Timothy Gilligan, M.D.
Co-Director, Center for Excellence in Healthcare Communication
Medical Director, Inpatient Solid Tumor Oncology
Program Director, Hematology/Oncology Fellowship Program
Cleveland Clinic
Dr. Baile: So, today we're really pleased to welcome our guest ACE lecturer, Dr. Timothy Gilligan. Dr. Gilligan is a medical oncologist at the Cleveland Clinic with appointments in the Departments of Solid Tumor Oncology, Urology and Bioethics. Tim did his medical school at Stanford and residency at Brigham and Women's Hospital and his fellowship at the Dana-Farber Cancer Institute. He's published numerous scholarly works in peer reviewed journals, book chapters and really given a lot of lectures. And interestingly, while he's focused a lot of his more recent work on communication skills, he's also a key member of ASCO's advisory boards on genitourinary cancers and testicular cancers and given a lot of talks on these topics across the country. And currently, he directs the Cleveland Clinic Taussig Cancer Institute's Late Effects Clinics which addresses the needs of cancer survivors and serves as Program Director of the Hematology/Oncology Fellowship Program in the Cancer Center and is Vice Chair of Education. Importantly for his visit here, he's co-director of the Communication Skills Program at the Cleveland Clinic and has pioneered the development of comprehensive communication skills training for faculty, fellows and others at the Cleveland Clinic. So, Tim welcome and we're eager to hear about your doings at the Cleveland Clinic and teaching communication skills and improving quality.
Dr. Gilligan: Thank you.
[Applause]
So it's a pleasure to be here. Thank you Walter for inviting me. Walter has been my most important mentor in this work, so it's a real honor to be here. I have learned a lot from him and continue to learn from him. I am going to give a talk today that is really conceptual. I'm not coming here as a PhD who does outcomes research to flood with you with a lot of data and slides. That work is important, but I'm not the best person to give that talk and I think some of that stuff actually has been presented here recently in some of the other ACE lectures. I really wanted to talk about our hospital's attempt to take on the challenge of helping doctors become better communicators. And the clinic has made a major push, some of it has been very successful, some of it has been more of a learning opportunity. I want to talk about kind of the background with how that happened and what we've done and what some of the remaining challenges are.
I'm curious, in terms of the audience here, how many people here are involved directly in patient care if you don't mind raising your hands. It's just helpful to know how--because I'm hoping this will be relevant in terms of--like anyone who is talking to patients, interacting with patients, these skills come into play. A lot of my talk is really going to be emphasized on doctors because we do believe at the Cleveland Clinic the doctors are special and they have special needs. And you have to have special education for them. There are a lot of other healthcare professionals who figured out how human beings work to more of an extent than some of their physician colleagues. So, it seems bias towards physicians is--honestly because we think they need the most help in terms of people who interact with the patients. So, in terms of framing this, one of the things that was really striking to me around becoming an oncologist was that when I had to learn how to put the central line, it was very structured. I had to review the anatomy, I had a book with guidelines. The steps, I had to watch someone do it, I then had to do it under close supervision after I've done it five to 10 times and they signed off, I was then allowed to do it myself. But when I went in and had to tell someone they had metastatic pancreatic cancer, there was none of that. I could look up Walter's paper on SPIKES and have some guidance, but I didn't even have a mentor telling me I should find the equivalent of how to put in the central line and think about it. How are you going to tell someone the worst news they've ever heard? When I have to answer medical questions like these, I have studies to go to. You know, what's the best treatment for a heart attack? Which drugs are most effective for metastatic lung cancer? I do a ton of testicular cancer. Why do I give three cycles instead of four of BEP for good risk disease? Because there's a randomized trial showing me that it works just as well and has less toxicity.
But if I then switch over--I'm sorry, I'm going the wrong way--to communication questions, I have another set of issues that I don't have a great body of literature or clinical trial to turn to nor is our medical education asking doctors to approach these questions in the same way. How do you make someone feel important? How do you start off the interview in a way that makes them feel engaged with you? If the patient demands something inappropriate, is there a way of not giving it to them without damaging that relationship? When we do scenarios at the Cleveland Clinic the doctors tell me about the worst case. It's often about conflict. The patient wants narcotics, I don't want to give them narcotics. The patient has a viral upper respiratory tract infection that they want antibiotics which won't help, I don't want to give them, but they don't know how to negotiate their way through that conversation without getting into a fight with the patient and then worrying about their patient's satisfaction scores. What's the best way to give someone terrible news? What's the most effective way to achieve adherence? So I can know all my medical facts, I can come up with the world's most brilliant plans for treating the patient's problem, but they go home and they don't do it then I've really wasted my day. I've had no impact. Knowing what to do is very different than delivering it in a way that the patient actually does it. And that really comes down to communication and to what extent that we've been trained to do that, there are motivational interviewing techniques that are very well validated, but the extent to which doctors really master it is a whole other question.
We have to obtain informed consent. My brother is a surgeon, he used to play this game when he was a resident. His job was to go consent the patient for a trial, I mean for a surgery, and the next morning, he's in the pre-op area, he will go down to the patients who he had consented and he asks them, "What are we doing today Mr. Jones?" And he said he was shocked, they had no idea. But he knew he had told them. But he had never been through a training course that actually used patient understanding as an outcome. And a lot of ways--informed consent, our current standard is, "Did I tell the patient?" Shouldn't it be, "Did the patient understand?" That the patient remember? We don't accept this kind of business when we're dealing heart attacks and cancer outcomes, but we accept a much lower standard for communication and that's part of I think why we're in trouble around it.
