It’s not my journey, how to be an effective empathic guide

Podcast Transcript

Adrienne Boissy:  Welcome to another episode of Studies in Empathy, a Cleveland Clinic podcast exploring empathy and patient experience. I'm your host, Adrienne Boissy, chief experience officer here at the Cleveland Clinic in Cleveland, Ohio. I'm very pleased to have Dr. Katie Neuendorf here from the Cleveland Clinic.

Katie, welcome to Studies in Empathy.

Katie Neuendorf:  Thanks. I'm happy to be here.

Adrienne Boissy:  So you and I already spent some time talking this morning that you have too many titles to possibly put in an introduction.

Katie Neuendorf:  That's right.

Adrienne Boissy:  Do you want to walk me through what some of your current roles are and what they've been recently?

Katie Neuendorf:  Yeah, sure. I think the role that brought me here is I'm a palliative medicine physician here at Cleveland Clinic. I do inpatient consult work with anybody, any patient in any situation. My other title is the associate chief experience officer, and I got that title after having directed the Center for Excellence in Healthcare Communication for a few years. Those are my favorites.

Adrienne Boissy:  Those are a lot of good titles.

Katie Neuendorf:  Yes.

Adrienne Boissy:  So talk to me a little bit about palliative care. We haven't really covered that topic in these podcasts. And you have a front row seat to what families, as well as our own caregivers, go through in palliative care. Talk to me a little bit about what the pull was for you to go into that as a field.

Katie Neuendorf:  Sure.

When I was in medical school, I thought maybe I'd do geriatrics. And so I did a certificate program in geriatrics, and they had an entire semester on loss. Because if you're going to work with somebody in a geriatric population, they will experience loss. And that's not just death. It might be loss of the ability to drive or the loss of your home, all of that, loss of memories. If the person who knows you the longest dies, all of the memories that you shared can die with that person.

So there was an entire chapter on loss. And in this study of loss, they talked about when people have well-grieved losses, they are more prepared to face the next loss that comes. But when they have traumatic loss in some way, shape or form, the subsequent losses can also be traumatic, because you're bringing all of your losses with you.

I was a medical student at the time, and so in the intensive care unit and listening to what we were saying to patients or their family members, more often than not in the room, and it might be something like, "Well, we're going to try some different medicines, and there's still antibiotics, and we're going to keep working with the ventilator settings."

And then we would get out of the room, and the team would talk, and we'd be like, "Yeah, that guy's not going to make it out of here."

And in my head, going through this whole process of loss, we're setting up traumatic loss because this family can have no idea what's coming, that this person is most likely going to die based on what we said in the room. So all of that together really fueled my passion for trying to figure out a better way. What is the way that we in healthcare can also be honest when that might not work, and then how to help them through it.

I think for me the other main interest in palliative care is that I was in my internal medicine clinic, and patients didn't thank me very often for getting their A1C under better control or their blood pressure numbers were finally better. But I would get significant gratitude for these serious conversations, things that nobody had talked to them about yet or working with their symptom control. So that led me into that field.

Adrienne Boissy:  So I heard a couple of interesting things. If I'm hearing it right, you're proposing is that part of our job may be to actually prepare people better for ... what did you describe it, well-grieved loss, as opposed to traumatic loss in healthcare, which I haven't quite heard it articulated that way.

Katie Neuendorf:  Yeah, absolutely.

I don't want to make it seem like that's all I saw. I definitely saw the opposite as well, where you saw physicians who were helping families and set them up for what was most likely to happen. And when you see that, people find a way to cope with that. It is hard. It's news that they don't want to hear. And yet they still find their wells of resilience, of coping, and they lean on each other and they get through it.

Adrienne Boissy:  It's interesting, because I'm a neurologist specializing in multiple sclerosis, and in multiple sclerosis, I think often the patients mourn the same loss. It's not loss of a life per se, but it's loss of many of the things that you listed, right? You used to be able to walk without a cane, and now you need one. That's a loss. You used to be able to drive independently, and now you might need some help. I think each of those, I almost feel that my patients mourn, and yet they don't know they're actually mourning the loss of something.

