Communication the Cleveland Clinic Way

  What makes people resilient or what can reduce burnout in today’s caregivers is allowing space for decompression, reflection, and connection.

  By connection, we mean connection to patients, each other, and purpose—your meaning as you define it. Some people naturally may be able to handle these stressors better and regularly practice mindfulness or yoga, but telling young working parents to go to art class or spend 30 minutes at the spa requires a support system, resources, and adequate reserves. Many haven’t figured out how to manage the stress, and self-care can come at the cost of not spending time with family and feeling guilty about it. So if our caregivers can’t figure it out on their own, how can we support them more effectively in the workplace? In addition, because many clinicians may not be receptive to such stress-reduction efforts (or balk at them), these must be designed to feel relevant to clinicians and be reinforced by the organization itself. Remember, if clinicians don’t think they are burned out or believe that feeling burnout means they are wimpy, they are unlikely to show up for a class called Resilience Training. What we learned from running our R.E.D.E. to Communicate: FHC course (which had a title relatively unappealing to physicians) is that if an experience is designed from the ground up to be responsive to and respectful of clinicians’ experience, participants generally feel grateful for having attended, even if they hadn’t been looking forward to it. The course ended up being a stealth resilience effort that presented itself as relationship-centered communication skills training, and participants felt it even if they didn’t recognize it as such.

  The training experience you created transcends any prior work in communication skills, and I am so grateful to have participated. The relationships and development of community among all of us cannot be overstated.

  —PHYSICIAN PARTICIPANT AND MEDICAL SCHOOL FACULTY MEMBER

  The common highlight of participant feedback was the value of spending time with colleagues. We captured the significant, sustained decrease in burnout with surveys after the course, and the questions moving forward will be: How does this change over time? How can we better intervene for our colleagues at different stages in their careers? In the end, it wasn’t just sitting in a room with colleagues. It was forming relationships with them: knowing someone you could call for a consult (or had been calling but never met), sharing stories of providing care and being cared for, and becoming part of something bigger than yourself—a community of caregivers. If we are thoughtful about curriculum design, we can deliver an experience that allows caregivers to feel safe to decompress, reflect, and connect.

  Communication skills training between clinician and patient reinforced skills for a better patient experience and ultimately improved the clinician . . . the human experience.

  The Awesome Power of Vulnerability

  I sat in plainclothes at the bedside of a patient who participated on the Neurological Institute Voice of the Patient Advisory Council. I had come in to see him after his fourth or fifth back surgery. Gordon was a director of safety and quality efforts at a local company, and his wife, Jody, was at his side. The origin of his back problems was uncertain, but over years of surgeries, the couple had grown close with their neurosurgeon and one of the facilitators of the course, Dr. Ed Benzel. On this occasion, Gordon was lying on a bed in a dim room a day or so after surgery. This day, however, was unlike any other. After this surgery, Gordon had lost the use of his legs. Gordon and Jody recounted the story of how Dr. Benzel had come out of the OR to tell Jody that Gordon couldn’t move his legs. He had closed the surgical site on Gordon’s back, realized Gordon couldn’t move his legs, reopened his back, yet was unable to change the outcome, despite all his efforts. I managed to maintain my composure as I listened to the suffering of my dear friend. What hit me was when Jody recounted how Dr. Benzel came out of the OR, apologized to her, hugged her, and cried with her. Imagine the impact he made on them.

  Contrast that scenario with the behavior of a resident coming into Gordon’s room the next day to change his bandage. As I sat there in my plainclothes, I watched in horror as the resident barely introduced himself, dismissed Jody’s suggestions for more bandages, and then asked Gordon to roll on his back and push with his legs in order to do so. The nursing staff intervened after seeing my face, and I later asked the resident to join me to discuss what had happened. When speaking about this experience, he became emotional and shared the embarrassment he felt. When asked what he thought had happened, he explained that he had been loaded with “tasks,” was covering for a colleague, and came into the room without having read anything about the patient.

  The very nature of what we do as healthcare clinicians requires us to have resilience. We can’t cry after every sad patient encounter and be fully present for the next one. That said, the person in a patient gown who is on the threshold of walking or not, talking or not, seeing or not, breathing or not, dying or not warrants recognition and respect. The physician drowning in tasks will never be able to fully provide recognition and respect, much less meaning for anyone.

  I recently attended the International Leadership Board. This is a gathering of individuals from across the globe who come together for philanthropy in healthcare. I was quite nervous about presenting to this group. As I formulated a presentation, I was encouraged by the great Stewart Kohl, CEO of Riverside Companies, to be myself and to tell a story about patient experience. I told my story, or rather my mother and father’s story.

