it even more than the benefits of interprofessional training. Think for a minute about a scenario in which physicians object to having a nurse practitioner facilitating their course. They become vocal about the nurse practitioner not understanding their unique, daily job challenges and disengage actively from the training. The course easily can become about managing their issue, when it is really intended to strengthen the communication skills of the entire group. We wanted to make participants feel safe and supported so that they could engage in the training—and part of that safety was honoring the sacredness of the conversations physicians have with patients and the conversations advanced care providers have. We also were aware that it might be equally problematic to have a physician lead communications skills training for a group of NPs. We prioritized the participants above all else, and for our culture at that time, it was the right strategy. In addition, the first physicians to take the course during the rollout phase were those whom we wanted to master and model the skills for colleagues and trainees. We hypothesized that both groups would find greater validity if the content came from peers. We worried about pushback in the form of “You don’t understand what it’s like to do my job.” A peer-to-peer format seemed most likely to reduce resistance, although we recognized that it deprived us of the opportunity to work on interprofessional communication issues in a way that an integrated approach would. So, using R.E.D.E to Communicate: FHC as the foundational prerequisite course, we subsequently built advanced courses that integrated physicians and ACPs.

  For ACP FHC classes, we originally sought to identify those who had substantial patient contact. In the initial discussions, this included nurse practitioners, as well as physician assistants. However, as the course continued, we soon found that we had an audience of PhDs, PAs, advanced practice nurses, certified nurse specialists, certified registered nurse anesthetists (CRNAs), perfusionists, physical and occupational therapists, speech therapists, dentists, podiatrists, optometrists, and dieticians, to name a few. We accommodated almost anyone with the understanding that our target audience performed direct patient care, was working with patients routinely, and was comfortable participating in the skills practice exercises. We initially included those individuals who had a National Provider Identifier (NPI) number on our target list of folks who should participate. Everyone with an NPI is a billing provider and has direct patient care contact. The list is easy to compile and keep track of within a large healthcare system.

  The How of ACP FHC Training

  In one course, a nurse practitioner, who worked in a 24-hour nursing call center, reported never actually interfacing with people in person. Instead, she exclusively talked with people on the phone. She was the only one in the class who did not see patients in a clinic setting and reported that she was uncomfortable in the skills practice portion. She expressed resistance and negativity about the class at first, which is understandable if you don’t think it applies to you! Our challenge was to find out what specifically made her uncomfortable and brainstorm with her how the skills applied. In the demonstration, we put two chairs together, back to back. The simulated patient and ACP sat in these chairs, which replicated the real-world experience of the nurse. She immediately felt more at ease, and we had a productive exploration of how and where the skills applied in her world. Creativity and flexibility were keys to our success in the ACP courses.

  As illustrated, a significant challenge facilitating courses for ACPs is the variety of settings and types of interactions that they may have with patients. This led to creative and innovative ideas for skills practice sessions constructed to closely resemble the participant’s environment and challenges. Understanding this need and being flexible and able to adapt the case on the spot requires a talented facilitator; this resulted in lasting and profound rewards. Adapting the case and helping the participant step into a more realistic role is a way to relieve anxiety and facilitate effective skills practice. If the participants are ACPs who mainly work in pre- and post-op areas, and they are asked to practice communication skills in the context of seeing a patient in clinic, their discomfort rises and is prohibitive to the learning process. They become distracted, worrying about identifying the best treatment. By adapting to what providers know and the setting in which they practice, the facilitator enables them to fully engage in the process and focus on communication skills.

  Standard cases can be adapted in a variety of ways to meet the specific needs of the clinical care providers and other caregivers. The cases can be adapted with regard to who attends the appointment with the patient, the circumstances surrounding the patient encounter (emotions, specialty, problem), and where the encounter takes place (phone, front desk, office, inpatient setting). For example, some of the other case adaptations involved parents bringing in their children, adult children bringing in their parents or senior parents, and family members bringing in non-Eng
lish-speaking family members or friends. These cases focus not only on the patient but on treating the entire family system. This type of adaptation often requires participants to take on these roles and mirrors the actual complexity of issues that all caregivers face.

