Communication the Cleveland Clinic Way

  Connecting the Ability to Communicate Effectively to Leadership

  Leadership is the art of causing others to deliberately create a result that otherwise would not have happened.

  —ANONYMOUS

  All humans lead. An individual influences another by employing leadership skills, which is of particular relevance to surgeons. The expectations of surgeons as leaders are higher than for most professions. Surgeons lead teams that perform highly technical and orchestrated tasks. The successful completion of such tasks requires teamwork, a high level of organization, and guidance by an accomplished and skilled leader—the surgeon in the operating room. Surgeons, unfortunately, often fall short of such high leadership expectations, particularly outside the operating room environment. Patient compliance with medications, exercise regimens, weight loss, and so on is notoriously suboptimal for all physician groups.3 For some, it feels more authoritarian and, therefore, more familiar to stay the “leader” in patient interactions; the price paid is the comforting component of the relationship between the surgeon and the patient. Too often, interactions become so doctor-centered that the patient can’t get a word in, is smothered by the physician’s monologue, and understands and retains only a small fraction of the transmitted information.4 This approach results in suboptimal communication.

  The practice of medicine is much more complex than simply writing a prescription for the right medication or performing an operation well. If the patient does not take the medication or the operation is not followed by appropriate rehabilitation, the surgeon may be guilty, to one degree or another, of ineffective communication and, arguably, suboptimal care. We understand that in expanding this definition of our role, we are making people uncomfortable, but if your role as a physician is to fix, then who determines when what required fixing has been fixed?

  Expertise and execution that is appropriate in the OR may be inadvertently carried over to the bedside. One may derive from this discussion that the surgeon is the patient’s leader, and consequently, his or her role is to tell the patient what to do and how to do it. This, however, would be taking leadership in the wrong way: the surgeon playing a paternalistic, autocratic leader. Such a surgeon (or medicine specialist, for that matter) may see herself as a leader, but in fact she is functioning as a boss. In this context, the boss tells her constituency (the patient) what to do, while a leader “causes others to deliberately create a result that otherwise would not have happened”—she actively participates by pulling in the same direction as her constituents. To quote Teddy Roosevelt, “People ask the difference between a leader and a boss. . . . The leader leads, and the boss drives.”5 Furthermore, if the surgeon is the leader, then the patient also assumes a role, and most patients these days don’t consider themselves followers.

  Many surgeons function as bosses, rather than as leaders. The end result is that the patient is not seen as a partner in the process, but rather, as someone in need of being told what to do. This is the doctor-centered approach. Effective relationship building via the employment of effective communication causes patients to do something they otherwise might not have done—take their medicines, come to appointments—the very definition of leadership. This is nearly always achieved via the use of a collaborative decision-making process. In a sense, the surgeon, by employing such leadership skills, is attempting to cause patients to play more of a leadership role in their own lives by respecting their autonomy, engaging them in their own care, and forming strong patient-doctor relationships. So, in this sense, both the patient and the surgeon are leaders. This is a win-win situation and at the core of a relationship-centered approach.

  There are lapses in communication with patients and lapses in communication and behavior among colleagues. Since 2009, all hospitals have been required to generate policies for disruptive physician behavior. An internal review of such cases in our organization found that although there were few cases, the vast majority of these were related to the behavior of male surgeons. In fact, even though at the time, surgeons made up 20 percent of the organization, they accounted for 60 percent of the reports of disruptive physician behavior. Even more fuel for the empathy-is-needed fire is that the root causes of these cases included dealing with stressful and emotional situations, fatigue, and burnout. How we communicate as surgeons affects our colleagues, our teams, and our patients, and it reflects our leadership ability.

  Surgical Education

  The traditional approach to surgical education, which began in the latter 1800s (the modern surgical era), emphasized the diagnostic and technical aspects of medical care, while deemphasizing humanistic aspects such as empathic communication. We all know or have heard of surgeons who were tyrants—great surgeons, but people who made patients and colleagues feel awful. Their understudies modeled themselves after their mentors and defined surgical culture. They threw scalpels, pushed interns’ heads into the surgical field so they could see, and berated and humiliated nurses and innumerable others. Generations of surgeons were trained to be unfeeling. Surgeons were expected to operate and operate well—lives were at stake—but to be blunt, focused, and relatively noncommunicative. Times, however, are changing—and changing for the good.

  The modern-day surgeon uses effective and empathic communication skills, including reflective listening, to enhance the diagnosis, treatment, and care of the patient. Of course the act of surgery is critical, but there is much more to an episode of surgical care than the operation, and it is no longer enough to do only the operation well. An operation should only be performed on a clinically appropriate patient and should be followed by a focus on the details that optimize recovery and functional improvement. Diagnostic acumen and accuracy and patient adherence can be enhanced by knowing the patient. There is only one way to know the patient, and that is via effective communication.6

  Traditionally, leading from a surgeon’s perspective was thought to be commensurate with surgical prowess. The authoritarian aspect of traditional surgical leadership and training can be stifling regarding the educational process and be a detriment to patient care. This is not simply because of the direct impact of a monarchical culture, but because of the fear it fosters. The Joint Commission has an entire campaign dedicated to speaking up because they know safety depends on it. Their research suggests that wrong site surgeries, also known as never events, occur because no one wants to tell the surgeon it’s the wrong leg, not because no one noticed. How does that happen? It happens because other people are afraid of the wrath of one individual.