These are some of the challenges we face in oncology, especially I work--I run the Fellowship Program and I have to help my fellows cope with this. What do I do when the patient starts to cry? What's a response to a crying patient that makes the patient feel cared for? Is that a question that got addressed in your medical school curriculum? These days, it's starting to get addressed but it hasn't. These are other challenging questions that we need to help people address the same way we help them address when to give aspirin and beta-blocker for someone having a heart attack. So why should we care about this? I think--I like to think it's intuitively obvious but there actually is data about why we should care about this. So what does effective communication do? Patient satisfaction improves, that's one potential outcome. It decreases emotional stress, it improves treatment adherence and compliance. So if we care about outcomes, we have to get the patient to adhere to the plan. Communicating is the root to that. It has been shown that it correlates strongly with medical outcomes.
Some of the earliest communications research wasn't about hugging the patient or making the patient happy, it was about what happen to their COPD and their diabetes. And if it turns out, if you communicate better, the objective measures of their disease status improves because they stick with the plan better. We reduce medical errors and malpractice, and we improve for this in satisfaction and I think that's a key point because I think the reason we've gotten traction around doctor-patient communication education at the clinic is that the doctors are finding that their satisfaction goes up when they have a better relationship with their patients. So, I want to approach this from a slightly different angle for the next several slides. Communication skills challenges. What do we encounter when we decide we want to teach people to communicate better, we want to improve how things go at our hospital, we want to work more effectively with our patients. One of the best medical journals to address this is the New Yorker Magazine, because doctors--a lot of them like to read the New Yorker and they don't feel like they're reading a medical journal so there is a stealth series on doctor-patient communication that the New Yorker has been running that I would like to share with you. So this is one of the first problems we run into. My patients love me, I am a great communicator. It's not me, it's the other guy, that other guy. I love it that they have doctors as kings in the New Yorker. So you have to get people to buy into the fact that we don't know how good we are at communicating because we've never measured it. Very few doctors have gotten really good feedback on whether they're communicating well. And often, the people who are the best communicators think they're the worst communicators because they are the most aware of how hard it is and how much better maybe they could be. Our second cartoon, the medical environment is a challenge right now. We have a lot of things on our plate. This poor soul is being thrown off the cliff because it's the only treatment option he has under his current health plan. If we're worried about these issues, how do we have time to talk about doctor-patient communication? It's important to be sensitive to the pressure healthcare providers feel under these days. One of the--one of the challenges we face is that everyone says, "I'm not a touchy-feely person. I don't want to hug my patients." It's not about hugging your patients. It's about figuring out who your patient is and what they want, right? So this patient is uncomfortable, because he doesn't want his psychiatrist on the couch with him. That's not good communicating. It's a misnomer, but--so we have to separate out being touchy-feely from being a good communicator. It's a different issue. I don't hug my patients a lot, that doesn't mean that I don't communicate well with them.
The flip side is that people think, "Well, how can I possibly take this on? I need to think of something beautiful and profound to say." Here we have, I think Plato talking to his family, if you don't have anything profound to say, don't say anything at all. Doctors get hung up. What I can say, I'm going to go the room to talk to someone with metastatic pancreatic cancer. What can I say that measures up to that moment? There's nothing you can say that measures up to that moment, that's not a fair burden to put on yourself. You just have to show up and sit down, listen to them and connect with them, it doesn't--it's not that hard, it's not rocket science. But I think people get intimidated and they think, you know, what can I say that really rises to the occasion? The best thing you can do is to show up.
This is a lesson I learned from Walter. So what is death doing? Death has shown up at apartment 3B, he is giving his save the date card, he's saying don't freak out, right? So, well how do we label that in the communication world? He is trying to reassure the inhabitant of apartment 3B. Does he have --does he look reassured? No, no. Don't freak out, it's only metastatic pancreatic cancer, right? Don't freak out, you only had four vessels bypass surgery. It doesn't help people when they're freaking out to tell them don't freak out, but doctors do it all the time. We try to make it better. You cancers come back, but you know, we have this really exciting phase one trial, we're seeing really great results in mice, I can't wait to get it started. Like it's--it's not speaking to the patient's experience. It's trying to get them to not freak out, but our goal shouldn't be to get them to not freak out. Our goal should be to talk them about the fact that they're freaking out and what that feels like. But it's a hard lesson to teach.
So here we have Shakespeare, right. Shall I compare thee to a summer's day. So what's the point of this cartoon? If you don't get the body language right, it doesn't matter what you say, right? There are no words, there is no words that could make the scene look romantic. He's using incredibly romantic language. It's the Love Sonnet from Shakespeare. So, there is a certain problem that certain people have with failure to have consonance, that what they're feeling and thinking inside is not projected in terms of their body language. So they actually maybe feeling very caring and warm, but they are sending body language that suggests otherwise. They are typing on the computer, they're not making eye contact, they cross their arms, they're not sending a signal of--so helping people to become more aware of how they're seen is very important. Sometimes video work is the best way to do that, to videotape a doctor with a patient or a provider with a patient and let them see what they look like. They're often very surprised. I don't know what I look like to you, I have no way unless there's a mirror that I can see it so I do my best guess. And it actually is an important issue because if the body language says you don't care, it really doesn't matter what words come out of your mouth.
And then lastly, I think this is the last one. This is a major problem in the hospital, the patients don't know who their doctor is. There is a survey of major American hospitals and most patients don't know who's in charge of their care. They don't know what's going on. And it's very disruptive when the nephrologist comes in and says we're going to start dialysis and the doctor in charge comes in and says no way are we doing dialysis, they need to know what's going on. It's very unsettling to be sick and vulnerable and to feel like no one is in charge. No one is in charge, no one knows, when is my CT scan? When am I going to be able to eat? Are we going to do surgery or not? So it's, it's--I think for anyone who does quality work in the hospital or monitors how hospitals work, it really drives you crazy that the doctors don't talk to each other when there are multiple consultants involved, or the doctors' don't talk to the nurses. I run our solid tumor inpatient service at the clinic and the amount of work it's taken to get the doctors to include nurses on rounds, so that the nurse will know what the plan is for the day. I mean, it was like I was trying to move Mount Everest. So it's--this issue of being clear to the patient who's in charge and what's the plan is important.