  Another example of an adaptation involved the dietitians and nutritionists, particularly those who work in our Employee Health Plan (EHP) Program. They reported challenges related to treating employees and family members of employees who used their services as part of the EHP. In our organization, efforts have been made to reduce the cost of the EHP through employee engagement in preventative health programs and activities. Our dietitians routinely indicated that many of those visits were difficult because patients felt they were being forced into participating. By building a case with these basic features and then applying the R.E.D.E. skills, the dietitians were able to see the value of the skills to their primary communication challenge. An additional, unforeseen benefit to this group was the opportunity to air these challenges and discuss management options. We could see the stress on their faces and feel the anger as they shared the frustrations they had been dealing with silently. This spurred empathy and encouragement from the group. The group developed ideas and shared insights on how best to apply the R.E.D.E. skills, and the dietitians received validation.

  Despite the diversity and differences in duties among different ACPs, each provider deals daily with core communication challenges such as breaking bad news, strong emotions, and unrealistic expectations. The medical issues of the case or the setting are not as relevant in this training as the emotional ones. The skills practice emphasizes a focus on the emotion at the core of the communication challenge, which is shared by all providers, no matter what degree is after one’s name.

  Although ACPs ultimately engaged in the course and rated it very favorably, they were “healthy skeptics,” as we call them. When they arrived to take the course, they expressed it would be a “waste of time” or asserted that they were already well trained. We endorsed lifelong learning and also sought out “cofacilitators” in the audience to balance these expressions, rather than argue with them directly. To engage them, we also had to demonstrate benefit and applicability to their particular role by facilitating skills practice based on their work settings. The experiential piece was often the most eye-opening to participants, and so we moved them into these phases quickly. When they play the role of the provider and/or the patient, they feel the impact of the words chosen; there really is no substitute for that experience. As much as they may not have wanted to participate in the skills practice portion, on the postsurvey, we consistently heard positive comments about its impact:

  “The role-play—even though I hate doing it myself, that’s when I learned the most.”

  “Role-playing, uncomfortable but valuable.”

  “Role-playing and also giving input on others’ role-playing.”

  “The interactive group sessions. Getting the chance to practice skills.”

  With longer follow-up, participants reported that interactions with patients are more personally rewarding after taking the course, in part due to a more efficient use of their time because of more effective communication skills. Lack of time, regardless of the individual’s position, is routinely one of the most common issues providers discuss during the course. Facilitators benefit from showing how skills do not take more time but actually make the visit more efficient and effective.

  Participant feedback also has focused on the safety of the space, the relevance to their own practice, and the common universal themes in communication challenges. The following are typical comments:

  “All content was relevant to my clinical practice. This course provides the foundational elements for a cure for what ails medical care . . . establishment of a genuine effective relationship between patient and provider.”

  “Agenda building, empathetic expression, reflective listening.”

  “Reflective listening, the relationship model, and people’s experiences.”

  “I thought my communication with patients was excellent prior to this, but I think it will improve greatly after this.”

  “Nonjudgmental atmosphere. Nonintimidating environment.”

  “I really feel like my communication skills will be much more effective with patients and fellow staff.”

  Two words from participants that recurred over and over, year after year, were “safe” and “supported.” Whether participants vocalized this feedback directly to the facilitator or wrote it in the evaluations, the power of the environment created in the room was palpable throughout the day. At times, the clinicians shed tears, became emotional, and revealed to the group some of their greatest struggles, wishes, and regrets in their interactions with patients.

  One participant entered the class expressing verbally and nonverbally, “I don’t need this.” He crossed his arms and stated several times, “I don’t have time for this. My time is too important to be doing this.” By the end of the class, however, he reflected on his strengths and weaknesses and allowed himself to be vulnerable enough to say, “I need help with giving patients bad news.” Clinicians, even those who are initially resistant, often admit obtaining great value from the class because they were able to practice the skills and receive feedback from their peers who share similar challenges in their day-to-day work. It’s apparent that this “safe” and “supported” environment is essential.

