Communication the Cleveland Clinic Way

by Adrienne Boissy

  We want to acknowledge the thousands of caregivers who opened themselves to this training and who taught us many of the lessons and insights we’ve shared. They opened themselves to a process that they were skeptical about at times and that perhaps went against their grain, but they did it anyway. We’d like to spend time on some of the recurring themes they taught us (Table 12.1).

  * * *

  TABLE 12.1 Communication Dos and Don’ts

  Keep

  Stop

  Matching the gravitas of the emotion

  Saying I understand before you actually understand

  Expressing your intention of care and doing the right thing

  Telling people not to worry

  Being empathically curious

  Missing emotional cues

  Perceiving emotional cues

  Using reassurance or data to allay fear

  Saying you don’t know when you don’t

  “Winging it” when it comes to challenging conversations

  * * *

  Major Recurring Communication Themes

  Matching the gravitas of the emotion

  DOCTOR: Hi, Mr. Smith, I’m Dr. Brown. I understand you are here for a biopsy. How are you?

  PATIENT: I’m a little nervous. My friend bled and died from this procedure.

  DOCTOR: You’re at the best place. Our complication rate is less than one percent.

  PATIENT: OK.

  DOCTOR: I see you are from Indiana.

  This conversation elicits several observations: one is that we really like to respond to emotion with data. We suspect this comes from being uncomfortable and not knowing what to say, and then subsequently defaulting to what makes us more comfortable, which is medical knowledge and data. This is another good example of responding to emotion with not just information, but reassurance. And in most cases, the reassurance is premature. Patients need hope, and we desperately want to give it to them. But premature or inappropriate reassurance can feel to patients as if we are dismissing their concerns rather than trying to understand them. Halpern addresses this in an article about a rape victim whose anxiety about being tethered to an IV was not eased by the doctor’s description of all the pain management options she would have with the IV.1 In such cases, physician efforts to educate patients only succeed in isolating them.

  In cases wherein the patient is calm, not experiencing distress, and understands the percentage risk, it can be effective to discuss quantitative outcomes, but when they are hijacked by their amygdala, rational assurances generally don’t have the impact we want them to have.

  When patients are in their emotional brain, they need emotional responses.

  Expressing intention

  DOCTOR: We need to talk about quitting smoking. We talked about this last time, and there hasn’t been much progress.

  PATIENT: It’s been hard since my mom died.

  DOCTOR: Well, if you don’t quit, you are going to have another heart attack, and you might get lung cancer.

  If we were to stop this skills practice and ask physicians what their intentions are, they would respond that they care about the patient. If this is the case, it is generally much more effective to say, “I am really worried about you. I don’t want you to have another heart attack.” Or, “You mentioned to me how much you want to quit smoking. I want to do everything I can to support you in that goal.” Anything else feels like badgering, and badgering is not an effective way to change human behavior.

  Replacing judgment with empathic curiosity

  Empathic curiosity is best captured by our V.I.E.W. mnemonic. It’s a state of curiosity in the clinician that generates comments such as, “I’m wondering if . . .” or “Tell me more . . .” or “Help me understand . . .” When faced with patient behaviors or decisions that make no sense to us, perhaps we can start by trying to understand the patients’ perspectives before trying to change their actions or their minds.

  A middle-aged male was admitted to our hospital with metastatic testicular cancer, a highly curable malignancy, but he refused to let his medical team start chemotherapy. The team tried to talk him into it for two days. When a new attending took over, the team greeted him with “Maybe you can persuade him to start chemotherapy.” The attending asked the trainees what they knew about the patient. They replied that he was a middle-aged male with metastatic testis cancer who was refusing curative chemotherapy. The attending proposed finding out who this person was. Doing so revealed that his father was terminally ill and that his mother had interfered with the patient’s care when his illness was being worked up, telling her son, “Jesus will cure you.” The patient’s ex-girlfriend had thrown him out recently and had told him that she was pregnant, and that she didn’t know whether he was the father. The patient had a new girlfriend. He was wondering which of these two women would visit him in the hospital. If the new girlfriend came to visit, then he wanted to make sure he preserved his fertility so that he could have children with her. If the old girlfriend came, she was already pregnant, so fertility was less important to him. Taking the time to sit and listen to his story, to start to form a relationship, and to build some trust had an effect. The following day, he consented to beginning treatment. To us, the problem was simply that he had a deadly, but curable, cancer that needed treatment. To him, he was suddenly sick. He felt let down by his mother, father, and an ex-girlfriend; and he was scared and lonely, lying in a hospital bed, wondering who cared enough to visit him. To him, the cancer wasn’t the most important issue. Taking the time to get to know him and to form a relationship was more effective than using logical argument to persuade him that chemotherapy was worthwhile. His cancer was cured, and he remains well today.

  We have also repeatedly resisted the idea that difficult patients exist—you hear these words frequently in healthcare. We believe that if you were fighting a losing battle for your life, you might be “difficult,” too. You might raise your voice and even yell. You might behave in ways that make people not want to go in your room. Or you might seem irrational as you struggled with strong emotions. As our program evolved, we carefully referred to difficult conversations or scenarios, but avoided labeling patients as difficult, crazy, or otherwise. Once we label patients, our lens becomes tainted, and we start to respond based on our expectations of how the patient will behave rather than to the patient’s actual behavior—an unconscious bias. We search for clues that confirm the validity of our judgment and become less interested in data that contradicts it. Consistent curiosity is the only cure.