Then this actually is the last one. Which is sometimes we just don't communicate at all and I think we forget what that's like for the patient, to hear the doctor saying it's a simple stress test, I do your blood work, send it to the lab and never get back to you with the results. When you look at it from this perspective, you suddenly realize that's not cool. But it happens all the time, it happens all the time. So we, we could be more sensitive to this.
So, flipping back to a more serious approach, what communication skills do doctors need to be able to do? If we're going to--when we put together our program, what are we thinking are the skills that the doctors need to master? So one very basic thing is how to connect with human beings. I was talking today in a couple of conversations about the fact that you know, we select pre-meds to go to medical school. They don't get into medical school because they were the cool kid in the class who had lots of relationships, who could walk into a room and strike up a conversation and knew how to get along with other people, they were good at organic chemistry and physics. You know, I study like crazy for my MCATs, no one was checking in on how easily do I connect with people. And it sounds likes such a simple thing but it's not. For a lot of people, they form connections with people who have a lot in common with them where the connection is really obvious. But to feel like they really have strong skill sets, that they can go into a room and form a connection with a new person whoever they are, because that's what medicine is, you don't know who's walking into your office and you have to be able to connect with them.
And so basic stuff around greeting and welcoming and asking questions and showing curiosity and sincere interest and attention, the stuff that people actually need to practice even if it's basic human social skills. How do you listen without controlling the conversation? Doctors interrupt patients typically about 18 seconds into the patient's attempt to try to tell their story. It makes it very hard for the patient to tell their story if they're being interrupted all the time. It's--when you train, there's one study, to train doctors not to interrupt patients and the gap from interruption went from 18 seconds to 23 seconds. So, it's hard because we have this--we want them to tell a medical story. We want them to tell us the pain is eight out of 10, it radiates to my leg, it's been going on for three days, it gets worse when I jump and down, it gets better when I take aspirin. That's not the patient's experience of their illness. That's not the patient's narrative. So getting doctors to listen in a way that the patient can tell their story in their own terms is very important. So the patient feels heard. We want the patient to go home and feel like the doctor heard my story today. We have to let them tell it, otherwise, they go home and they feel like, well I never really got to say what mattered most to me. How do you recognize, identify and respond to emotion? It sounds so simple but after spending five days working with Walter in small workshops, I've began to appreciate that it's actually very complicated. It's--when the patient gets emotional, the first thing that happens is we get emotional. We need to understand our own emotional response to it. We need to get it under control and we need to figure out ways to respond to the patient that lets them know that I see what you're going through and I'm sorry that you're suffering and I care about you, and finding ways to do that. But what does the doctor have to do? They have to first recognize that the patient is emotional. For some people, that's actually not so easy to do yet, so they have to practice doing that. Once you figured out the patient is emotional, you have to be able to name, what is the emotion the patient is going through or make a good guess at it. And then you need to figure how do I respond to that? How do I respond to anger in a way that's helpful to my relationship with the patient or sadness or whatever? How do we respond constructively to difference, to controversy? When we ask doctors about their challenging cases they tell us over and over again, the patient wants antibiotics; I don't want to give them antibiotics. What do I do? Dealing with disagreement and controversy is actually an essential skill in medicine because you don't want to just cave in, but you also want to build the relationship, build a stronger relationship. And there are skills for doing that, I think one thing that's hard in our culture is that to some extent, we try to minimize difference. You know, we talk about sort of--as racism declines to some extent in our country, there's a lot of talk about, you know, race shouldn't be relevant, race should be--you know, we should just ignore it. But the fact of the matter is if you grow up with white color skin in the US, it is a different experience than growing up with black skin in the US. And can I be with a black person and connect without having to deny all of our different experiences or can we connect in celebration of the fact that my experience has been completely different from theirs, but we can still connect. Difference, conflict can be a bridge towards deep connection with people. Often when you're in conflict, people finally start saying what they're really thinking. So getting physicians and healthcare providers more comfortable dealing with conflict is really important, so that you can start to see conflict as an opportunity rather than as a sign that things are going off the rails.
And then lastly, how to communicate in such a way that the learner understands and remembers? I went to journalism school before I went to medical school and they actually spent a lot of time in journalism school trying to teach you how to do this. They recognize this is hard. You want to write about the latest developments in nuclear physics in the science section of the New York Times, but you have to write about it at a level that anyone who reads New York Times can read it, or if you're writing for the New York Post, it has to be at a simpler level. You're writing about the conflict right with now Iran, it's a complicated subject, how do you right about it if there's someone at the sixth grade reading levels can read it. When you're a journalism student, they spend a lot of time working on that simple tense and structure, simple vocabulary, presentation of basic ideas. But when you go to medical school and you--I have to tell a patient that you just had a heart attack and it involves two vessels of your heart, how do I explain that? That's actually not so easy. I think people really, really underestimate how hard it is to give medical information in a way that lay people can understand it. And the result is that most patients leave without understanding it. And learning how to give the information in a way that the patient can, so don't give them too much information and give it to them using clear language and simple language, give them diagrams, give them the written materials. Being flexible about it is really very important.
So I talked about the benefits of communication skills. There's a new issue on the block obviously, right? There's HCAHPS scores and SIGECAPS, there's money on the table so that's why people are paying attention to it now. So for people like me who are interested in it, HCAHPS is the best thing that ever happened because finally the hospitals are paying attention to it, and they're actually investing some of their money in it. And what's happening is we're seeing increased individual accountability so whereas before, it was really on the hospital and its reputation, we now have individual doctor scores and we can break them down. The patients could ask these questions in terms of inpatient HCAHPS, how often do the doctors treat you with courtesy and respect. How often do doctors listen carefully to you? How often the doctors explain things in a way you could understand?
