My pager went off before I even made it through the hospital doors. Returning the call, I was greeted with “Hey, good morning. It’s Joe in the ER. Your patient in Bed 5 is asking for Dilaudid. I don’t want to give it to her, but it’s up to you.” I didn’t know the patient in Bed 5 and communicated that as soon as I met her, I’d be happy to treat her pain with something else. Shortly thereafter, I was rounding on the neurology inpatient service, and the residents told me about a young woman, “the patient in Bed 5,” who had been admitted overnight for two months of head pain with innumerable requests for Dilaudid. Their frustration and annoyance were palpable. They described treating the patient with IV steroids, magnesium, Compazine, Toradol, morphine, and Dilaudid in a span of a few hours since her admission, as well as starting prophylactic medications to prevent her head pain. I could see the costs compounding in my head. In addition, she had been admitted to our hospital for three months the year prior. I took a deep breath and entered the room.
“Good morning, Ms. Hide. I’m Dr. Boissy, the neurologist in charge of your care while you are here. I’m so sorry you spent the night in the ER and are here.”
“Thanks.” A somewhat groggy young woman with multiple tattoos rolled onto her back to speak with me. She had her forearm over her eyes and wouldn’t look at me.
“I’m wondering if you can tell me about yourself.”
“My pain is ten out of ten, mainly on the right side …”
“Thank you for telling me. What I meant was about you as a person.”
“Oh.” She shot me a surprised look as her arm came down from her face. “OK, well, I live at home with my parents. It’s not that great because we don’t really get along. They don’t think anything is wrong with me.”
“I’m sorry to hear that.”
“It’s OK, I’m used to it. I also work as a pharmacy tech.”
“That must be interesting. Have you had to miss work because of everything going on?”
“I bet you miss it. This pain that you’re having seems to be really impacting you. Most people have ideas about what’s happening with them. What do you think?”
“Well, I think I either have MS (multiple sclerosis) or parasites. I read about them online.”
“I’m glad you told me. The good news is I’m an MS specialist, and we can easily check your stools for parasites.”
“How are you hoping I can help you?”
“I don’t think you’re going to fix my pain.”
“I think you might be right about that. Sounds like we have been trying a lot of different things without much success.”
Fast forward two minutes. “Any history of verbal, physical, or sexual abuse?”
She looks down. “I was raped twice as a teenager. No big deal though. Same thing happened to my best friend, and we worked through it by talking about it with each other.”
“Oh my God, I’m sorry to hear that. That must have been awful. How else did you make it through?”
As I began a general exam, I noted scars along her forearms. “Tell me about these.”
She smiled and said, “I used to be a cutter. I haven’t done that since my teens.”
“Sounds like you suffered a lot in your teens.”
“I guess so. I’m OK now.”
As the physical exam went on, I noticed a large, deforming scar running up her right arm and into the depths of her gown and right chest wall.
“Tell me about this if you can.”
“Last year, I set myself on fire.”
In 2009, Cleveland Clinic started a program to improve healthcare communication. When the work started, inpatient patient-satisfaction scores related to doctor communication for all hospitals was in the 24th percentile, and for hospitals with over 1,000 beds, it was in the 46th percentile. Five years later, we were in the 99th percentile. This book tells the story of our journey and our work in the hope that you can learn from our experience and launch your own programs to improve patient experience and reinvigorate clinicians’ passion for their work.
In healthcare, communication skills are key. “Never events” such as wrong site surgery, ethics consultations, and cases that reach the physician conduct committee, as well as over 50 percent of complaints or grievances in our ombudsman’s office and 72 percent of patient reasons for dissatisfaction with their healthcare providers, are related to ineffective communication. Yet with all this knowledge, doing the work and providing the resources necessary to train clinicians in sufficiently rigorous, comprehensive programs that will result in improved performance remains the exception rather than the rule. Instead, we continue to hold physicians accountable for patient satisfaction scores that they don’t particularly care about or understand and ask them to sit at the bedside, smile more, and adopt what look like customer service behaviors. We can do better.
People are drawn to healthcare professions at least in part by a desire to care for the sick and to promote health. The opportunity to serve our fellow humans when they are at their most vulnerable is a sacred privilege. To be the person who has the knowledge and skill to help is a profound and anchoring experience. Customer service skills and scripting will never work for healthcare professionals, for those invested in the care they provide patients. They won’t work because our patients don’t want to be in the hospital and often face life-and-death issues. Although service excellence absolutely has a role in not adding to the patient and family burden and easing anxiety, the gravity of what our patients face at times must be witnessed honestly. Their suffering deserves a place where it can come out, be acknowledged as a substantial ingredient to their experience of illness and hospitalization, be talked about with people they trust, and be shared with us for a little while. This gesture on the part of our patients to crack the door into their hearts and souls is a gift. This gift sets in motion a mutual respect and emotional connection that fuels a relationship of meaning. And once you have that, you’ll never go back to the old way of talking to people.
So why is it that we healthcare professionals sometimes lose track of the humanity of those we are treating? What happened to our antennae for emotional cues from our patients? Why do we sometimes judge them as difficult or drug-seeking or manipulative? Why do patients too often experience their encounters with healthcare as unfeeling and uncaring? Can we in medicine imagine doing better and, if so, what would be the most promising course of action? What should we be willing to do?
These were the questions we confronted when we started our journey to improve healthcare communication. Our culture prioritized excellence in medical and surgical care above all other goals, an academic medical center in which being an excellent clinician was a more prominent priority than publishing research or bringing in grant dollars. So why weren’t our patients reporting that they felt that they were the center of our attention?