  Over time, as our culture evolved and the course developed a strongly positive reputation, we became more confident that we could create a safe environment for more diverse and integrated groups of participants. If the primary goal was to improve healthcare communication—and we know much of healthcare is conducted in a multiprofessional environment—then pairing physician and ACP facilitators and integrating physician and ACP participants would be helpful and important.

  What to Consider when Launching an Interprofessional Program

  Education and background

  Physicians and ACPs often report having had different types and levels of training and various experiences practicing their communication skills in their roles. For example, ACPs often have more extensive training and backgrounds in communication skills. PAs spend an average of six years in college and graduate school, the first four years completing undergraduate studies and the next two years toward their master’s degree. NPs are similar in that they must first obtain their RN-BSN, which is also a four-year degree. Additionally, they must practice as an RN for one to two years before enrolling in a master’s program, which is one to three years, depending on the specialty. The curriculum has a heavy emphasis on developing interpersonal and communication skills, which encompass verbal, nonverbal, written, and electronic exchanges of information. Throughout their education, ACPs must demonstrate skills that result in effective information exchanges with patients, their families, physicians, peers, and other professionals within the healthcare system. These skills are measured and evaluated objectively as core competencies during their course work and the practical clinical rotations of their training.

  In contrast, physicians typically spend eight years in college and medical school before three or more years of postgraduate training as residents. They complete some coursework on communication and interpersonal skills, but this has, until recently, been extremely limited for most physicians. Many complete five to seven years of postgraduate training without ever formally revisiting these skills. According to one review, less than 5 percent of the physician curriculum time is spent on communication skills training.1 During the residential years, when the physicians specialize in a particular medical discipline, even less attention is given to the subject.

  Once they have graduated and start working, ACPs continue to engage regularly in communication and relationship-focused seminars and training. This is in part due to their role as patient educators. In the traditional setting, physicians diagnose and develop a treatment plan. They may impart that information to the pa
tient succinctly and move on to the next room. For a variety of reasons, schedules often are constructed such that physicians have less time in the room with patients than ACPs do, and in such instances, the physician may rely on a seasoned nurse or ACP to help patients understand the information and address their questions. Thus, ACPs have multiple opportunities to practice and hone their skills daily. Whether it’s obtaining a history, explaining a diagnosis and treatment plan, or giving therapeutic instruction, the ACP may serve as the anchor for patients and their loved ones. An increasing number of ACPs are running their own clinics daily, seeing patients, diagnosing and delivering information and education, and developing patient relationships.

  Tension

  Despite increasing attention on interprofessional communication and education, data suggests tension in the physician and ACP relationship. This was discussed in a recent study published in the New England Journal of Medicine that highlighted that many nurse practitioners believed they should be in charge of the medical home.2 When asked whether physicians performed a higher quality exam and consultation than NPs, there was a discrepancy among the responses, indicating that the vast majority of physicians believe this to be true, whereas 75 percent of nurse practitioners disagreed. If ACPs often feel they are doing the same job as physicians and not receiving the same benefits, then the stage is set for tension and resentment. Recent literature has brought this issue to the forefront. In one study, 30 percent of residents reported bullying behaviors by their nursing colleagues, most commonly in the form of being ignored by them when they approach.3 Similarly, we hear stories of nurses suffering backlash from physicians because they called an ethics consult or the emergency response team when they became concerned for a patient. In one study, 31 percent of nurses reported feeling bullied in the workplace, and this was associated with their leaving the organization.4 From a communication skills program standpoint, interprofessional tensions are important to recognize and to actively seek out, as it may be insulting or threatening to some ACPs to put a physician facilitator in front of them for a communication course just as the converse may also be true. Our belief is that the path forward is for different types of clinicians to cultivate a curiosity about and an understanding of the experience of others. Replacing judgment with curiosity is a key pathway toward forming authentic relationships, improving engagement and resiliency, and managing conflict in a productive manner.