All right, so these issues in HCAHPSs are not that different from the issues that I would identify and did earlier in this talk, is being basic fundamental issues to what doctors ought to be doing. And then we also get verbatim which we can breakdown into different categories as to what issues patients are most unhappy about in the hospital. And not surprising, a lot of it is whether they have enough time with the doctor, access, did the doctor--whether the plan of care is clear, whether things are being explained to them by the doctor in terms they can understand. So we're getting a lot of data now in terms of what's going on and it's being linked to the individualization and our hospitals now are actually mailing this out quarterly fully labeled. So I know all my friends' scores, I know my score, they know my scores. So the message of the clinic is this is part of your professional identity and you should own it and if there's problems you should figure out how to fix it. Not in the sort of blame mentality but this isn't the ocean we're swimming in right now.
So, one of the things that I wanted to do today was to talk about then how we have tried to implement our approach to this problem. What have we done? So three or four years ago, they formed a committee of people who had been working in this area and we studied the literature, we visited a number of other hospitals. We talked to experts in the field and tried to figure out what do we know? If we wanted to, we could see that our doctors were going to be held accountable for their scores, they're communication score, patient satisfaction scores, we wanted to be able to offer them something that would help them get better. So the initial step was to try to figure out what does the science know about how people can get better at communicating and improve patient satisfaction. We talked to our top performers, the doctors we had who had--actually we have some doctors who have basically perfect patient satisfactions scores and tried to figure out. What could we learn about them because they were doing it in our environment, with all the constraints that our doctors face, our reality so that we could see if there are certain ways that they adapted to the difficulties of our environment in a way that made it work better for them. And then we hired the American Academy of Communication in Healthcare to come in and train a group of us in how to facilitate communication skills training, how to work with people so that they will get better. That was very important work because most of the stuff that I had seen on communication skills was delivered as a lecture, sort of similar to this. And this doesn't change anyone's behavior when they get back to clinic looking at slides. We wanted people to really be good at working individually or in small groups. And teach the material in a very hands-on way with lots of skills practice. And we developed a seven-hour course that would deliver this. And I'll describe sort of what was included in that course in a little bit. And then lastly is an ongoing faculty development and we've been bringing in experts.
So Walter comes a couple of times a year to work with fellows and staff and, and has given the number of talks on how to do this work well and what we can learn from his experience. Tony Back has come from University of Washington. We have other people from AACH who've been coming in, so we’ve tried to bring fresh blood and fresh ideas on an ongoing way. And what this led to was this new organization called the Center for Excellence in Healthcare Communication that I'm involved with. We have a communication curriculum, a coaching program, a faculty development program and we're starting a research program that's more in its infancy right now. This basic course we call Foundations in Healthcare Communication which is the seven hour course, but then we have advanced level follow up courses on giving bad news, dealing with end-of-life issues in a variety of things like that. I'd like to have something on consenting for trials at some point as well. And then the faculty development, we started training our own people so that we can grow a larger program.
So what has happened over time is we started with this course one day a month, we're now offering it six to seven times a month, we have about eight to ten people in this course. We have--we used to have five facilitators, we now have 29. It used be elective, it's now a mandatory part of on boarding for any new faculty physician that the clinic has to go through it and we're starting to ramp it up so that we can include fellows and residents as well. We use to bring in the American Academy Communication on Healthcare to teach, to Train-the-Trainer, we now teach to Train-the-Trainer ourselves and have developed their own version of that program. In the first three to four months we managed to get 50 physicians through, we've now trained over 700 doctors in the seven hour course and we have a long wait list. We can't--even with our large capacity right now we're still not exceeding demand. We started with the four habit model from Kaiser which is invest in the beginning, a list of the patient story in their own terms, use empathic skills and then invest in the end of the visit in terms of delivering diagnostic information. We've now delivered--developed our own version of what we think this should like using education experts at the clinic. So the structure of the course, as you try to present basic skills in communication, around, again, empathy, forming a connection with the patient, listening to them so they can tell the story in their own terms and providing diagnostic and educational information in language that they can understand and retain.
So the format for this is very hands on and experiential. We start with a very brief didactic, just what are the basic skills you're going to practice, 10 minutes or less. We then try to demo what this looks like using the facilitators, sometimes we're able to video what it should be like, and then most of the time is spent practicing that skill. We told you about the skill, we've shown it to you and now you have to do it because it's like--in a lot of ways it's like tennis lessons for me, I'm a tennis player and a squash player and I have had lots of lessons and none of them have included PowerPoint slides, right? There have been no lectures, when I studied piano, I studied piano for 12 years, I was in a conservatory for a year and there were no lectures. When you went to music theory there were lectures, but a piano lesson you sit down and they make you play the piano because the bottom line is what are you able to do? They don't care what you know, they care what are you able to do? So the skills practice is a big part of this and I can't overemphasize that. And then we try to bring it back to their practice. So we've given you all these skills so what? Well let's talk about a case you saw two weeks ago that was really challenging, let's see if we can apply these skills to what you do every day and see if we can make it better.