The issues we confronted are common across American healthcare institutions. While the challenge of communication in healthcare has often been dumbed down to something along the lines of “doctors are poor communicators,” that rang false to us. When we looked at our colleagues, we saw amazingly talented people who were deeply committed to the care of their patients. The time and effort they expended, striving to make the right medical decisions for their patients, was inspiring. And their ability to articulate how they thought and the basis of their decisions contradicted any notion that they couldn’t communicate clearly. We noted that when we looked outside of medicine, we saw the same problems in communication that people often complain about in healthcare. Communicating and forming relationships with other human beings is one of the great challenges we face in life and, for the most part, we are expected to figure this out on our own through a process of trial and error. We often communicate poorly in our marriages, with our children or parents, in our work, and even with ourselves.
What sets healthcare apart is that it is a world of particularly difficult conversations and stressful relationships. Patients are sick, treatments are often less than fully effective, and complex medical information must be translated into a form comprehensible to laypersons. If you pulled a stranger off the streets and asked her to sit down with someone that she has never met and tell him that he had a terminal illness or that one of his loved ones had died or that the medical field had not figured out how to make his chronic pain go away, she would refuse and run. These are difficult conversations, and the intensity of training in our experience must be commensurate with the difficulty.
Moreover, illness transports many of us to a strongly emotional state, while clinicians are generally more comfortable in the cognitive realm. Plato described this as a chariot with two winged horses to represent the soul trying to direct rational and irrational pulls. A theme in many observational studies of physicians in practice is the strong tendency to respond to patient emotion with cognitive reasoning. Although we like to think that our rationality can tame emotions, we humans are much more prone to letting our emotions take over our rationality. We decide to eat the cake when we feel sad, even though we know it’s not great for our health. We delay making the colonoscopy appointment because we are anxious about the procedure, but we know finding cancer is important. When we feel emotional distress, our rational brain contrives actions that will diminish our distress. But it is our distress that governs our behavior.
Physicians will avoid having tough conversations or resort to labeling patients as a means of coping with the stress of actually communicating with them. We walk into a room and see “the pain patient” demanding narcotics. We don’t have the power to eliminate the pain. We are confronted with our helplessness to fix the patient’s problem, while at the same time we resent the pressure from the patient to prescribe a medication that we think will do more harm than good. We see a middle-aged mother or father of young children who is diagnosed with a terminal illness and desperately wants more time alive than we have the power to give. We have parents who are convinced that antibiotics will cure their child’s viral upper respiratory tract infection despite all the evidence to the contrary. What words make sense, and when did we learn them? How long is it fair to make our other patients wait while we “try our best” with the person in front of us? And will our department administrator yell at us for taking too much time with these patients and not clocking enough Relative Value Units (RVUs)?
What we came to realize was that clinicians had generally not been provided with an opportunity to study and practice healthcare communication skills the way they had been required to study and practice medical decision making, the maneuvers of the physical examination, and invasive medical procedures. In many ways, communication skills are similar to physical examination skills. They need to be practiced, like motor skills, and skilled feedback must be provided so that practitioners can learn from their past performance.
Most important, we came to appreciate that relationships lay at the center of healthcare. All work was conducted in the context of relationships: clinician-patient, doctor-doctor, nurse-doctor, attending-resident, clinician–family member, and so on. Human beings feel a need to be seen and heard, to feel a sense of belonging and connection, to be appreciated. If we ignore those needs and focus only on physiological and cognitive processes, we alienate patients and make them feel that they and their experiences are invisible to us.
Our project became an effort to build connections, nurture relationship skills, and awaken our and our colleagues’ latent empathic capacities so that not only our patients, but also we clinicians would feel a greater sense of belonging and appreciation. Practicing relationship-centered communication skills turned out to be a highly effective way of reengaging clinicians with why they pursued healthcare careers in the first place. It reminded them of what made the work rewarding and fulfilling. After all, at the end of the day, the patient is much more interesting than the disease.
Equally important, we aimed to model the behaviors that we thought would help them in their work with patients. If we wanted them to listen to their patients, then we needed to listen to them. If we wanted them to express empathy with their patients, then we needed to express empathy with them. If we wanted them to work in a collaborative way with patients, then we needed to work in a collaborative way with them. Lecturing physicians not to lecture patients is hypocritical. So, too, is telling clinicians to just deal with it when they are struggling to adjust to the new reality of ubiquitous patient satisfaction surveys. If we collectively can move healthcare institutions to work from top to bottom in a more relationship-centered way, we will accomplish a profound and valuable change of culture that will help patients and healthcare workers alike.
These issues led us to reject the model of patient-centered communication and instead to focus on relationship-centered communication. We did not want to tell clinicians that they were in the periphery while the patient was in the center. Rather, we wanted to challenge them to develop skills that would help them establish more effective, functional, and satisfying relationships with patients, relationships in which both the patient’s and the clinician’s experience mattered. We believe that relationships are therapeutic and that relationships function best when all parties to the relationship matter.
Calling Ms. Hide “annoying,” “crazy,” or “manipulative” is easy, expected, basic even. What requires actual skill is to move beyond these labels and find Ms. Hide. For Ms. Hide, there is no lurking, hidden medical diagnosis that no one has discovered yet after months of testing. For this individual, that isn’t the medical challenge to be solved. But there is a young woman with unimaginable wounds dating from her teenage years that haven’t healed and that keep asking to be seen. Maybe, just maybe, the most therapeutic thing we can ever do is to look for her in all of our patients.