  Perceiving emotional cues

  Patients drop emotional cues all the time. These are flags that signal what is going on in the hidden self that requires exploration or encouragement to draw out. Our perception is that, for a variety of reasons, many clinicians’ antennae for these cues are poorly tuned or have been turned off. To have empathy, we must perceive the emotional cue in order to respond appropriately to it.

  DOCTOR: Why did they get the ultrasound?

  PATIENT: I don’t know . . . my husband and I want to have kids, so I am pretty worried.

  DOCTOR: What’s the pain like?

  This type of exchange is well described by Suchman et al., who categorized such moments as empathic opportunities that should generate empathic responses on the part of clinicians. In reviewing videotapes of physicians, they found that most emotional cues were “allowed to . . . pass without acknowledgement” and there was a quick return to the prior topic, which was usually a diagnostic explanation by the doctor.2 When this happens, the patient’s emotional state is invisible to the clinician and the patient feels unseen.

  What struck us is that lack of attention to emotional cues has been going on for a long time. Suchman and others wrote about this phenomenon in the 1990s. There is no great mystery to why physicians think they are effective communicators and why patients don’t perceive them that way. The disconnect has to do with our inability to be fully present with patients, pick up their cues, and be willing
and able to respond to them. In our experience, this issue underlies innumerable cases in which doctors don’t understand why their patient satisfaction scores are low despite all the explaining and listening they feel that they do. The truth is they still don’t see the patient.

  Saying you don’t know when you really don’t

  PATIENT: I don’t know. I had a friend who had bariatric surgery. I’ve also had diabetes my whole life. Will that get better with surgery?

  DOCTOR: We can’t be completely certain. It’s a confusing topic, even to doctors.

  We suspect that, for most doctors and advanced care providers, saying they don’t know something after years of schooling feels odd. Perhaps even wrong. However, we embrace it as a phrase that acknowledges that although we know a lot, we don’t know everything. When used in this way, it can align the provider with the patient, convey the complexity of the issue, and humble the clinician in the patient’s eyes. Simply put, if we don’t know the answer, let’s just say that.

  Phrases to Consider Eliminating from Our Language as Caregivers

  I understand

  PATIENT: I’ve had nausea for ten years.

  DOCTOR: I see. What else is bothering you?

  PATIENT: I’ve also been fatigued for ten years. It’s been awful.

  DOCTOR: OK. I understand.

  PATIENT: You don’t understand. I’ve been feeling ill for years. I can’t work full-time. It interferes with my family life. You have no idea what that’s like!

  Many a time we have heard the words “I understand.” These words seem harmless enough. Our desire to understand our patients is a good thing. Yet we’ve noticed that often these words are used very early in the conversation with a patient, long before the clinician has taken any time to actually understand or imagine the patient’s perspective. Even later on in encounters, to what extent can we truly understand what it’s like to be the other person? Have we experienced what this person has? In the scenario above, the patient knows this and becomes angry when the physician claims to understand.

  If we haven’t taken the time to understand, then we don’t and we shouldn’t say that we do.

  Rather than routinely saying, “I understand,” it is best to modify it so that understanding is a goal rather than something that has already been accomplished. This doctor recognized the communication misstep and followed the patient’s expression as follows:

  DOCTOR: Of course you’re right. I haven’t walked in your shoes. I want to take the time to better understand so that I can help you.

  When tempted to use the words “I understand,” clinicians should instead go for the powerhouse statement above or others, such as “I want to understand,” “Help me understand,” “I can only begin to understand,” or “I can only imagine.” Similarly, it is very different to say “I understand that you feel overwhelmed” or “Your frustration is understandable” than to say “I understand how you feel.”

  Don’t worry

  In talking to an orthopedic surgeon, a patient’s family members expressed that they were worried about the hematocrit and the bilirubin. The physician responded with “Don’t worry, we’ve got it covered.” The comment felt like a pat on the head and a dismissal, despite what was probably the surgeon’s best intention to reassure the patient and family. In another instance, a patient with a solitary kidney who was preparing for thyroidectomy told his surgeon that he wanted to make sure that the surgery didn’t injure his remaining kidney. The surgeon replied, “You don’t need to worry about your kidney. What we need to worry about is your thyroid gland.” The patient fired the surgeon and chose to have his surgery at a different hospital.

  Telling human beings not to worry is a highly ineffective strategy for reducing worry and can weaken relationships. Patients and family members will worry about their loved ones. Worry is completely natural and should absolutely occur when a loved one is ill or has an upcoming medical procedure. Telling loved ones not to worry is the equivalent of telling a child who has broken his leg not to cry. It negates the emotion itself, feels patronizing to most patients, and misses an opportunity to better understand the emotion in a meaningful way. Moreover, worry may have rational components, but it is not an inherently rational state; explanations without empathy generally fall short. We clinicians are more effective if we lead with curiosity and try to understand the worry rather than shut it down.