And the nice thing is that most of the time we can make it better, we can help people see things that they weren't able to see when they were caught up in the encounter. Each session, this is sort of a size and scope, we have eight to 10 participants so we can break them into two groups of four or five people so people are really engaged heavily in skills practice and observation. We have two facilitators and two standardized patients. So my point is that this is labor intensive, this isn't cheap because this is a doctor's time and we have a lot of very busy clinicians who are helping to run the course because it's a priority for us, but I don't want to be misleading about that, it is a big investment. The key strategies that we have learned, it is not about hugging, right. My point about in saying that is that you don't have to become someone else to do this, you can communicate well in your own personality in your own style. You don't have to be more touchy-feely than your comfortable being. It needs to be authentic, in fact that's incredibly important, if you start just mimicking lines that you learn in a communications course the patients are going to see through that in a second. It has to be your own language and sometimes what we have to do is to get people not to become too techniquey in how they talk to people. They'll throw in a lot of unnecessary language. Would it be okay if I ask you to tell me about your experience with your abdominal pain? You can just say tell me more about your abdominal pain. They'd start just throwing a lot of nonsense. So we try to reassure them that you can do this, you can be yourself and do this.
We have been very heavy on the doctor to doctor side of this, as I said before doctors are special, they have special needs. But it's also true that you know we tend to work really hard in school to get to medical school and then we worked hard in medical school to get the residency and then we--it's a lot of hours and if I've been doing it for 10 years and I go into a room and someone tells me, I'm going to tell you how to talk to your patients better, I might punch them. Because--come to my clinic and tell me that. And so we want to be sensitive to that, that these aren't lazy people who are the stereotypes that we're off playing golf, but that's really not what we're doing. And so there has to be some sensitivity so that if someone has been practicing medicine for a long time, they have learned something from that. They have their own expertise, they know what it's like to be with their patients and we really have to honor that. And for us having clinicians teach clinicians has been a way of keeping it very collegial. I have the same challenges you do, let's talk about it. Let's talk about our tough cases, let's see if we can come up with some new ideas by pooling our--the intelligence in the room, it's like running a tumor board. It's not I'm the communication expert and I'm going to shower my wisdom on you because that doesn't go over very well. We try to have a safe setting, we try to build a group dynamic during the course of the day so that people trust each other. Attention to that is really important, people will come in with some degree of alienation or reluctance or wishing they were somewhere else, you have to build the team and build the group and get it going well.
So attention to basic facilitation skills is very important. Focusing on skills practice is the only way people get better, that's what the literature tells us. The only way people get better at communicating is to practice communicating and then to get structured feedback, they need the structured feedback. I often think the analogy for me would be I'm a tennis player, suppose I hit the ball and I couldn't see where it landed. How would I ever get better? If I can't see when it's in, when it's out, if I can't see it if it’s a down the line shot instead it went cross court, I need to see where the ball goes, that's my feedback and then I adjust my swing to try to get the ball to where it's supposed to go. So when you--when I talk to a patient I don't get that feedback, I don't know where the ball goes, I don't know when I've hit it in and when I've hit it out unless I really hit it out and the patient does something extraordinary. But that's--usually I don't get a lot of feedback, so I need in my skills practice to be getting feedback from someone who knows how to get feedback and, "Tim well it worked really well when you did this but at this moment in the interview what if you tried a different strategy," and then I can try it out and see what it feels like and that's how people improve. We try to make it real so we really do focus—we spend a significant amount of time on talking about real world cases from doctors and we're dedicated to this model facilitation, so I can talk about a little bit on one of the next slides.
We included surgeons among the facilitators. One of our teachers is the Chair of Neurosurgery at Cleveland Clinic. There's a reason for that, no one can say to him that they don't have time to attend this course because they're too busy because he is the chair of neurosurgery. If he can get out of the OR they can get out of the OR. If it's so important that they will sacrifice 12 days of billing in a neurosurgery OR every year so that he teaches this course, it sends a very powerful message to the staff that we're serious about this. This matters. And just like, doctors sometimes need to learn from doctors, surgeons sometimes need to learn from surgeons because, my experience with surgeons is that there are only two good surgeons in the world. The surgeon you're talking to and the surgeon who trained them. And so it tends to be a very critical environment, so having support from the surgical community has really helped us a lot.
Leadership support, the clinic talks about this a lot when we did our Train-the-Trainer course, our chief of staff came and spent an hour talking about his experiences as a patient and what it was like when people were not empathic, and what it was like when his wife was in the hospital and he didn't like the care she was getting. There's really been--trying to get a strong message from the top thing, our job is to reduce suffering and we can't do that if we don't communicate well. Our job is not necessarily to cure disease because we often can't do that, but our job is to address human suffering. And having a strong leadership support from that has been vital for us.
I will say a couple brief words about facilitation. The data on adult education suggests that people remember about 10 percent of what they hear in a lecture. So if we want to change behavior, PowerPoint is not an effective way to do that. If you see someone performing and they are not doing a great job you will improve their performance more if you figure out what they are doing that's working and reinforce it, than if you try to find all things they're doing badly and try to change them. It's just the way what sort of education theory has taught us, can I absolutely prove that to you? No, but this is a philosophy that we believe in, so we really try to learn to identify effective communication skills and sometimes that's hard. You see someone and you think, "Wow this really isn't going well, how am I going to fix it?" Well it's the same thing, you know that impulse to fix it is actually something we're trying to get our doctors to stop doing with the patient. The patient is crying, how am I going to fix it? We want to teach them to see in learners what strengths they do already bring to the table so that we can grow from those strengths, we will get much more effective change if we do that and that's learning to facilitate so that you can support that process, because actually we have found it to be incredibly important.
If you want--this is actually another key lesson I've learned from Walter and Tony Back and the people at OncoTalk. If you want to be able to reinforce success, so if our learning model is I'm going to set you up to succeed and I'm going to watch you succeed and then I'm going to reinforce all the things you did well, well I have to set you up to do that. And there's a lot in medical education in which we're setup to fail, that they watch us and as long as we're doing well they don't say anything and then you do something stupid and they jump on you and that's not an effective model if the goal is to really fix him, is to improve performance future. So what we want to do instead is we anticipate what's going to be the hard part, talk about in advance, strategize, let the person go in with a plan and then hopefully have some success with that plan and then to reinforce that and then that will echo into the future and influence their additional behavior going forward.
