Dr. X is not singled out as a poor performer but rather takes this training along with the rest of his colleagues. Although initially skeptical, Dr. X is engaged by skilled facilitators who focus on the benefits of communication skills and peers he respects who are in his course. He leaves the course sensitized to the impact his communication behaviors have on others and commits to practicing and learning how to listen more effectively in his work with nurses and patients.
To Act as a Unit
Cleveland Clinic was founded in 1921 and was profoundly influenced by the experience of three of its four founders, who worked shoulder to shoulder providing medical care to wounded soldiers on the battlefields of France during World War I. The ability of strong individuals to come together and “act as a unit” in war led the founders to see the benefits of group versus individual practice. Our model, “to act as a unit,” represents the core values of patient care, research, and education embodied in our credo, “to provide better care of the sick, investigation of their problems, and education of those who serve.” Cleveland Clinic also embraces innovation and individualism, celebrating pioneering advances in medicine led by physicians who pushed the boundaries of practice.8 The organization is now a large multispecialty practice that is recognized widely as providing the most technically advanced medical care for the sickest patients.
One of the unintended consequences of this emphasis on technical care, which largely paralleled the emphasis on science and technology from the mid-twentieth century onward, was that we paid less attention to the more humanistic and relationship-centered aspects of medical practice. Consequently, unintentionally, we may have embraced and reinforced individuals who were disruptive because their technical innovations were not matched with effective relationship skills. When reflecting on his own career, Cleveland Clinic CEO Toby Cosgrove acknowledged that while innovating and mastering technical aspects of cardiac surgery, he did not fully appreciate the importance of developing relationships with his patients. He established the Office of Patient Experience to integrate empathy and humanism into our medical practice. In 2008, Cosgrove reorganized our clinical structure into institutes designed to align services with the care of patients as opposed to traditional academic departmental silos.9
The culture of individualism and innovation that has propelled our reputation has resulted in some cases in discounting or ignoring elements of professionalism. In the past, Cleveland Clinic may have tolerated and even defended some disruptive physician behavior (angry outbursts, mistreatment of patients or nurses, etc.) if the individual(s) involved exhibited technical expertise and/or were high revenue producers. Fortunately, with the new emphases on relationship-centered communication and improving organizational culture and professionalism, the identification, remediation, and/or dismissal of disruptive physicians from the medical staff is now more systematic, and the focus of a Clinicwide Physician Conduct Committee (PCC).10 The PCC was developed in response to the Joint Commission sentinel event alert of 2008 that identified disruptive physician behavior as a factor undermining the culture of safety in hospitals.11 Its primary objective is “to eliminate disruptive and inappropriate behavior involving members of the Professional Staff.”
Dr. X continues to struggle with his communication in the operating room. For physicians like him, with a long history of disruptive behavior, a single course, while helpful, is unlikely to deal with the root cause(s) of the problem. The head nurse in the operating room makes a confidential report to the PCC. A member of the PCC meets with Dr. X. The focus is on validating the value Dr. X brings to the organization because of his technical skills and ability to manage complex problems. After the committee determines that there are no personal issues at play, Dr. X is referred to a surgeon colleague with advanced training in communication skills who acts as a peer coach.
Professionalism Begins in Earnest
Despite progress in changing the culture of practice through communication and conduct, there was still a gap in the area of medical professionalism. Professionalism currently has a prominent and defined role in training medical students, residents, and fellows at all academic medical centers, and we are no exception. What became apparent, however, was that we lacked any formal program in professionalism for members of our medical staff. In response, Cleveland Clinic formed a Professionalism Task Force in 2011. After a six-month study period, the task force issued a series of recommendations to senior leadership, which included the formation of a Professionalism Council to enhance professionalism across the organization. The task force also consulted experts with experience in the area of organizational professionalism and culture change12 and was introduced to the method of appreciative inquiry (AI).13 AI focuses on what is going well and gives life to an organization and asks how to get more of it, rather than focusing on what is wrong with an organization and how to fix it. AI has been used successfully in worldwide business settings and now in medical organizations.14 We ran an early exercise in which all members of the task force were asked to tell a story about a time that they were at their best. Powerful stories emerged, including how the death of a child led to an organized effort to improve patient safety in pediatrics and how going above and beyond in the service of Patients First translated to wonderful patient outcomes that provided meaning for our caregivers. Telling our stories as part of AI transformed the group from interested individuals into a cohesive team. The stories connected our caregivers. At the same time, we realized that the relationships among task force members were as important to the process of culture change as they were to the organization as a whole15—a theme that has been critical to the success of the communication skills training with R.E.D.E. After all, clinicians have relationships with their patients and each other, but they also have a relationship with the organization they work within.