Katie Neuendorf:  Yeah. And when they don't mourn it or recognize it as a loss, there might come a time where these losses are too many. And for you, you're thinking, "Oh, well you know what's losing the ability to drive when you've already lost the ability to do something else."

But for them it's ...

Adrienne Boissy:  Right. And that idea that it can compound if each isn't dealt with. It's fascinating.

I bet it's a ton of fun to talk to you at a party or a block party event about what you do.

Katie Neuendorf:  Right.

Adrienne Boissy:  I'm guessing people don't know what to say after you say, "I'm a palliative care physician." People are probably like, oh-

Katie Neuendorf:  Yeah, if they even know what it is.

Adrienne Boissy:  That's great. And then you describe it, right? Then you're really at a conversation starter.

Katie Neuendorf:  Yes.

Adrienne Boissy:  So most people would shy away from a career in palliative care. Or many, let's not say most. So how do you communicate the value of what you do? How do you stay tuned in every time to show up for work the next day? How do you refill your own ability to do it?

Katie Neuendorf:  Yeah. I would say that the most common response I get is something like, "Well, it takes a special person."

Adrienne Boissy:  It's true.

Katie Neuendorf:  It takes a special person to do a lot of things. There are so many parts of medicine that I have no interest in.

Adrienne Boissy:  Well you could say that.

Katie Neuendorf:  Wow, you must be a special person.

For me, it is because of this work that I feel like I can show up every day. And what I mean by that is every day I get to focus on what matters most to people, and every day I show up and hear people talking about what they're most proud of in life, what they are hoping to put closure to before they die, the people that they want to spend their time with. And that, every day, is a reminder to me of what's important.

Adrienne Boissy:  I have to imagine that the work you do leaves an impact on you. Once we spoke about how do you shed that or let that go so you can transition from the end of a day into taking the kids to soccer or whatever.

Katie Neuendorf:  Right.

Adrienne Boissy:  You have something that's really interesting, I think just mentally, that you do. Would you mind describing it?

Katie Neuendorf:  Not at all. And I got it from the American Academy of Hospice and Palliative Medicine and the work that they do. They call it a role-shedding ritual. And so what that is is they recommend at the end of the day, when you take off whatever uniform or what was a part of your uniform, that you take off everything else that came with it.

So at the end of the day, I'm taking off my white coat and my stethoscope, and I put that on my chair, and with it I leave the grief that was never mine to begin with. It was the grief that I felt. It was the grief that I experienced in the moment talking to the patients or family members that I talked to. It's the loss of whatever it is that they're worried about losing. But I take that off with my coat because it's not mine to own. It was never mine, even though I felt it. And then I leave that there. And then the next day, I'll know that I'll come in and I'll pick up my coat again and I'll put it back on as needed. So that that helps.

I'm constantly looking for different things too, and my family is helping me to figure out some things that might help work all of us. Like, "Mom, how was today? Do you need a minute?"

Adrienne Boissy:  Yeah. That's good. Just a process.

Katie Neuendorf:  That's right. Yes.

Adrienne Boissy:  While we're on the topic, I just want to give a shout out, you were recognized ... was it last year or the year before ... as one of the top leaders under 40 for your national organization. I'm sure you're really excited though.

Katie Neuendorf:  Yeah, absolutely. It was a big honor. And a lot of that came from the work that I've been able to do here in communication.

Adrienne Boissy:  Yeah. So let's talk about that. You had mentioned to me that your work in palliative care ultimately led to a really strong focus and interest in the words we use to communicate. So a couple years ago you became the director of our Center for Excellence in Healthcare Communication, which trains everybody in more effective communication.

So was that a natural transition, or what got you interested specifically in training clinicians in communication skills?