One of the key models from--I think originally, I saw this on a paper by Richard Franklin [phonetic], I'm sure other people have made this point. You need to treat the clinicians who you are teaching the same way you want them to treat the patients. If we are not empathic to them then we are not teaching them to be empathic to their patients. So, doing a parallel process is very important. And when you are teaching you need to embody the behavior you want them to embody so they can see how effective it is. We want to increase volume by having the learner identify their own goals; I think that's basic adult education.
And then lastly it can be intimidating to teach if you have to come in with all the knowledge and be able to answer every question and to have all the solutions. That's a hard burden to put on yourself and I think what we've learned is, it actually doesn't work very well, that if the learner discovers for themselves something they already knew but weren't aware of or they experiment with a new technique, it lingers for them in a much more profound way than if I tell them. I think it's similar to having kids, I would love it if my kids could avoid all of the mistakes I made by me simply telling them. Don't do this, don't do this, don't do this, that doesn't work, they're going to go and do it and they're going to learn from their own mistakes.
So to some extent, people have to learn from themselves, and so our facilitation is very much based on respecting the group process and letting the group teach itself and trying to be judicious about how much actual--like hands on teaching we're doing, it's more about discovery. If you start doing too much teaching you vastly escalate the amount of resistance you start encountering. Because then you get into an argument of whether or not they agree with the teaching point you're making. Well I don't think that's going to work better I don't want to try that. But if it's--they're coming up with it on their own, you bypass a lot of that kind of resistance. The other thing you'll discover is that most communication skills problems fit into one of a few categories which I've listed here. So, one of the things that makes it easier to teach communication skills is there's not actually that much you have to teach. The problems people are having are relatively predictable, failure to express empathy effectively. The patient gets upset and the doctor doesn't know what to do so they start throwing lots of medical facts at the patient.
We do a scenario with a woman who is--has had a heart attack in front of her children, she's fine now, she's had a stent, her heart's okay, but she was very traumatized by having her children see her collapse and be taken off by 911. And so, so the woman gets upset and she's reenacting--she starts telling the doctor what she went through and often the doctor will say, "But it was only one vessel that was blocked off." Like, that's not what she's upset about. She's not upset about whether it's one vessel or two vessels, she's upset that her children saw her sick. And getting people to be able to do that takes time and takes practice and they need to see what it feels like. That was really hard for you wasn't it? Imagine what your children saw. Allowing unnecessary conflict to develop. De-escalation skills are so important and they're not very well developed in many physicians. So how do you respond to conflict in a way that doesn't just escalate it? One way is to respond empathically because if you don't respond empathically you do tend to escalate emotion, but there are other tricks when there is clear conflict, the patient really, really wants the narcotics and you really, really don't want to give them to him, how do you have that conversation in a way that maintains the alliance that you're actually on the same side.
What's really dramatic to me is when you talk to doctors about challenging cases, it's them against the patient and they're butting heads and this back and forth and back forth but why is that? I mean we're there to make them better. The patient is there to get better, we're not fundamentally opposed, it's not like Republicans and Democrats. I mean you and your patient actually have a lot in common, you both want the patient to get better. So can you have the conversation in a way that reflects the fact that you're on the same side, you have to use actively partnering language, I want to help you, I am worried about you, I know your pain is terrible we really have to figure out a better treatment for it. But that kind of language doesn't come naturally to a lot of people. Talking too much, when I go in and I watch my fellows communicate, what strikes me as the biggest difference between them and me is how much they talk. They talk and talk and talk and talk and talk, the patient asked a difficult question, they talk and talk and talk and talk. And I'm wondering like, what is the patient going through and I can't tell because the patient's not allowed to say anything. So, teaching them to just listen and observe is really very important. Communicating in a way that does not result in increased patient understanding, similar to what my brother was doing. He was consenting patients and they weren't understanding what he was saying and they couldn't remember it the next day. So if our outcome is that the patient understands and remembers we need to learn how to communicate in a way to achieve that outcome. If the outcome is simply that the doctor can document in their note that they said the words, that's a different outcome, I don't think that's a very good outcome and we need to change that. And then not allowing the patient to participate, one of our major philosophies and this really comes from the Kaiser Four Habits Model that we started with, is to give the patient more control. Let the patient participate in setting the agenda. Let the patient participate in setting the plan, be flexible so that the patient's priorities are taken into account not just the medical priorities. I want to reflect for a moment on this character, this is an actor who's supposed to be portraying Sherlock Holmes I suspect that's obvious.
My daughter is a voracious reader, but when she got to the end of the Harry Potter series she couldn't find another book series that really engaged her in the same way until she found Sherlock Holmes. So we have been spending this spring, I've been reading Sherlock Holmes out loud to her. And he has really become my role model in medicine. That what I think is fascinating is that he walks into a room and he sees an incredible amount of undiscovered evidence waiting to be discovered. And he has trained his eyes and his ears and his senses to pick up on stuff and he takes it different. So in a “Study in Scarlet,” the first Sherlock Holmes book, he spends 20 minutes at the murder scene crawling around on his hands and knees and inspecting the dust on the floor, smelling the breath of the dead person and figuring if he was killed by poison, figuring out how tall the people are from the space between the footprints, figuring out that they are of different social class, the victim and the killer because of the shoes they were from the mud prints outside. I worry that physicians have really lost that sense of curiosity of how much you can discover. We've lost it with the physical exam.
