Communication the Cleveland Clinic Way

  Power

  Power differentials matter, and they can threaten the clinician’s perception of safety. Power differentials can also threaten patient safety if they prevent clinicians from speaking up or otherwise communicating critical information. In the book What Keeps Leaders Up at Night, Lipkin discusses how power can be perceived or real, and can manifest as different types, including coercive, expert, legitimate, reward, and referent power.5 When different professionals work together, these power differentials, whether real or perceived, can significantly distract from learning. When power, hierarchy, and diversity factors are present, emotional issues and needs often rise to the surface and individuals can become emotionally hijacked. While this can represent an opportunity to work on these critical issues, it can also distract from other important agendas in a foundational communication skills course. Balancing these competing issues and recognizing the implications of any course format is the name of the game. Ultimately, thoughtfulness and sensitivity to emotional and psychological safety are required, no matter what format is chosen.

  ACP advantages

  There are pros and cons to teaching within or across professions. Several studies indicate that physicians and other medical professionals can be trained together to help patient care be seamless, to improve outcomes, and to acknowledge that a team, rather than one provider, is responsible for the patient. Interprofessional education is receiving increasing attention as an important type of training in healthcare, given that team approaches to care are increasingly the norm.6

  As noted earlier, communication skills are more heavily emphasized in ACP training, education, and work flow, and ACPs often are allotted more time with patients. It is not surprising then that there are perceived differences in the care provided by an ACP and a physician. Overall, ACPs receive higher patient satisfaction scores compared to physicians (internal data). The differences are small, but they are consistent across multiple domains: provider gave clear information, 95.1 percent versus 93.0; provider spent enough time, 96.6 percent versus 92.9; provider knows my medical history, 91.1 versus 88.4; provider explained, 96.8 versus 94.1; provider listened, 97.2 versus 94.6; and provider respects me, 97.4 versus 95.8. These differences may be reflective of the team approach to healthcare infiltrating inpatient and outpatient environments, with ACPs increasingly being delegated to performing the bulk of follow-up communication and responding to patient phone calls or e-mails. If patients are able to communicate or make a request directly to the ACP, they may get a response more quickly and more reliably.

  Several factors may contribute to these differences. As mentioned, scheduling may give physicians less time with patients, and much of the communication may be delegated to ACPs. In addition, ACPs may take a more holistic approach to the patient. Often, they know more about what is going on with patients besides their primary medical problem. If the ACP has spent more time with the patient and is more accessible by phone and e-mail, the patient may feel a stronger connection with the ACP. Second, ACPs receive substantial course work, clinicals, and training on the value of patient education and the importance of conveying detailed, understandable information and instruction to patients. Third, ACPs on average may be more prone than physicians to emphasize relationship building as central to their role. Many ACPs voice expecting this relationship and seeking it within their practices. Consequently, the relationship with their ACP may feel more intimate and personal to patients, well beyond their medical symptoms and diagnoses. Last, in many practices, ACPs manage the day-to-day with regard to inpatient service or the relationship in the outpatient setting, where they may also see patients independently. In such cases, the physician (resident or attending) is a more transient provider of care and may change more frequently in either setting. This lends itself to patients perceiving the ACP as the most consistent and present member of their care team.

  Working with hospital administrators

  Our ACP courses also provided opportunities to work with colleagues in the healthcare organization who did not see patients. One group in particular that was eager to participate was hospital administrators. We have had regional hospital vice presidents and CFOs who were very curious about the course and wanted to experience for themselves what their clinical teams were doing. After participating, many expressed experiencing benefits from the course, although they found the skills practice portion challenging. This is a good example of how relationship-centered communication skills can expand beyond the patient-clinician interaction. This we accepted as a challenge and opportunity to make the course even better by adapting the skills practice session for comfort and applicability for such nonpatient care roles.

  During one course, we asked one of the hospital administrators to identify his most common communication challenge that he would be willing to work on. He shared that talking to physicians about rules or policies was the most challenging. He gave an example in which he had to inform a surgeon that he could not travel to a lecture without obtaining approval from his chairman. He shared that he became extremely anxious in anticipation of such interactions and that they always ended terribly, with physicians storming out. He would “hold his breath” throughout the entire conversation, bracing for the worst. Not surprisingly, he reported trying to rush through these encounters.