Katie Neuendorf:  There's definitely a natural link between communication skills, passion and the palliative care realm. There are many people in palliative care who are passionate about communication.

When I came to Cleveland Clinic, I wanted to continue that passion. Our fellowship program had some training in communication. It wasn't as robust as I knew that it could be. So I was trying some different communication teaching with our fellows, and some of them worked and some of them really didn't work. So I started to explore how do you teach communication, what does this look like. And it went from trying to find something for our four fellows that grew much, much bigger than that.

And mainly because my work in communication, and what I have learned in communication, helps me every patient encounter. And the more I learn, the more I'm helped by it. And I feel like encounters where I used to be nervous or worried or concerned, now I see as let's see what happens, because I feel very much that I have the skills to deal with whatever comes, even though I don't know what's going to come.

I wanted to be able to bring that to more people, that I am so much more relaxed when I see patients or families having strong reactions to whatever's happening around them, when I wasn't always before. And if I can bring that to colleagues, not only will it be great for them, but it'll be great for the patients and families that they encounter.

Adrienne Boissy:  And I actually remember the first day I saw you facilitate, and then I think I went over to you at the lunch break and I was like, "Hey, I think we have a job for you. You want to direct the Center?"

Because you were so talented, both I think naturally and because you were so eager about learning how to do better. It was really spectacular. So at this point you should be an expert in empathy. Right?

Katie Neuendorf:  Yes.

Adrienne Boissy:  You should have it all figured out. So are there moments you still struggle with? Where do you struggle with conveying empathy? Where is that learning edge still for you?

Katie Neuendorf:  The times that I still struggle with conveying empathy is when I care a lot about my position, whatever that position is. I find that that happens more often outside of work.

Adrienne Boissy:  I thought you were going to say the other person.

Katie Neuendorf:  No, no.

Adrienne Boissy:  But then switched it up on me.

Katie Neuendorf:  I find that it happens more outside of work than in work, where I just feel very passionately about what I am hoping to convey or feel that I'm very right about something. And while I can see that other person and I can understand what they're feeling or I think that I understand what they're feeling, I don't want to acknowledge it, because I still feel like what I have to say is right in some way, despite the fact that I know that that construct's not as helpful.

The funniest story about empathy and teaching empathy. I have three children, and they're very close in age. So there was a time when they were all three of them in a bathtub. They were all under five years old, in the bathtub together. And my oldest, he kept standing up and standing up. And I'd say, "Honey, sit down. That's not safe. Please sit down."

And so of course I got to the place where I said, "What do I have to do to get you to sit down in the tub and stop standing up?"

And he looks at me and he says, "It must really be hard to be a mom, isn't it?"

Adrienne Boissy:  He got you.

Katie Neuendorf:  He got me.

I bring that up because that is the moment for me that I would not have been able to bring empathy out. And yet my four-and-a-half-year-old was able to see it and bring it in that moment.

I think for patients and families, there are still times that I struggle with the empathy, but it's not as much. And one of the reasons that I feel that that is true is that I always remind myself that it is not my journey. I can be a guide, I can be an information giver. At the end of the day, it's not my journey and it's not for me to decide what that journey is supposed to be.

So because I feel like there is no right way to go through illness, that allows my empathy to come a lot greater for my patients and the families that they deal with.

Adrienne Boissy:  I had a similar situation with my nine-year-old, when I was yelling at him about getting off his electronics. And he turned to me and said, "That is not very empathic of you."

I thought, if I just conveyed less empathy, we wouldn't even be having this conversation. It is quite sobering.

Alright. Recently, you've spent a lot of time ... in the communication courses we've had, we've played with a lot of different techniques. Recently, you spent a lot of time exploring improv as a technique to quickly engage people and be an effective learning mechanism. Talk to me about why improv has such a draw for you and what your favorite improv exercise might be.

Katie Neuendorf:  I will.

