Adrienne Boissy on how physicians are learning to improve doctor-patient relationships at the Cleveland Clinic

communication-the-cleveland-clinic-wayCommunication is a key to a successful business, but it is paramount in health care. The need for transparent dialogue between doctors and nurses is a given, but now greater attention is being paid to the interactions between caregivers and patients, and how those relationships affect health outcomes. Adrienne Boissy, a neurologist and the chief experience officer at the Cleveland Clinic, has co-written a book entitled, Communication the Cleveland Clinic Way. How To Drive A Relationship-Centered Strategy For Superior Patient Experience. She wrote the book with Tim Gilligan, former co-director of the Cleveland Clinic Center for Excellence in Health Care Communication. Boissy shared some the lessons she has learned on the Knowledge at Wharton show, part of Wharton Business Radio on SiriusXM channel 111. (Listen to the podcast at the top of this page.)

An edited transcript of the conversation follows.

Knowledge at Wharton: The patient experience is one of the most important focuses that hospitals have these days, right?

Adrienne Boissy: You’re absolutely right. We’ve been thinking a lot about patient experience for probably the past decade. I don’t know how familiar you are with Toby Cosgrove’s story in that, but that was really the spark that lit the fire for us around patient experience.

Knowledge at Wharton: In your title and the work that you do there, it is a point of emphasis for you because the experience is not just how the patient is treated when they’re being looked at by a doctor or a nurse, but it’s the whole experience of coming to the hospital and the neighborhood around the hospital.

Boissy: We know that patients are making choices about where they’re going to go and who they’re going to see based on the experience that they have at that hospital or organization. Those are the things people go home and talk about at the Thanksgiving Day table, and that’s what they’ll remember.

Knowledge at Wharton: Is the training for doctors, nurses and the staff at a facility like the Cleveland Clinic being tweaked so that this patient experience is a growing part of their whole understanding of what it is to be a doctor or a nurse these days?

Boissy: There’s lots of humanism and communication skills training going on in medical schools and nursing schools, probably even more so. And I think that’s great. It’s important to understand that before you’re a staff physician or a nurse out on the floor, when you’re in school or a student, you have minimal responsibility.

“The challenge is that all of us have a role in modeling the skills we want to see in the world.”

You don’t have a lot of on-the-ground, real-world experience, and your empathy levels are at an all-time high. Yet the challenge comes when you’re really the one with full responsibility to sit down with a patient you’ve never met before and tell them they have ALS, or to tell someone who thinks they have one disease that they have another. Those types of conversations carry the emotional burden, I think, for the clinicians who have those.

Knowledge at Wharton: How much of teaching does the Cleveland Clinic have to do on top of what the doctors and nurses learn in school?

Boissy: It’s really important for a couple of different reasons. The first of which is just what I said, that it’s very different being a student and studying it versus being immersed in it up to your chest. The second thing is, transparency is a driving force across health care systems today. Not only is patient experience valued, but we’re transparent about how organizations and individual doctors, clinicians are performing. That’s both internally as well as externally. A patient can go on Google and look up Cleveland Clinic physicians or clinicians and see what other patients are saying, and we know that guides choices.

We learned that once you make it transparent at that level, you also really have to be able to follow that up with training. Meaning, what’s the point of being transparent if you don’t have programs that actually support your people to get better? That’s the definition of futility. It’s very risky, in my mind. You have to be able to do both: be willing to be transparent and drive that as an organization, which I think we did, and to be able to back that up with resources to help your people.

Knowledge at Wharton: The model that Cleveland Clinic uses in terms of the communication process is called REDE. Can you explain what that is and how it has been implemented?

Boissy: I’ll tell you a quick story. When I was asked about eight or nine years ago to develop a communications skills training program for the Cleveland Clinic, I thought that would be great. — trying to deliver training or teaching around a product or a service that most people think they’re already good at and don’t think they need. Yet the complexity of the conversations and the fragility of those conversations really became very interesting to me. Could we deliver training that would honor that?

As a practicing neurologist, I never really thought much about how I communicated, even though I had gotten training in school earlier and thought I was really good. One of my colleagues came up to me and said, “You know, I think we should couch these communications skills in the context of a relationship.” I looked at her and I thought, what are you talking about? My job as a doctor isn’t to build relationships with my patients. I’m stamping out disease. I prescribing medicine.

“Empathy is a relentless pursuit. You can’t … just expect that empathy is thriving around every corner.”

It was an a-ha moment because I reflected back earlier on my career when I had tried to tell some patients some really difficult information. It was the first time I was meeting them, and it didn’t land on them really well. In my youth, I didn’t understand it. I thought, what’s wrong with you? I’m telling you the truth, this is really important. I’m telling you things nobody else said. But giving that information in the absence of a relationship, people won’t hear you.

To me, that was an a-ha moment. Although it may not sound earth-shattering to you, for many clinicians it might be because not all of them necessarily view their job as building relationships with their patients. Yet that is the one thing that is incredibly therapeutic for both.

Knowledge at Wharton: You talk in the book about how there are certain situations or certain diseases that doctors have a very hard time discussing. I think we assume that doctors who have expertise in a field or a disease don’t have any concerns in terms of having the conversation. You talk about the fact that they do.

Boissy: This work leaves sort of an emotional residue on caregivers, without a doubt. The training we offered was an eight-hour training. It’s a lot of creative methods of improv and group facilitation, physicians to physicians.