My wife is a cardiologist who has unbelievable ears. And she was written up in a local paper recently because she has diagnosed a couple of patients with congenital heart disease who are now adults and no one had ever heard it before and were being worked out for this weird symptoms that no one could explain until finally they realized, "Oh there's a hole in her heart." And then they fixed it and then the symptoms went away. So I think we see that with physical exam, I see it at home with her skills, I can't hear what she hears, but there's also a psychological side to it. Who is this person? What have they been through? What does their illness mean to them? Who were they before they were sick? All these questions that we could be asking that would then lead us to a much more sophisticated understanding of the case in front of us and instead we're like the Scotland Yard detectives and Holmes where we look at the most obvious data, reach the quickest conclusion, look for confirmatory evidence and don't maintain that sense of wonder how much information is available if we just remain curious and look for it. And that's something I really try to work with very much with our doctors, is to be curious, be interested. If you approach the patient with a deep and profound curiosity that is a great way to form a relationship and a connection with them. And I think a lot of us went into healthcare out of curiosity about the human body and biology, but it gets kind of lost along the way as we worry about getting patients to our clinic and getting our notes done.
So our data, what just happened as a result of all this work that we've done? Well our rank in the nation in terms of doctor-patient communication has improved. The increase started before our current work, so, how much credit we can take for it, one can argue but it certainly has increased at a nice rate since we started doing doctor-patient communication training. I think--I hope that we have had a part in it, we have played a part in improving our scores, certainly there's more to the story than just our course. If we look at what happens to individual physicians before and after they go through training, so the--just to orient you to what these graphs look like, I'm going to go back a slide. The Y Axis on this slide is--our rank in the country in terms of where we rank in doctor-patient communication. The Y Axis here is what proportion of patients click always, because your score is based on how often you get always. If you can improve the percent of patients who say that you always communicate well by two points you will dramatically improve in your national readings because doctors are pretty tightly grouped. So these are relatively small changes but they actually reflect relatively large changes in what your percentile is, so that's--I just wanted to make sure that was clear.
And then if we look at our outpatient survey, almost every question we see, at least a little bit of improvement after the course compared to before the course. These are physicians who went to the training. We're in the process of trying to do a more robust comparison where we look at changes in doctors who have gone through our course versus changes in doctors who have not gone through our course, because it's possible that everyone's improving and the course isn't having an impact. But at least we see some evidence that we're having a positive impact, certainly things are getting better, the challenge is figuring out exactly why.
So for anyone who is taking this on, these are some key lessons that we have learned. This is about culture change, I can't overestimate that, those are the words I first heard when I went to OncoTalk and I have seen it firsthand. You're going to encounter resistance. I trained in residency at Brigham Women's Hospital and the program there had a curious motto, it was, "continuous improvement without change," I never quite understood it. People don't like change, if you try to change things you will encounter resistance, progress will be slow you don't change culture quickly. So for me I really focused on the process much more than I focus on the outcome because this is going to be a marathon not a sprint. You need to cultivate internal and external allies. So, internal allies, when we first started our course, we educated all of our friends, that will be great, they'll come and they'll love it because they like us and they don't want to say bad things about their friends course. So, we got our buddies who were interested in communication, who were good communicators, they took the course, they helped us figure out how to make it better and they told everyone else, "wow there's this great new course on communication skills, you ought to take it." And that's how we built up this very high level of demand that we have now and you need to have external allies. So having Walter here, having Tony Back in Washington, having Calvin Child [phonetic] with the University of California, San Francisco, having people to call who will keep your morale up when you have bad days and encourage you when you have good days and give you fresh ideas when you get stuck, someone you can--it's just really important because this is hard work and having someone to call who's been doing it longer and say, you know I got to tell you what happened today in class help me understand you know why this happened whether it was a success or a failure. You need consistent reinforcement and it needs to be a part of an institutional commitment.
I think the clinic's work has been effective because it's not the only thing that we're doing, we're doing a lot on patient experience, and we’re working with nursing intensively and in different ways. Not so much around these communication skills and there's a lot of cultural focus on--we are about attending to human suffering that's why we come to work every day and try to really build that message up from the ground level. We used to be a hospital that was primarily about technical inventions and doing things that no one else could do. And we're trying to sort of change that identity to some extent and it is a real cultural shift. To some extent it has meant de-emphasizing the role of doctors, that we're a very doctor heavy hospital and we're trying to become more balanced in terms of who gets attention and resources.
So finally, I think a key quality is to--and capacity is to cultivate. I mentioned curiosity, I really think it's key, getting people to be more reflective is part of what we're doing. Bringing openness, empathy and respect to every encounter, to every interaction are key qualities that help all of this work go better and are not ideas that clinicians are necessarily thinking about when they go into the room to meet with a patient. Unanswered questions going forward this is a real limitation of this work right now. How do we reliably measure our communications, physicians or nurses or anyone's communication skills? If I put someone in a room and put them with a patient do I have a scale of one to 10? I can say, "Well, you know, today Tom is a four and now he went through this training and now he is a six." We don't have a great measure for that. I can say well in this interview he made three empathic statements and after training he made eight empathic statements and that's valuable information, but is that really something that we're satisfied with or I would love someone to come up with, please someone here come up with a good measure of--and it could be in multiple domains, I think a single number would be foolish. I'm an eight communicator, I don't know what that means, but you could have specific domains.
We need a better measure of that than we have, there are some measures but I don't think there are great measures. And you could argue about what should we measure, should we measure the patient's experience? Should be measure performance of specific skills? Should we measure medical outcomes? It's a complicated issue. And then how do we reliably measure the impact of improving communication skills? So I spend all this time teaching, how can I go to my boss and say you know you're paying 20 percent of my salary now and this is what I have to show for. I mean I can show him this data I showed you but can I prove that that's because of anything I did? Not really. So there's a lot of work at this sort of scientific level that would really be helpful in the communication world to try to come up with harder, firmer measures of this. It would allow us to bring more hardcore quality improvement techniques to this kind of work. So I'm happy to take questions thank you for your attention, it was really an honor to be here.
