Adrienne Boissy didn’t take no for an answer when she wanted to implement a program to improve communication at Cleveland Clinic. But how much of a need is there to improve communication at one of the leading health care institutions in the world? How do you engage physicians to improve when they already think they’re pretty good to begin with?
“Adults choose to learn, or not,” Boissy says. “But if you don’t have an interest in learning or don’t think you have any blind spots, you absolutely won’t engage in the learning process.”
The Center for Excellence in Healthcare Communication addresses this head on, and with scalable success. The program, intended for experienced physicians, residents, students, and fellows alike, may be 8 hours long, but it’s essential for building trust and commitment, even for those who don’t think they need to be there.
“Although there is the tendency to try to convince people how important communication skills are, there’s actually 30 years of literature that support how important they are, right? In preventing malpractice, safety, quality teamwork, patient satisfaction, as well as physician satisfaction and engagement. And yet, oftentimes, we still feel this responsibility to try to convince people of how important it must be,” Boissy says.
Boissy sat down with NEJM Catalyst’s Tom Lee to discuss why communication is so important, and how to break down barriers so physicians engage better with one another, with themselves, and ultimately, with their patients. Read or listen to the interview below.
Tom Lee: This is Tom Lee for NEJM Catalyst. I’m speaking today with Adrienne Boissy of the Cleveland Clinic. Adrienne is a good friend and colleague. She’s the Chief Experience Officer at Cleveland Clinic. She’s an outstanding practicing neurologist, a leader in multiple sclerosis at the clinic. She’s been in this very important role, at one of the greatest health care institutions in the world.
I want to start by noting that it’s hard to get physicians to change how they do things, particularly when they think things are going pretty well. How are you and the other leaders at Cleveland Clinic getting physicians to be interested in learning new communication skills, as a way of improving their care, when they’ve got to be thinking they’re pretty good to begin with?
Adrienne Boissy: Overall, pretty good to begin with, I think. And thank you for the kind introduction. I would say, we focused on two main points. One is probably a favorite topic of yours, I know, which is about transparency. There’s an old educational model from Taylor that talks about medical education and how adults learn. And certainly, adults choose to learn, or not. But it talks about this concept of unconscious incompetence. That if you don’t have an interest in learning or you don’t think you have any blind spots, you absolutely won’t engage in the learning process. And one of the ways to move people out of unconscious incompetence is through transparency, to reflect back to them their blind spots. And that model describes putting them into we call “conscious incompetence,” which is this time when you realize, maybe I’m not as good as I thought I was. And only then will people be perceptive to the training or programs about learning, how to be a better communicator.
And so that was an important strategic lesson for us as an organization, because putting patient comments about how they felt when you communicated with them, about how effective your language was, and how that made them feel — putting that back at the physicians, and showing them, “this is how patients felt during their interaction with you” — I think is a very powerful way of driving that interest and change.
The second thing is around being willing, in your training, to talk about the cases or the communication challenges that haunt clinicians the most. If you think you don’t want to learn about listening or the predictable topics that we talk about in communication skills, that’s probably a common phenomenon. But these cases that haunt you, that you remember for the rest of your career as a physician, where you struggled or it left an emotional residue on you, those are the opportunities to not just maybe do some healing, but to create, and give you new skills to navigate that the next time it pops up. I think that’s critically important, because if you’re not addressing the sweet spot for clinicians, the learning won’t have the impact we want it to.
Lee: You and your colleague, Tim Gilligan, have created a program at the Cleveland Clinic, where physicians all get taught communication skills. And you described it very nicely in your new book, Communication the Cleveland Clinic Way. For people who haven’t read the book yet, (if there are any out there), can you give a quick thumbnail sketch of what that program looks like? What does it mean for physicians at the Cleveland Clinic?
Boissy: Well, the book is meant to talk about not just the program itself and how it was structured, but as we were rolling out the program, our own doctors taught us a lot about what they needed the most. Meaning, when I started, or seven odd years ago when we were asked to roll out communication skills training, we had no idea what we were doing — we were just “doctors.” And we thought a lot about what people would be interested in learning, and what would be relevant and get them engaged in training, and thought about our own experiences. We also made sure we did our homework around learning what evidence-based, best practices were across the country and the globe, as interns and programs that had driven meaningful change in behavior and practice.