  I showed a picture of my parents in their younger days. Despite knowing that my father had leukemia, they married and had two children, and my father managed to keep his sense of humor. For Halloween he threw a white sheet over his head and ran around calling himself a white blood cell, the kind that causes leukemia. When my mom went to visit him in the hospital, she would stare at the IVs and medications and feel small. One evening, my mom was sent home with assurances that everything would be OK. Just a few hours later, my father died alone in the hospital. Twenty years after my father died, I wrote a letter to the woman at the National Institutes of Health who had hired my father as a statistician despite knowing that he had a “preexisting illness.” He had been rejected for employment time and time again. I thanked her for giving him a chance. I wasn’t looking for a response. It was just something that I felt I needed to do to complete one part of my life’s journey. Unexpectedly, she wrote me a beautiful letter explaining that she “always felt he didn’t want anyone, including himself, [to] allow his illness to keep him from doing what he [most] wanted to do.” My father’s struggle with leukemia was wrapped in suffering and death. Yet his boss’s insightful recognition of my father’s goal to remain vibrant as long as possible was a gift I unwrapped years later. The lesson for me is that we all just want to be seen, valued, and embraced for who we truly are—a lesson that profoundly influences how I lead patient experience efforts at Cleveland Clinic. It was hard for me to keep it together as I told my story.

  Later in the afternoon, Dr. Brian Donley, our new chief of staff, gave his presentation. His first slide was a picture of his parents. He spoke of how his mother, a nurse, and his father, a pharmacist, had shaped his life and values. Here we were as the faces of leadership presenting at a global conference, and unknowingly, both of us had led with stories rooted in relationship and wounds.

  Later that evening, Mr. Story, a cowboy-boot–wearing Texan who owns a multimillion-dollar company, came up to me, grabbed me by the shoulders, and said, “What you did up there was fantastic. I couldn’t have done it.” In that moment, I appreciated that it takes guts to share your scars and that being vulnerable is the path to strong connection.

  Vulnerability can make most people feel deeply uncomfortable. The words commonly used to describe effective leaders, such as “decisive,” “fearless,” and “strong” are seemingly in contrast with what it takes to be vulnerable. Wikipedia defines vulnerability as the inability to withstand a hostile environment. No wonder we consider it a weakness! It is the Achilles’ heel of a w
arrior, the weak spot in the fortress wall. The word itself is derived from a Latin root that means “to wound” or “wounding.”

  What’s so interesting about vulnerability is that showing our wounds on occasion is precisely what enables empathy and human connection. It allows others to see us as human beings who, like all human beings, are imperfect and suffer. The human condition is a vulnerable one, and if we only project confidence, strength, and success, we are inherently inauthentic. Acknowledging that sometimes we fail, sometimes we’re wrong, sometimes we suffer, allows others to see us as real. Acknowledging vulnerability requires humility, courage, and strength. Even the fiercest of warriors needs that every once in a while.

  There was a time when the perception was that leaders knew what was best for those they led. Sound similar to doctors knowing what’s best for their patients? It should. But the future is relational leadership, one that requires humility, engages empathic communication, values the opinions of others, and recognizes the power of relationships and how they influence behavior. Leaders also have to make decisions and are held responsible for those decisions. It is a burden that leaders bear, not one necessarily greater than those of the people they serve, but a responsibility that differentiates leaders from others.

  Please don’t get us wrong. We’re not encouraging leaders to walk around sharing their stories of failure and suffering in every meeting or staff presentation. This is not about wearing your heart on your sleeve; it’s about being an authentic human being and recognizing how this can impact the people around you. We are simply suggesting that with the appropriate opportunity, a dose of vulnerability can be uniquely powerful.

  Why is this relevant for this work?

  Building a communication program requires a willingness to model the behaviors you are trying to teach both when leading and when facilitating.

  It’s somewhat disingenuous to espouse these skills when teaching only to throw them out the window when interacting with colleagues or making a decision for an organization. If leaders show little empathy for and curiosity about the people they lead, then it is hypocritical for them to ask for more empathy for patients. Yet developing relationship-centered leadership presents a real challenge. If you invest in your team as individuals and actively encourage and grow relationships among team members, then the failures or missteps of any of the teammates can sometimes mean more. The failure becomes a collective failure, not that of the individual.

  In facilitation, there are a few ways to approach vulnerability in a group. This is important to understand because if you are effective at creating a safe space, then vulnerability will come, and you should be prepared for it. If someone starts to cry in a session because the topic has hit too close to home or some other emotion wells up, interrupt the session and ask the person what is present for him or her in that moment. We’ve seen this work beautifully when the person feeling emotional was willing to give it voice, and the approach was gentle. At the same time, this strategy calls tremendous attention to the vulnerability of a member of the group who may or may not feel safe sharing an emotion. Consider instead the statement “I’m noticing that something has come up for you. I’m wondering if it’s something you want to take a minute to discuss or if it would be more helpful to you to keep it private for now?” Statements like this give power to the vulnerable person in a moment when the person probably doesn’t feel very powerful. Another option is to ignore the emotion in the moment and address it on a break. But this strategy runs the risk of modeling to the group a behavior we strongly discourage in clinical work: ignoring other people’s feelings. Perhaps the most effective method we have come across was modeled by Walter Baile and Rebecca Walters. A facilitator unexpectedly became emotional when another person was describing the loss of a child. The story called forth the agony of losing her own child. She excused herself from the room. Shortly after she left, a member of the team described his shame at not having realized what he had brought up. Rebecca and Walter asked the team who else felt shame or sadness for ever having inadvertently touched on the pain of another person. Everyone in the room raised a hand. It was a moment in which the vulnerability of the group member was validated, shared, and released from isolation. He did not carry the feelings of shame or guilt alone.