  This is not to deny that respecting hierarchy in the operating room is important. Hierarchy and role clarity ensures that patient care is guided by an expert, the surgeon leader, who is empowered to maintain order by directing team-member activities toward the common goal of an optimal outcome. Interpersonal skills can be employed so that a strong team is created, while giving all team members, including the patient, a voice. The voice of all team members is critical in promoting a culture of safety and preventing medical harm. Surgeons who have strong listening skills are more likely to hear their team members and their patients, who often have important information to share. In contrast, when a surgeon throws an instrument on the floor, swears, yells, or is bitingly sarcastic to a nurse, technician, or anesthesiologist—events that anyone who has spent time in an operating room has probably witnessed—those actions are destructive to the team caring for the patient and jeopardize relationships. Fear replaces trust. Fear of angering the surgeon not only makes an authentic relationship impossible, it undermines patient safety. If decisions are made in an unhealthy environment in which fear prevails, then cover-ups occur, personnel are afraid to speak up on the patient’s behalf, communication breaks down, and complications result. This is a conclusion well supported by data from The Joint Commission and mortality and morbidity conferences.

  Empathy for the Surgeon May Become Empathy for the Patient

  What is the role of empathy in surgery? Do patients even want empathy
from their surgeons? Surgeons go where other physicians don’t. We open the human body and delve into its interstices. In this regard, we are perceived by some as playing God. We are thrust into a position in which we risk harming the patient. An element of toughness is required of surgeons that is not necessarily expected of many others. The surgeon must cognitively separate himself from the patient’s pain and create some emotional distance between the patient and himself in order to be truly effective. This may be what prevents us from seeking a relationship of meaning with our patients. A neurosurgery resident once remarked, “Yesterday I had to tell a surgical intern not to cry over a patient who had died on the table because we had to move on to the next patient.” This may seem callous, but it is nothing more than a learned coping mechanism within a system. In fact, this ability may well have adaptive advantages when caring for patients with life-threatening emergencies. But is it the only or best way to cope in the long run? The same resident asked, “If the military has required debriefing sessions with soldiers, why don’t we have this for surgeons?” We witness trauma day in and day out, some of which we ourselves have caused. The work we do leaves a mark on us and, in most healthcare environments, we don’t have anywhere to go to process our experiences.

  If we expect our surgeons to care effectively for patients in a deeply empathic way, why then don’t we take care of our surgeons? What is often lacking is an expression of caring. Caring and the expression of caring are two distinct things. The behavioral component of empathy, the expression of caring—a kind word, a show of concern, a touch, the verbal articulation of what the other person is experiencing—this is the essence of empathy. One study reported that when presented with empathic opportunities, physicians only responded to 10 percent of them.7 Missed opportunities include not acknowledging, inappropriate use of humor, denial, and ending the conversation.8 Another study looked at what behaviors from surgeons led patients not to recommend them to others, and 52 percent of the time, interest in the patient as a person and appropriate explanation were lacking.9 Patients respect surgeons who care. Patients listen to surgeons who care. Patients want to be cared for by surgeons who care. Patients will not appreciate that a surgeon cares, however, unless the surgeon expresses this care.

  Listening as a Lost Art

  Levinson et al. published a review of communication approaches in surgery. The paper confirms that, unfortunately, most surgeons spend their time in a visit—up to 60 percent—conveying biomedical information in a one-way direction, that closed-end questions are the overwhelming norm,10 and that psychosocial aspects of a patient’s care were rarely addressed, in one study only 3 percent of the time.11 Multiple studies have suggested the need for surgeons to explore a patient’s ability to cope with the surgery itself, as well as managing the recovery process.12

  Surgeons, perhaps more than their medical counterparts, are prone to lecture to, rather than dialogue with, patients. Such monologues are not effective means of education, nor of transmitting information. Patients do not accurately retain the majority of the information spewed by the lecturing physician.13 Dialogues, as opposed to monologues, are much more effective means of educating and conveying vital information. A dialogue with the patient facilitates patient interaction, participation, understanding, and adherence.

  Relationship-Centered Communication

  Isn’t it the surgeon’s job to remove the diseased body part or repair what’s broken? As long as the operation is successful, why is a relationship necessary? Isn’t a great surgical outcome enough? Indeed, in some circumstances, the answers to these questions may be yes—and in some cases the patient might agree. All that the patient wanted was to be fixed, like taking a shaky car to the shop to have the wheels balanced. The surgeon easily could just balance the wheels. But patients aren’t cars. And thinking of surgeons as mechanics is reductive and is a disservice to all the skills and value they bring—or can bring—to the table. As the surgeon grows in mastery of the surgical technique, it will be the human dimension that will challenge, engage, and reward the surgeon for performing the same surgery well 30 years from now.