And so, although the book talks about the content of the program, it also walks people along the journey we took as an organization to shift culture around communication skills, and intentionality around the words we all choose. How do we leverage transparency to raise engagement? How do you invite people to attend and ask them to help, rather than just tell them they have to go? Talking about lessons we’ve learned around . . . oftentimes, in a course, talking about HCAHP scores or patient satisfaction scores, is not the greatest inspiring force. I think you talk about that a lot, too, in your own work. That putting the scores in front of people doesn’t necessarily make them want to change their behavior, in and of itself. So, you have to tap into something deeper and richer that has meaning for them. And I think, the book talks about a lot of those lessons for us as an organization. And building a program that was empathic to our own physicians, just as much as it was meant to drive empathy for our patients. We learned a lot in that process. So, hopefully, the goal of the book is to detail that journey, share some of the lessons we learned, as well as communicate the structure of the course and what our docs taught us about that.
Lee: So, is this a required course for physicians at the clinic? And how many hours does it take?
Boissy: Good question. When we started, we trained thousands — and we’re talking about experienced physicians, as opposed to residents or medical students and fellows, at least when we started. When we started, we trained a thousand people by invitation. So, we were very intentional and grassroots about it. So we sent out, maybe, an invitation to about 10 people to say, “Hey, we’ve got this course, why don’t you come take a look?” And then we asked them to suggest 10 additional names. And then, slowly, it spread and trickled throughout, to the point where we were able to train a thousand people just by invitation. And then it hit this critical tipping point where we wanted to make it scalable to the entire enterprise, which was about 4,000 physicians, including residents and fellows. And at that point, we made it an expected requirement of all physicians across the enterprise. And since then, have incorporated it into our ongoing process, as well as into ongoing training for physicians, as more advanced courses have evolved. Again, trying to keep the topics relevant to what’s most important to the physicians, that they’re most interested in learning in their own practice.
Lee: How big of a time commitment is it?
Boissy: Oh, the full day course is 8 hours. And that number scares a lot of people, as it may scare you, and others who are listening. But the important thing that we pushed back about, when we received some requests to shorten it, was that there are two agendas in the course, or at least there evolved two different agendas in the course. One was to teach content, to be an informative course on effective communication skills. But the second was more transformative, which is this idea that you’re changing thinking and attitudes and belief. And much of that was about this context of relationships. What would your language sound like if you were trying to build a relationship with someone, as opposed to just trying to get them to take their medicine? And can we play with that? Can you think about what your role or responsibility in that would be, as a physician?
And so, we felt very protective of creating enough space and enough vulnerability over the hours that we were together to get people to that transformative thinking. And throughout the course, in fact, we’re very intentional about how we structure exercises and relationships within the course of the day, to deepen the amount of work people have to do. And that requires trust that we build very intentionally over the 8 hours. So, although it probably is an unheard of commitment, in order to demonstrate the impact, which we ultimately did — [a] statistically significant impact on patient experience, empathy, and burnout — that structure was essential.
Lee: Okay, in everything that I’ve ever led, it seems like my colleagues split themselves into three groups. There’s one group that’s really into it. At the other extreme, there’s another group that is really not, they’re rolling their eyes and they can’t believe they’re stuck there, they’re trying to get out. And then there’s a group in the middle that says, okay, I’ve got to do this, I’m here. What percentages of your docs were in each of those groups? I’m assuming there were representative of all three?
Boissy: Yeah, I think you’re right. We had them all, probably. I think what’s interesting about your comments is that although the tendency is to try to convince people how important communication skills are, there’s actually 30 years of literature that support how important they are, right? In preventing malpractice, safety, quality, teamwork, patient satisfaction, as well as physician satisfaction and engagement. And yet, oftentimes, we still feel this responsibility to try to convince people of how important it must be. And so, when you describe those groups, we probably had, as I said, a thousand people. So, literally, up to, I would say, 25, 30 percent of people of our entire staff went through the entire course, completely voluntarily, just by invitation. I think that’s a highly engaged group. I would say there’s a majority in the middle, who engaged, thinking that there was some relative benefit to them.
And I would say the degree that were actively disengaged is probably somewhere around the range of 5 to 10 percent. And the reason I say that [is that] we talk about in the book [how] there were two people we had to pull aside at some point and say, “Wow, this really seems to be a struggle for you,” or, “Tell me a little bit about how you think your behavior might be impacting the rest of the group.” Because I think all of us, too, need to be aware that even if we don’t think it’s important, there are lots of other people at the table who probably could derive something. It was a very interesting finding in the study that no matter how many years of training you’d had, no matter what your patient satisfaction scores coming in were, no matter what specialty you were in, everyone who went through the course became better. And I think that’s an important lesson. That all of us have something to learn. And when people said, “I don’t need to come, I’ve been teaching communication skills in the medical school for five years,” we said, “That’s great. We need your talent in the room just as much as someone who hasn’t been doing that.” And so, you just have to meet people where they are and we were pretty intentional about doing that.