  While visiting a hospital in New York, I heard the following conversation:

  PATIENT’S MOTHER: I’m nervous about lung infection.

  DOCTOR: We didn’t find anything. You’re right, that’s concerning. We’ll see what happens, but I don’t think we’ll start antibiotics.

  MOM: So you aren’t going to start oxygen?

  DOCTOR: No, I think we’ll stay where we are.

  MOM: So you’ll come down slowly on the fentanyl drip?

  When you reflect on this dialogue, the mom effectively named the emotion in her first two words. Although the clinician briefly acknowledged it, the mother kept asking specific questions as a result of her nervousness, and the clinician kept responding to them. This is a common scenario in which the patient is asking a series of questions, and the doctor responds to them one by one without stepping back to try and understand the emotion driving the inquiry. A statement like “As I’m listening to you, it sounds as though you are really worried about your son” might go a long way in making the mother feel seen.

  Consider this similar example:

  DOCTOR: What do you know about a brain aneurysm?

  PATIENT: Not much. A vessel can burst in your head and you can die.

  DOCTOR: You’re right, but do you know what it actually means?

  In the first example, the patient’s mother named the emotion she was feeling. In the second, the patient told the provider the reason for his fear: death. We’ve noticed that the word “death” no longer gives many clinicians pause, but it should. The words “dying,” “death,” “killed,” “suffering,” and “devastated” are significant clues to the patient’s emotional state and need to be addressed directly. When a patient asks, “Am I going to die?” or “How long have I got, Doc?” there is a literal meaning to the question, but there is also an emotional one. The patient isn’t simply asking for a numerical time interval, he is expressing despair: “Am I really going to die? What about my children? How will I tell them? How will they cope with losing a parent so early in life? Will I be in pain? Will I suffer? I promised my spouse I would be with her, and now I’m leaving her as a single parent . . .” The time interval is not necessarily the most urgent issue in the patient’s mind. If we answer emotionally laden questions literally without addressing the emotional content directly, either the emotions continue to surface or the patient shuts down. Conversely, if patients feel there is safety and a willingness to hear and listen, they are more likely to disclose their feelings, and a stronger, more effective relationship can be developed.3

  At the core of the discrepancy between clinicians’ perceptions that they spend time, listen, and explain well versus the patients’ perceptions that their main emotions are being ignored is the ability to recognize emotional cues and respond to them empathically.

  Relationship Building as a Stealth Strategy: Decompress, Reflect, and Connect

  We’ve spent a lot of time talking about programmatic considerations and lessons about facilitating experienced clinicians. We’ve been working in communication skills training for several years. Although we are newbies to the field in many ways, we have accomplished a great deal that many other organizations have not yet been able to accomplish, which is to develop and roll out a communication skills program that touches all our staff physicians and hundreds of advanced care providers. The program was scaled rapidly, and we honed our messaging and strategy.

  During this period, we ourselves changed. We ventured out thinking that we would teach communication skills, hoping people would pick up a thing or two, but as time went on, we stumbled upon
something much bigger. We learned that what we were actually doing was building a community where one didn’t exist, reinvigorating clinicians to find meaning in the care they provided to patients, and creating a space of healing for them as well—and we did it by leveraging an effective communication skills program. We also captured the significant impact of the program on validated metrics of empathy, patient satisfaction, and burnout for over 1,500 physicians.4 These accomplishments distinguish us from other efforts out there and define what makes us successful in engaging clinicians.

  Nearly everywhere you turn today, you hear about the significant degree to which clinicians are burned out. Their own humanity is being suffocated because they don’t have time to eat lunch or exercise or take a deep breath for that matter. The Wall Street Journal article “Why Doctors Are Sick of Their Profession” explored this very issue. Suicide rates, depression, and substance abuse are prevalent among doctors. Yet in some ways, the doctor has fallen out of the “patient-centered” solution.

  It began early. In our own experiences, this was reinforced in a variety of ways. Medical school interviewers ask about hypothetical medical cases and what one might do in them rather than about the very personal essay a candidate wrote. In addition, exams in medical school are all about minutiae, thus developing and encouraging our laser-focused, data-driven, left-side brains. When graduating from medical school, the term “delayed gratification” was used to describe what we shouldn’t do, and yet, it’s what we have seen modeled for us at every step of our professional development. Wait to take a vacation until after MCATs, wait to decide the fate of a relationship until after residency matching, wait to have kids until after residency. Work hard now so you will be successful later. “This is a good time to invest in my career. I’ll have time to take care of myself once I’ve finished my training,” we told ourselves. But it never gets less busy and the years slip by. The current state is to sacrifice everything, despite the fact that we are no longer waiting for anything. The relentless work habits and long hours of medical school and residency create behavioral norms that stay with us through our careers. Add all the other pressures for RVUs, clinical transformation, quality, safety, and experience, and it’s no wonder clinicians are disconnected and disenfranchised. We essentially built a “how to disconnect from other humans” system, reinforced it every step of the way, and then are surprised when caregivers are disconnected.