  From a historical perspective, the surgeon-patient relationship is perhaps one of the most revered and honored. Harvey Cushing, the father of modern neurosurgery, repeatedly documented his relationships with patients and how meaningful these relationships were to him.14 In an ideal relationship, both parties benefit. Effective communication, therefore, is not just for patient benefit. The surgeon can feel enriched and revitalized as well. In an environment wherein clinicians are suffering from burnout in record numbers, we are all asking the question of how to engage them and provide meaning. In large part, the answer is to create relationships that matter and have meaning. At the end of each workday, clinicians should feel like they did good for patients and, hence, for themselves. And if they couldn’t do the good they wanted to or if something went wrong, then they have valuable relationships with their patients, the stakeholders, and their teams, who will support and forgive them.

  Power Points

  Provide surgeons with communication skills training. They need it just as much as their medical colleagues and should not be exempt.

  Identify surgeon facilitators who not only have foundational skills in communication but also influence within the organization to get surgical buy-in.

  Approach surgeon colleagues with the same empathy and relationship-centeredness as you bring to others. It will do wonders for engagement in your process.

  Know the evidence. Evidence suggests that patients want their surgeons to express empathy and interest in them as persons, which has implications on whether they will recommend a surgeon to others.

  Surgeons have power over the environment they create in the OR and at the bedside. Adapting communication skills to each setting is critical to relationship building, safety, and resilience.

  Chapter

  11

  “Trust Me, I’m A Doctor!”

  Building, Supporting, and Maintaining Professionalism

  Dr. X is a 53-year-old surgeon who is nationally recognized for his surgical skills and innovative surgical techniques. He is a top revenue producer in his department. Recently, reports have surfaced that he often fails to show up for mandatory huddles in the operating room and often curses at nurses for being incompetent. His patient communication scores are low. Patients comment that his listening skills are poor, and time spent with patients is short with no opportunity for them to ask questions.

  Professionalism as an Emerging Concept

  In light of this scenario, it isn’t surprising that there is a renewed emphasis on professionalism in American medicine. In 2002, a Physician Charter on Medical Professionalism was published with wide endorsement from multiple medical organizations in the United States and Western Europe.1 This document aimed to update the concept of professionalism and bring it in line with values of late twentieth-century medicine. The charter is based on three principles (social justice, patient welfare, and autonomy) and nine commitments, including honesty with patients, patient confidentiality, maintaining trust, and professional competence. Most medical schools now have an explicit emphasis on professionalism as a core competency that students must demonstrate prior to graduation. Similarly, in 2003, the Accreditation Council for Graduate Medical Education (ACGME) established professionalism as one of six required core competencies that every graduate medical education program is required to incorporate into training.2 The other five are patient care, medical knowledge, practice-based learning and improvement, systems-based practice, and interpersonal skills and communication.

  Dr. X’s behavior demonstrates a lapse in professionalism, is disruptive, and threatens the quality and safety of patient care. Poor communication skills are clearly part of his problem; however, a formal curriculum and training in communication skills was not included in his surgical residency. When medical students or residents exhibit poor communication skills that lead to lapses in professionalism, there
are clear mechanisms for identification and remediation. For attending physicians, such as Dr. X, the path to reporting and remediation of professionalism lapses is often unclear.

  The focus in the physician charter, and the ACGME competencies for medical schools and residency programs, is on the responsibilities of individual physicians to fulfill the obligations of a medical professional. Recently, the question of “organizational professionalism” has been raised.3 Organizational professionalism recognizes the fact that there are important and systematic ways that organizations behave that are out of an individual’s control but that nonetheless impact professional behavior.4 Conceptually, there is increasing recognition that professionalism is more than a simple set of rules that medical professionals follow blindly, but is, rather, a complex interplay between individuals and the environments in which they work, or what has been termed a complex adaptive system.5 Along with recognizing the importance of context and complexity, scholarship is emerging around the theme of relationship-centered care, the idea that the smallest unit of measure in understanding communication is the relationship, not the individual.6 This view is an elaboration of the concept of patient-centered care, which takes into account patients’ values, preferences, and goals. Patient- and relationship-centered care are essential to providing high-quality, safe care.7

  At Cleveland Clinic, relationship-centered communication using the R.E.D.E. model is a critical resource and a programmatic thread woven into our efforts. The R.E.D.E. model is an example of organizational professionalism that works by providing every physician training in relationship-centered care, thereby giving them the tools to meet the expectation that they will demonstrate effective communication skills in the work environment. In other words, the R.E.D.E. model represents how we expect professionals in this organization to communicate. This chapter explores efforts to integrate relationship-centered communication and professionalism into our culture.