  We ran the skills practice a few times to allow him to experiment with different approaches. At first, with him playing himself as the administrator, he seemed defensive and aggressive. He did most of the talking, avoided eye contact, ignored the surgeon’s reaction and emotions, cut the surgeon off each time he began to respond, and ended the interaction abruptly. He then switched into the physician role. After hearing his own words spoken to him, he articulated a greater awareness of his own style and developed more effective language. “That doesn’t feel so good” or “I never realized” are common reflections after switching roles.

  Thinking about this more broadly, relationships certainly aren’t limited to healthcare, and effective techniques work in healthcare administration and leadership as well. This experience reaffirmed for us how powerful the relationship-centered techniques can be and how easily they apply to all types of communication interactions.

  Every Word, Every Decision Matters

  When considering which ACPs would be appropriate for relationship-centered communication training, we realized we needed to replace the references to a specific type of provider with the generic terms provider, caregiver, or clinician. This broadened the description and included others who might want to participate and allowed us to reduce the focus on particular academic degrees. We also added a point about the applicability of relationship-centered communication skills to contexts beyond the clinician-patient interaction (e.g., colleague to colleague, with family members, etc.). Helping providers to see that the skills transcend the patient-clinician encounter increased buy-in. In addition, we explicitly gave permission to participants not to do a traditional medical interview. If a clinician is not accustomed to using the traditional medical interview, the training session is not the time to start. Adapting the skills to how you have been trained to do the initial interview is critical. When we worked with standardized patients, we developed a case with the potential for various primary medical concerns, including psychosocial issues, in the hope of better generalizing the case to a large number of disciplines (e.g., social workers, dieticians, nurse educators, physician assistants, and clinical nurse practitioners). When we worked without standardized patients, we had the participants develop their own cases to make them relevant to their own experiences. In relationship-centered communication skills training, there is much more that binds us together than pulls us apart. Attending to the key issues of safety, respect, and learner-centeredness allowed us to work effectively on universal healthcare communication challenges.

  Power Points

  Stay relevant. We started with physicians because we knew that they hadn’t been exposed to communication skills training as st
aff, and we wanted them to model the skills with their teams and with colleagues. As culture evolved, so did the training.

  Be creative and flexible with the program content, depending on the diversity of your audience.

  Appreciate differences in emphasis on communication skills throughout training for physicians and ACPs.

  Know your environment. Deciding whether your culture is conducive or detrimental to integrated training from the outset is critical to protecting the safety of your learners.

  Chapter

  10

  Empathic Communication Through the Loop Lens

  A Surgeon’s Perspective

  For this is the great error of our day in the treatment of the human body, that physicians separate the soul from the body.1

  —SOCRATES

  Dr. Adrienne Boissy writes:

  We knew early on that a communication skills program that was built and rolled out in a healthcare system that was largely run by surgeons needed not only surgeon input into content, but surgeon facilitators. People would make assumptions about “the type of person who teaches communication skills” and we wanted to highlight those assumptions and then squash them.

  With some anxiety, we approached surgeons one by one and invited them to join our work. This was couched as, “We need your help. Surgeons are a huge part of the organization. You are well respected in the field, and we don’t want a program to move forward without making sure we capture your voice.” The overwhelming response to this approach was “OK.” We wondered what we had been so afraid of.

  Benzel was one of the first surgeons that we thought of and one of the first to come onboard.

  Hog-tied. That’s how I (Edward Benzel) initially felt about my involvement in facilitation training. I used that phrase liberally. Dr. Boissy had approached me about becoming a facilitator while I was the chairman of Neurosurgery. I responded that I thought there was a young female neurosurgeon who had just joined the clinic who might be ideal. Boissy and my institute chair pushed back, saying that having the younger, less experienced female surgeon sent a message. Perhaps a message we don’t usually talk about: that communication skills training is a gentle, feminine matter. Ultimately, I dove in.

  I often hear that there is trepidation about approaching surgeons to participate in communication skills training. Surgeons have long been represented as aloof, highly intelligent, disconnected people. Look no further than the movies or TV. This was encapsulated by William Hurt in the film The Doctor: “I’d rather you cut straighter and cared less.” There is no question about the importance of surgeons’ technical skills. Who wants to suffer or die from unnecessary surgical complications? However, the dichotomy that implies that we must choose surgeons who are either technically skilled or empathic is a false one. Do you want an airplane pilot who knows how to take off or one who knows how to land? Is it too much to ask for both? Why can’t we expect surgeons to be able to operate and to communicate? Strong communication skills are critical to a surgeon’s work. They help in obtaining an accurate and complete history, educating the patient about treatment options, obtaining informed consent, helping the patient to understand the care plan, reducing patient complaints, and lowering the risk of malpractice suits. Medical and surgical colleagues face similar challenges, but some communication challenges have a unique flavor in the surgical setting—error disclosures, discussions about surgical complications, and at times, unexpected death at the surgeon’s hands. One of the toughest conversations that we surgeons have is about what we are not going to do: “We are not going to perform your fifth back surgery for chronic pain.” Sometimes the best thing we can do for a patient is not do anything at all, and it’s a conversation we’ve never been taught. If we rely purely on our surgical techniques, what do we do when they aren’t needed?