Improv is probably the thing that I'm most excited about right now when I'm teaching. The main reason that it has a draw for me in particular is that there are lots of different pneumonics or constructs or drills out there to help people in terms of communicating more effectively with patients.

What I find over and over is that the most effective communication strategy is when you show up and you're there and you're present and you are building on what that person is bringing, and those are the main tenets of improv.

If you think of Improv, most people think of comedy. It's not comedy. It's the idea of being able to improvise. So being in a situation, having some construct for what the scene is going to be, and your whole job is to accept everything that comes in that conversation as a gift, and to build on it, and to make your partner look good.

If we, in medicine, had that construct in every conversation that we had, to build on what the patient or family member is saying, make sure that we see whatever they bring to us as a gift, and make them look good in the conversation, I think that our communication strategies would be in a much healthier place.

While we do have frameworks and constructs that I do think are helpful for people to start or find a way to start, knowing that in the moment I might have to improvise and being comfortable with the ability to improvise and seeing some of those tenets of making them look good when you're improvising, those pieces of it are exciting to me, and I like to keep building on those, and I like to bring them to the people in the classes.

Adrienne Boissy:  It's interesting you say that, because in some sense then we're improvising all day long as clinicians, but without necessarily with those other constructs, to build on what the other person is saying and make them look ... those may not be the rules that we're playing by, but we're improvising conversations every day.

Katie Neuendorf:  That's right.

Adrienne Boissy:  And it's also interesting because I know when we started the communication courses, we used to have these really standardized cases, and the classic communication training has these cases, 45-year-old woman, blah blah, blah, blah, blah, and then we threw that out the window. And then part of it it seems to play into some of the tenets of improv, right?

Katie Neuendorf:  Mm-hmm (affirmative).

Adrienne Boissy:  The more real situation is people are actually just trying to have these conversations on the fly.

Katie Neuendorf:  They are. They're trying to have these conversations on the fly. Kelly Leonard, who's an executive director at Second City, talks about improv being yoga for your social skills.

Adrienne Boissy:  I think I need to go there.

Katie Neuendorf:  Yeah. That's a very apt metaphor.

If you think about it, it's not even just with patients and families, we're improvising with our team all the time as well.

Adrienne Boissy:  True.

Katie Neuendorf:  And again, if we do work with the construct of helping people to look good in those moments, I think that we could build something that's a lot more helpful.

In the classes themselves, one of the ways to think about communication skills training is if we're going to do a sports analogy ... my kids all play soccer-

Adrienne Boissy:  You're not going to do the tennis-

Katie Neuendorf:  I'm not going to do tennis.

Adrienne Boissy:  Tim Gilligan thing, are you?

Katie Neuendorf:  No, no.

Adrienne Boissy:  Okay.

Katie Neuendorf:  We're a soccer family.

But if you are a soccer player, part of your practice is dribbling and part of your practice is passing and part of your practice is shooting. It's not always a scrimmage. And so communication skills training should not always be a scrimmage, because you are never going to know what that person is going to say. There is no such thing as the same communication conversation from one patient to another.

Adrienne Boissy:  Actually, as you're talking, it's reminding me of, I think, a story you had told me of a patient that you had seen. So it's not even the communication challenge, I'm thinking the actual patient's story. Sometimes they are unlike anything you've ever seen before.

I think you had told me a story of a young woman who had cancer who was pregnant. Remember?

Katie Neuendorf:  Yes. I have dealt with a few.

Adrienne Boissy:  And how do you have that conversation?

Katie Neuendorf:  That's right.

Adrienne Boissy:  Right? That they're finding out before or after the baby's born about their stage of cancer. How would you possibly prepare for that conversation? You might know the guardrails, but the context you can't possibly have in your back pocket until you're in it.

Katie Neuendorf:  Yeah. And we can't have people in the that moment going, "Well, we didn't practice this in the communication course."

Adrienne Boissy:  That's right. "I don't remember what to say now." Right?