What was so interesting was that the first rendition actually didn’t allow them to bring their toughest cases. We added that later. The reason we added it is because their suffering was so palpable. You could hear these stories of these incredibly powerful, awful, tragic moments that they had witnessed or been a part of that had never maybe really been processed in any other space. We recognized we had an opportunity to draw out what are the moments that have haunted you in your career? Let’s talk about those and not just get a shared experience or viewpoint that it is suffering everybody has seen, but let’s help you from a communications standpoint.

I think it is part our own discomfort about having those conversations, and it’s probably really underestimated, the impact those conversations have on us.

Knowledge at Wharton: There are some doctors who have been in the industry for 30, 40 years, they’re well-respected, they have an old-school type of mentality and maybe haven’t had that relationship with their patients. How challenging is it for doctors to understand that these relationships often make the difference in the health outcomes of a patient?

Boissy: I have no idea what you’re talking about when you say it might be challenging for doctors! I’m just kidding! I think the challenge is that all of us have a role in modeling the skills we want to see in the world, without being too cliché.

Our facilitators who were physicians, who sat in many of those conversations, we actually trained them on how do you stay empathetically curious. Let’s say somebody comes into the course, and you can see them kind of kicking back or rolling their eyes or not fully engaging. Our job isn’t to convince them of how vital this is. Our responsibility as a facilitator is to sort of approach them with the same empathy and curiosity we would anybody else and to say, give me a sense of what your exposure to prior training has been? Tell me a little bit about why think you this could be helpful or maybe why it wouldn’t be helpful in your environment. Let’s just stay curious about it without judging where it’s coming from.

“We actually trained our physician-facilitators on, ‘how do you stay empathetically curious?’ “

Knowledge at Wharton: This training is happening more in medical schools. Not that you want to have the training that you’re doing go away, but it will become more the norm as the cycle of doctors changes over the next couple of decades. Doctors that had this training in medical school understand right from the get-go how important this is.

Boissy: I would agree with you. Empathy is a relentless pursuit. You can’t, in today’s environment, just expect that empathy is thriving around every corner. There’s incredible pressures in the health care atmosphere. It’s an incredible time of change, resources are constricting and expectations are higher. Empathy needs to be very intentionally fostered and garnered and reinforced — and people need to be held accountable. I would go so far as to say people need to be held accountable for it as all of these changes continue. We can’t just think it’s going to happen. It doesn’t always just happen.

Knowledge at Wharton: You also talk in the book about how the doctors at the Cleveland Clinic end up showing kind of a vulnerability that they have in terms of being a doctor on a day-to-day basis.

Boissy: This is incredible complicated work. And it’s human work. We can’t forget that you’re working with other human beings. We’re not just patients and doctors. We’re humans, and that’s a shared experience. It’s a shared emotional experience.

I talk sometimes about this concept called empathy and design, that if you were going to design a communication skills training program, and you go at it just with the idea that you’ll teach people reflective listening and shared decision-making, when the very people you’re trying to teach are burned out and exhausted and just lost all of their resources, your training will fall on deaf ears.

The training just needs to attend to both end users. The idea that both caregivers and patients need to benefit. There’s reciprocal influence on each other, and that relationship in and of itself is really therapeutic for both.

Knowledge at Wharton: Is this a program that really benefits not only the doctors but the nurses and many of the employees that work at a hospital?

Boissy:  Yes. When our journey began about 10 years ago, we put all caregivers through something we called the Cleveland Clinic Experience. It was a cultural leveling where we didn’t call people doctors and nurses, we called them caregivers because we all are here for the same purpose. We talked about the mantra of patients first, that’s our north star. We talked about how do you deliver service? How do you respond when it doesn’t work? We’ve built that into expectations of every caregiver at the Cleveland Clinic. I think of it as a continuum. Service is bit different in my mind than complicated, advanced topic communication skills for a surgeon who’s been practicing for 50 years. I don’t think you can necessarily simplify a lot of the conversations that clinicians have, and that complexity needs to be honored. Organizations need also to embed that level of service across every single touch point.

Knowledge at Wharton: The book is geared toward medical professionals, but I almost think it’s a book that gives the general public more of a sense of what it’s like being a doctor or a nurse, and understanding the struggles that some of these people have. It’s a book that a lot of people can benefit from reading.

Boissy: That’s right. The public can absolutely learn, and again, we’re talking about the human experience, which has universal appea

There are a couple key concepts. One is people behave differently when they’re in a relationship and when they’re not. I mean, I might be nicer to you if I’ve already met you or I know you a few times. And your language changes. It’s the difference between saying to your partner when you come home, “Why haven’t you taken out the trash already?” Which probably isn’t the most effective language to build relationship, right? You might want to reconsider if that’s your goal. Similarly, if you were trying to get somebody to quit smoking, your language would sound different versus if you were trying to build a relationship with them first. Even those small examples draw out the same skills. There’s not something fancy and complicated about the techniques, it’s just intentionality and application of those.

Some of the lessons in the end were really around giving simple dos and don’ts based on what we learned from the clinicians. Some of the don’ts were things like, “Please stop saying ‘don’t worry’ because as family members and loved ones, we worry. Please stop saying, ‘I understand’ unless you’ve really taken the time to understand and explore. And please start using phrases like “and rather” than “but.” It’s not, ‘I understand you want that medication, but I’m not going to give it to you.’ It’s ‘I understand you want that medication, and let’s talk about next steps.'” So, there are some real universal lessons in there.