Lee: One of my very favorite parts of your book was how you wouldn’t take no from the Chair of Neurosurgery. He wanted to pawn the role of leading this off on some new person and you wouldn’t take no. Can you quickly summarize that little vignette? Why you wouldn’t take no, and how things worked out?
Boissy: Sure. So, for anybody who may not have met me before, I am a relatively young female. And I, at the time, was exquisitely aware that communication skills training could be viewed as a soft and fluffy skill that perhaps only some of us need or believe in. And I was very interested, at the time, in choosing people who had [what] we hear called “nodes” or “organizational influence,” and “longevity.” And I had very intentionally chosen people from across the organization who I thought can bring that as facilitators for the training. People who had been here for 30, 40 years. People who were surgeons; if your organization is 60 percent surgeons, you need to have that represented in your facilitator pool. So, I wanted, again had thought and strategized, about who would serve best as facilitators for a variety of reasons.
I went to the Chair of Neurosurgery and said, “I’d really like you to be involved in this effort. I think this is a part of who you are,” as well as, “You could be a very powerful influence on many others, in terms of turning this tide.” And, as you mentioned, he wrote back saying, “That’s very nice. I appreciate that you thought of me. There’s a young woman who recently joined our practice. I think she might be better. I think this would be perfect for her.” And I think I wrote back and said, “I appreciate your suggestion, and I’d still like you to do it.”
While he was thinking that over, I had engaged the institute chair. So I give him a lot of credit at the time. And I just said, “I don’t want a younger person, and I certainly don’t want a female. I’m being very strategic about who has organizational influence here, and I think he’s the right person.” And [I] garnered support, and as I often say, was relentless in my pursuit, I think, to make sure that was brought to bear, and trusted my gut on that.
And to be honest, it was absolutely the right choice. People often come to me and say, “I wouldn’t have come to the course, except I heard what you did with Dr. ____. I can’t believe you got Dr. So-and-So to teach the course.” That word of mouth has a very powerful effect on the rest of your organization. You can’t underestimate that power of one person who is that node, that sphere of influence.
Lee: I love that story. Now, all right, I trust you. My personal assessment of myself is that I’m a pretty good communicator. I am not a doctor at Cleveland Clinic, but if I was there and I acknowledge that as good as I might be, I could get better, what would happen to me during that 8-hour course?
Boissy: Is that even possible, for Dr. Tom Lee to get better? You’re already so good, Tom, I’m not sure that we could make any inroads. I’m just kidding. So, I think, if you came into the course, you would be greeted immediately, and we would engage you, likely, in a discussion about who you are as a person, and your prior experience with communication skills training. It’s very important to us to model the skills that we’re talking about, in the experience of the course itself, so that you, as a participant, feel what it feels like, to be listened to, to have empathic curiosity land on you, to be a part of what happens the rest of the day — shared decision-making. And we build that into your experience as a participant.
We ask you if you’ve been up all night, on call. We introduce some play and some fun, so you’re interacting with colleagues early. But it’s not just superficial questions. It’s questions driven with meaning: “Have you had a difficult conversation within the last week? Have you lost a patient?” We’re exploring that very early, to try to raise the amount of trust and vulnerability in the room fairly quickly.
As we go through the course, we’ll ask you to bring your toughest communication scenarios: “I want you to think about that. I want you to tap into that space where you struggled.” And we’ll ask you about that, Tom. And then, we’ll assess your level of comfort throughout the day. “Is the learning getting too much? How is the feedback landing on you? Are you engaged in the learning process or not?” And oftentimes, at the end of the course, we’ll ask you to appreciate other members who took the course with you, to end on a note of gratitude. And certainly, to reflect on what’s one thing that you’re going to take away and use, every single day, in either patient interactions or interactions with your colleagues. So, our real goal is to build an experience for you that you walk away talking about for a long time.
Lee: Well, the word of mouth I hear is that you’ve been successful. The data, as you described, indicate that it has had real impact that’s measurable. And I can tell you that the fact that you guys started this program and implemented it across the system, at Cleveland Clinic — one of the flagship institutions of the country — is attracting a lot of attention. I actually think you’re changing health care. And spreading word about that is part of our job with Catalyst. So, I want to thank you for your time today, thank our audience for listening, and I’m sure there are going to be more lessons learned in this and other areas, by you, in years to come. And I’m looking forward to staying in touch and bring you back to the Catalyst audience, as well. Thank you very much, Adrienne.
Boissy: Thank you very much, Tom.
This interview originally appeared in NEJM Catalyst on July 20, 2016.