Several months into the introduction of AI, the task force leadership presented its work to the chief of staff and senior administrators. Despite concerns that a “soft” approach would not sit well, the group decided to use a round of AI storytelling to explore its transformational power with executive leadership. They told several moving stories, including the following from a senior executive and neurosurgeon:
Early in his career as a neurosurgeon, he was in the midst of a complex brain surgery when he found himself unable to identify normal anatomic landmarks and, in his words, became “disoriented” and unsure of how to proceed. As a new staff physician, he felt vulnerable—he didn’t want to appear incompetent in front of the surgical team—but he also wanted to provide the best care possible for the patient. He decided to call the chair of Neurosurgery, who came directly to the OR and helped him complete the case. The patient did well. In retrospect, the support he felt from his chairman made the words “to act as a unit” a reality for him as a junior staff physician. He has vivid memories of this event to this day.
The engagement of the senior leadership team made it clear that the AI approach would have traction across the organization. Senior leadership immediately adopted the task force recommendations to create a Professionalism Council, which remains active.
Communication, AI, and storytelling are central to the work of the Professionalism Council and the goal of making our culture more relationship-centered. For example, the council offers the Dialogues in Professionalism series, in which caregivers share stories with one another in a safe, supportive atmosphere. In these hour-long sessions, the facilitators briefly outline the goals of the council, introduce the concept of AI, and ask participants to write a brief narrative about their personal experience of “professionalism at its best.” With permission, participants share their stories, which are recorded on video and catalogued. As a result of these sessions, several caregivers are now involved in professionalism activities within their own institutes or with the council.
Council members also felt that it would be useful to better understand how key leaders experience or think about professionalism at the Clinic. Several memb
ers of the council sat down with institute chairs for semistructured interviews. They asked chairs about professionalism challenges and best practices to enhance professionalism. There were wide variations in leaders’ ideas on defining professionalism, professional lapses, and remediation efforts. As might be expected, dealing effectively with disruptive behavior, workplace stress, and production pressures were common themes in professionalism lapses. Responses—such as “But he is a good guy” when asked about never events, or “This is absolutely ridiculous” when a new initiative was introduced—capture some of the subtleties and cultural realities that our own leadership feels at times.
The council believes that the integration of professionalism in the onboarding of new physicians is critical. Several senior members reflected that as the organization has grown, some of its traditions are fading or have disappeared altogether. For example, by tradition, if a primary care physician called a specialist with a request for a patient to be seen, the expected response from the specialist was that he or she would gladly see the patient immediately, that day. As time has become more precious and patient loads have increased, some felt that the tradition of collegiality and effective relationships among colleagues has suffered. At times, calling a consult became so difficult (due to disagreement on whether the consult was necessary) that consult pagers were used to minimize individual variation and response. The recording and playback of transfer calls also highlight the pressures that clinicians feel and how that impacts their willingness to bring in transfers. In response, council members organized To Act as a Unit: Professionalism at Cleveland Clinic (Table 11.1), a series of interactive sessions that includes a full day of the R.E.D.E. to Communicate: FHC program and six additional two- to four-hour sessions.
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TABLE 11.1 To Act as a Unit Professionalism Series
Cleveland Clinic Heritage/Introduction to Professionalism
Education of Those Who Serve
Physician Support
Leadership
Quality and Safety
Interprofessionalism
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A key component of these sessions is allowing physicians from diverse parts of the organization to meet, share their stories of professionalism at its finest, and engage through a relationship-centered communication approach.
The general introduction courses on heritage typically have 40 to 60 participants seated at round tables. Faculty and participants begin with relationship building and then listen to an interactive presentation highlighting our heritage. Following the heritage presentation, one of the faculty introduces appreciative inquiry and shares an AI story to illustrate the process. Importantly, facilitators demonstrate their own vulnerability prior to asking any participant to do the same. Participants share a personal story of professionalism. One participant spoke of initially feeling dismissive of the description of our organization as a group practice that “acted as a unit.” He came from a solo practice in another state where he hadn’t taken a day off in over 20 years. Shortly after he joined Cleveland Clinic, one of his parents died unexpectedly. He experienced unconditional support from his new practice partners who gave him time to deal with his personal issues. In his story, he expressed deep gratitude and a clear understanding of the concept “to act as a unit.”