  Amy Windover attended an improv workshop and taught us something she learned called the failure bow. In this exercise, you bring a group together, and participants take turns announcing what they have failed in before taking an enormous bow (or curtsy) to the applause of the room. The exercise sounds a bit silly, and yet prompts some reflection. When was the last time you took a failure bow? If you had to take one tomorrow, what would you say? And who would clap for you? Would your leadership team rally around you in a round of applause? The reason most of us probably don’t take a failure bow is because of the shame of failure. We are pretty sure no one would be clapping. Yet if we expect to live a life with no failures, we will be continually surprised and disappointed.

  Conclusion

  We opened the first chapter with the story of how our CEO, Toby Cosgrove, was floored by a simple question from Harvard Business School student Kara. We discussed the inspirational leadership of former Chief Experience Officer Jim Merlino, whose father died within the very organization he stepped up to serve. We shared more stories from our staff. These are examples of caregivers who achieved mastery of the science and surgical technique who were also willing to attend to the soul of the patient. Their willingness to share their own stories of emotion led an entire organization to Patients First. This book is the story of how relationship-centered communication and empathy for patients, our colleagues, ourselves, as well as empathy in leadership and strategy, can transform an organization.

  The authentic human state is one of vulnerability. The commitment to relationship-centered communication requires that clinicians move from watching the suffering from a distance to step into the suffering of the patient and perhaps at times ourselves. This shift is transformative for those who have managed to make it. The world of regulation and checkboxes will always swirl around us. We must define our own meaning. We must be grounded in vulnerability and emotion because that is the human experience.

  Notes

  Acknowledgments

  1. Ronald S. Burt, Brokerage and Closure: An Introduction to Social Capital (Oxford: Oxford University Press, 2005).

  2. Nicholas A. Christakis and James H. Fowler, Connected: The Surprising Power of Our Social Networks and How They Shape Our Lives (New York: Little, Brown, and Company, 2009).

  Chapter 1

  1. T. Cosgrove, The Cleveland Clinic Way (New York: McGraw-Hill, 2013).

  2. A. Cirillo, “The New CEO—Chief Experience Officer,” HealthLeaders Media, healthleadersmedia.com, 2007.

  3. J. Merlino, Service Fanatics (New York: McGraw-Hill, 2014).

  4. Cleveland Clinic, Empathy: The Human Connection to Patient Care, 2013, http://www.youtube.com/watch?v=cDDWvj_q-o8, accessed November 15, 2015.

  5. M. Neumann, F. Edelhauser, D. Tauschel et al., “Empathy Decline and Its Reasons: A Systematic Review of Studies with Medical Students and Residents,” Academic Medicine 86 (2011): 996–1009; M. Hojat, S. Mangione, T. J. Nasca et al., “An Empirical Study of Decline in Empathy in Medical School, Medical Education 38 (2014): 934–41; M. Hojat, M. J. Vergare, K. Maxwell et al., “The Devil Is in the Third Year: a Longitudinal Study of Erosion of Empathy in Medical School,” Academic Medicine 84 (2009): 1182–91; D. C. Chen, D. S. Kirshenbaum, J. Yan et al., “Characterizing Changes in Student Empathy Throughout Medical School, Medical Teacher 34 (2012): 305–11.

  6. Committee on Quality of Health Care in America, Crossing the Quality Chasm (Institute of Medicine, 2001).

  7. D. M. Berwick, T. W. Nolan, and J. Whittington, “The Triple Aim: Care, Health, and Cost,” Health Affairs (Project Hope) 27 (2008): 759–69.

  8. D. A. Hanauer, K. Zheng, D. C. Singer et al., “Public Awareness, Perception, and Use of Online Phys
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  9. A. Gawande, “Personal Best,” New Yorker, October 3, 2011, 44–53.

  10. J. K. Rao, L.A. Anderson, T. S. Inui et al., “Communication Interventions Make a Difference in Conversations Between Physicians and Patients: A Systematic Review of the Evidence,” Medical Care 45 (2007): 340–49; M. Berkhof, H. J. van Rijssen, A. J. Schellart et al., “Effective Training Strategies for Teaching Communication Skills to Physicians: An Overview of Systematic Reviews,” Patient Education and Counseling 84 (2011): 152–62; L. B. Mauksch, D. C. Dugdale, S. Dodson et al., “Relationship, Communication, and Efficiency in the Medical Encounter: Creating a Clinical Model from a Literature Review,” Archives of Internal Medicine 168 (2008): 1387–95; L. Fallowfield, V. Jenkins, V. Farewell, et al., “Enduring Impact of Communication Skills Training: Results of a 12-Month Follow-up,” British Journal of Cancer 89 (2003): 1445–49.