[ Applause ]
Dr. Baile: Questions for Dr. Gilligan, Let’s start off so you know um the issue has been brought up, you know this is great for the Cleveland Clinic, but can the same kind of thing be applied in an institution that’s research driven and that patient care is important but its patient care in the context of research orientation and I’d just like to get your thoughts on that.
Dr. Gilligan: I think, you know, facing that question for me the best response is that if our goal is for our patients to have better outcomes, there’s good evidence that our patients have better outcomes if we communicate better with them. That communicating is part of our fundamental medical work. So quite apart from the humanistic side of things um communicating in a way that a patient understands the diagnosis, they understand the treatment plan and they adhere to it. There are hard outcome reasons to get better at this, not just fuzzier reasons and not just HCAHPS reasons.
Dr. Baile: And I was thinking that getting informed consent is a very key communication skill also so it sort of fits in with a research driven institutions’s mission.
Dr. Gilligan: Yes, absolutely.
Dr. Baile: So here we have someone, let me give you the ah thanks Cathy.
Dr. Kleinerman: That was really a wonderful lecture, I’m Jeannie Kleinerman and I’m head of pediatrics here and just building on the question of research one of the things that we struggle with are phase I studies. Because these are children who are essentially at end of life communicating with parents but making them understand that a phase I trial is only looking at toxicity. So do you have any experience with that I mean we are struggling now with should we even broach with some patients how do we communicate it by not making it too dreary, or do you know, so I wondered if you had any experience dealing with parents of dying children going on to phase 1 trials.
Dr. Gilligan: I don’t have a lot of direct experience myself. Rick Kodish [phonetic] who runs our bioethics section is a pediatric oncologist whose done his research on consenting parents with trials mainly on Leukemia treatments so I’ve had a lot of conversations with him about models for how to do that. I think what is so difficulty is that phase I data shows that no matter how many times you tell the patient this is only about toxicity, if you go and ask them in private why did you go on the trial, put your child on the trial its always in the hope that the treatment is going to work and they are going to benefit from it. I’m not convinced that we need to squash all that hope, I meant they are hoping they are going to have a good outcome no matter what even if we don’t treat them so I think maybe part of is how do we sell it to them and I’m curious what you think, but the point I want to make is that Phase I trials are not about the patient they are about society. Parents of sick children often resonate around even though it doesn’t help my child it might help some other child. I don’t know if that helps or not.
Dr. Kleinerman: Well yeah and we don’t squash all hope. The problem is now with the way medical reimbursement is coming, particularly in pediatrics because the pharmaceutical industry, they don’t support it. This is a lot of out of pocket expense particularly in our patient population where most of our patients come from outside of Texas. So you want to balance the communication by saying you know we have a supportive care counsel all made up of parents who have lost children what do you want to hear, what do you want to know? Sometimes doing nothing is a good alternative because you have those last days that can be very meaningful, where if you go into a phase I trial you can have side effects and so that’s where we are struggling.
Dr. Gilligan: Yeah I know I think it’s hard. The model that Dr. Kodish [phonetic] emphasized was when presenting trials start with presenting what the standard care treatment option is and in this case doing nothing and what’s going to happen if we do nothing and then explaining one alternative to that is going through the trial. I don’t think there’s an easy answer. I think Phase I trials are hard and we know how important the pediatric oncology trials have been and the treatments have made such a huge difference for so many kids so obviously we need to get these trials done. It’s a very important issue but I don’t think we can achieve perfect informed consent around this issue. I think that is a very hard question. Another question? Danny
Dr. Epner: Dr. Gilligan, first congratulations that was a wonderful seminar. A really, really nice discussion. And also I think you and your organization deserve a lot of credit for being so forward thinking about the whole program but I really liked your analogy well a lot of your analogies but one that resonated with me was the piano lessons and I agree with all of your contemplation about how to measure and how do we put a number on this, but I guess the question is if people pay for piano lessons and they play piano and they get better how does one measure that I mean how do you put a number on someone’s piano technique? We can can measure how many notes they play per minute or whatever, but its analogous in that if people are flocking to your course and you’ve got 700 people already and people are lined up and you can’t keep up with the demand and its not mandatory I think that says a lot right there. When you look at this from our institution’s standpoint I think we have to be careful and I think we should ask the question. Do you agree that we should try to look at it and try to achieve objective outcomes, but also basically accept the premise that sometimes people just seek knowledge and they value it and that it is intrinsically important? Is that true or how do you see that?
Dr. Gilligan: So, yeah, I like your points. I don’t need outcomes to validate the work that we’re doing because I agree with you because if someone told me they were going to take 100 million of my tax dollars and study whether communication matters in medicine I would ask them to please spend the money some other way because I think it’s an obvious answer that communication matters. The reason I think outcome measures would be helpful is because I am in the middle of this work and next year I want to be better at it and the way the way I get better usually is that I try to measure my current performance and try to figure it out so for me it is more I’m very interested in quality and quality techniques and a huge part of quality in medicine is measuring outcomes and not just measuring outcomes, but analyzing what you’re seeing and changing your plans in response and coming up with an intelligent plan for better performance in the future, but if you can’t measure your performance its hard for me to know how to get better. Um so I mean I totally agree, I don’t think we need to justify the relevance of the work I think there’s plenty of evidence for that already. What’s hard for me doing it is knowing how to knowing that every year if I’m getting better what should I be working on? What’s the weakest part of my course? What’s the best part of my course? I wish I had a firmer answer to those questions.
Dr. Baile: Other questions? Okay well thank you very much for coming today. Thank you Dr. Gilligan.
Improving Communication Skills at a Large Academic Medical Center: Cleveland Clinic's Experience (56:48)
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