Facilitators introduce situational awareness and communication under stress as tools that support professionalism. Finally, participants share cases of professionalism challenges in small groups, and facilitators debrief and discuss common challenges with the large group. Cases focus on conflict between professional and personal obligations, the lack of appropriate expertise to provide care, and how to intervene with an impaired colleague. An example of the agenda for the professionalism course is shown in Table 11.2.
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TABLE 11.2 Agenda for Session on Professionalism
Introductions of faculty and participants
Introduction to professionalism: review of the Physician Charter
Appreciative Inquiry exercise Introduction to AI
Videotapes of students and faculty sharing stories in prior AI sessions
Pair up and describe to your partner a time in your career when you were at your best as a medical professional (small groups at tables)
Skills that enhance professional resilience Situational awareness
Teamwork
Communication under stress
Case discussions of professionalism challenges
Appreciative check out
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Other courses follow a similar interactive format. Participants discuss Dr. X and similar cases in the professionalism courses as part of onboarding. This enables new physicians to understand the value the organization places on relationship-centered care and the resources available to support these efforts.
Building Not Recreating
When thinking about professionalism, what worked well for us was that parallel efforts to train staff in communication skills were underway and ultimately touched all of the professional staff physicians and many advanced care providers. In addition, all caregivers had taken service excellence training in the form of the Respond with H.E.A.R.T. program. Learning occurs best when it builds on existing knowledge, so we reinforced communication skills and service excellence through professionalism efforts. Several of the facilitators of the R.E.D.E. courses lead and also serve on the council. Because professionalism and communication are intimately linked, we also have members of the council design and facilitate our advanced communication courses. Cross-pollination allows for a richer discussion of the issues and reinforces communication training in which significant organizational effort has been made.
Ongoing and future collaboration involves working toward developing an integrated model of support for physicians, including advanced peer coaching for professional development, online mindfulness training, and coordination of various programs in a Professional Staff Resource Center. In addition, as we analyze engagement results for our physicians, designing strategies that deeply invest in our own caregivers will be needed to drive the caregiver experience and, as a result, the patient experience. The council developed a concept map summarizing the various dimensions of professionalism at Cleveland Clinic (Figure 11.1).
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FIGURE 11.1 Concept Map of Professionalism at Cleveland Clinic
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Dr. X finished six months of peer coaching with a surgeon who is a trained communication skills peer coach. As a result, he gained new insights into himself and his behavior. He has also mastered new skills that allow him to be more effective without being disruptive in the operating room.
In response to a growing recognition of the need and importance of creating a culture of individual and organizational professionalism, the Clinic adopted relationship-centered communication and appreciative inquiry as foundational. Having a dual emphasis on individual and organizational professionalism promotes a culture that both values and respects the desire of patients to be known and understood by their providers, and also builds relationships among our caregivers. There is synergy between relationship-centered care and professionalism, and this powerful combination can be applied broadly. To quote a popular maxim of Francis Peabody, “The secret of the care of the patient is in caring for the patient.”16 We would add, “In an era of highly bureaucratized medicine, the secret of caring for patients is to create a culture of caring that rests on the twin pillars of professionalism and establishing meaningful relationships irrespective of boundaries, silos, and status.”
Power Points
Connect the dots. Communication is core to professionalism.
Get ahead of the curve. Medical bodies have outlined communication as a core competency both in medical training and for practicing physicians.
Tie communication skills to sentinel events to broaden the impact of effective communication on safety and quality and build a case for the training.
Foster your skill set with ap
preciative inquiry, which focuses on drawing out stories and qualities that represent people at their finest.
Ground professionalism efforts in R.E.D.E. or other communication skills training to reinforce a common language and cross-pollinate facilitators to maximize this benefit.
Chapter
12
The Awesome Power of Vulnerability
When you are the physician in the room, you fill the space, but as a husband, you are simply half of a patient.
—ANESTHESIOLOGY RESIDENT DESCRIBING GOING TO OB APPOINTMENTS WITH HIS WIFE
It is difficult for those who have worked so hard at perfecting their medical knowledge to reflect on the fact that they are not perfect at something—people who may be the only one in their families to become a doctor, who are following in their parent’s footsteps, who spent 16 years training for the moment when they are ultimately responsible for a patient. Acknowledging that they may not be great at something goes against their grain. And if we look to history, at times, keeping patients alive required our full attention, and communication skills probably mattered less to the patient than not dying. Yet today, patients expect both. They expect competent, high-quality medical care, and they expect a level of service that clinicians may or may not be used to providing.
Communication the Cleveland Clinic Way Page 20