  The Culture of Surgery

  The fundamental role of the surgeon is to “heal with a knife”—to “fix” things. The healing process, however, extends far beyond the operating room. It begins with the first and ends with the last interaction between the two parties. It may, in fact, last a lifetime. The bond between a physician and patient has been recognized and cherished for millennia. Socrates was well aware of the importance of this bond and of the importance of considering the patient as a person with feelings and emotions.2 The bond between the physician and patient is, in part, based on a commitment of the physician both to heal and to comfort.

  If it’s true that the “fixing” culture of healthcare gets in the way of relationship-centered communication, what might get in the way of surgeons comforting patients and attending to the more humanistic sides of medicine? Surgeons are thrill seekers. One of the main differences between surgeons and our medical counterparts is the appeal to the surgeon of the thrill associated with action. We surgeons perceive ourselves as doers and fixers. The appeal of doing and of fixing what is broken draws medical students to the surgical specialties. This macho aspect of surgery, in many regards, is fostered and nurtured in both the training and clinical practice environments. For example, the surgeon who swoops in to save the patient in an emergency situation feels the rush associated with swift and definitive action and is viewed, to some degree, as a hero.

  Inarguably, the healing component of surgery requires technical surgical skills coupled with medical judgment, yet these same skills are insufficient for the comforting component of the bond between the surgeon and the patient. Sadness, anger, fear, and uncertainty are not amenable to being fixed. Emotional distress cannot be sutured, yet its expression is usually therapeutic. A very different constellation of skills is required for this component, in particular empathic communication and listening.

  Our Experience Training Surgeons in Communication Skills

  Having decided that surgeons and physicians alike would benefit from communication skills training, we faced the challenge of getting surgical buy-in. As in most hospitals, our surgeons are busy. The request of a full-day commitment to work on the development of more effective ways to communicate with patients risked provoking enormous backlash. The leadership of the communication skills training team used several key strategies to anticipate and reduce resistance: all the facilitators had a substantial active clinical practice, the message to participants focused on improving the experience of both clinicians and patients, physicians were placed in physician-only groups to increase a sense of safety, and they recruited senior surgeons as facilitators. These surgeons’ humility and willingness to open themselves to the process sent ripples throughout the organization.

  At a very basic level, when the course was being facilitated by a prominent urological surgeon, colorectal surgeon, thoracic surgeon, or neurosurgeon, it became more difficult for participants to argue that they didn’t have time to participate or that the subject matter was irrelevant for surgeons. The fact that the CEO of our organization, a retired cardiac surgeon, had taken our course similarly supported our message that communication training was important and worthy of the time spent for all clinicians.

  When we say we have surgeon facilitators, people look at us as though we stole the moon. Their disbelief seems rooted in the perception that surgeons are difficult to work with in the area of communication skills training. However, we found the perception of surgeons as uncaring technicians disinterested in empathy to be largely folklore. Surgeons were receptive and open to changing and improving their communication behaviors. They appreciated and embraced the importance of self-improvement. If more effective patient communication skills existed, surgeons appeared eager to learn and adapt them, just as they would want to master a new or improved surgical technique. One of the surgeons said, “I’ve been waiting my whole life for someone to tell me what I should say in this moment.” This reinforced to us that healthcare is rich with difficult communication challenges, and clinicians do not always know what to say; they need the actual words and phrases. In addition, whereas internists and subspecialists in medicine who participated in our course enjoyed d
ebating the relative merits of a variety of approaches, our surgical colleagues tended to appreciate and accept the fact that the facilitators had spent more time than they had thinking about communication with patients. The surgeons more readily focused on developing an understanding of and mastering the skills presented.

  While surgical culture and training have not emphasized communication skills historically, our experience has been that surgeons are no less willing to work on these skills than other physicians if they are approached in a thoughtful and well-considered manner that takes into account their environment, culture, and experience.