Katie Neuendorf:  Yeah.

Adrienne Boissy:  It has to come.

Katie Neuendorf:  Yes.

Adrienne Boissy:  So many of those stories I just think we couldn't possibly be prepared for, and you've certainly taught me that as we've had many conversations.

Many people out in the world of patient experience are trying to drive empathic communication in the right way. Oftentimes, I continue to hear, unfortunately perhaps, that it's still very difficult for people who aren't physicians to engage physicians in the training. What advice or pearls would you have for people who are trying to do that in other organizations?

Katie Neuendorf:  When I think about communication skills, and especially teaching empathy to physicians in particular, one of the first pieces of advice that I would offer, or at least offer up for consideration, is that you want to be very clear in terms of what you are asking the physician to do. And here's what I mean by that.

Empathy comes in different forms. Sometimes empathy is nonverbal. Sometimes empathy is a verbal empathic statement. Sometimes empathy is the doing or the compassion piece of it, so it's the actual doing or fixing something because you've seen an emotion and you know you can do something right away to make it better. Or sometimes empathy is showing the person that you've heard them.

I just listed lots of different ways to express to a person that you have seen the emotion that they are displaying to you. If you are going to work with physicians, be very clear about this is the type of empathy that we're asking you to express.

Most of the time, in our communication training courses, we're looking at nonverbal empathy, and we are asking for verbal expressions of empathy, so an empathic statement. To be able to be clear about that, then you just have to define what an empathic statement is. An empathic statement is a statement that shows the other person an understanding, or at least the attempt at an understanding of the emotion that they're experiencing.

And so then, if you have a scenario, and a patient says, "You're so late. You were supposed to be here an hour ago, and I've been waiting."

If the physician responds by saying, "I'm so sorry. I was in an emergency with this other patient," then you can stop and say what of that statement acknowledged the emotion that the other person had.

Then go through it and say, "Okay, if that wasn't an empathic statement, how do we make it more of a genuine empathic statement?"

So I think that that's one of the first pieces of it. If you want the person to show non-verbal empathy, you need to give them some ideas of what that looks like.

Adrienne Boissy:  Right. I think we've often encountered people think they're doing it.

Katie Neuendorf:  Yes. They do.

Adrienne Boissy:  You say be more empathic, and they keep doing more of what isn't quite empathy. It can be very frustrating for both sides.

Katie Neuendorf:  That's right.

And I think that the hard part about that too is that we feel empathy. So if we're in the midst of a communications session, and I stop it and say, "What do you think the patient is feeling," most often, that physician is able to give me a pretty close estimate of what that patient is probably feeling. What is not happening is some sort of expression that they understand what the person's going through.

One of the ways that we think that we're showing empathy is to try to fix it. And communication, that often sounds like giving information, like, "I'm worried about this. Well, let me give you information so that you won't worry about it anymore." And that does not resonate with patients at all.

Adrienne Boissy:  It doesn't resonate with clinicians either, when they're patients.

Katie Neuendorf:  It doesn't.

Adrienne Boissy:  All of a sudden then, the light bulb-

Katie Neuendorf:  Doesn't resonate with human beings who are having an emotion, telling me why I shouldn't be having an emotion really doesn't help me [crosstalk 00:23:50].

Adrienne Boissy:  Doesn't work out so well.

Katie Neuendorf:  Yes.

So in those moments, in terms of what we're trying to teach, really just giving them the construct.

Another way I like to say this when I'm teaching is that we should all be in agreement that we saw what we saw. So if I tell somebody to be more empathic, we might have five interpretations of what it means to be empathic. But if I asked people to look for an empathic statement, and I have defined what an empathic statement is, then we now, five of us, can agree on whether or not that was done.

Adrienne Boissy:  That's right.

You also do that exercise where you get the empathic statement from different people.

Katie Neuendorf:  Absolutely.

Adrienne Boissy:  So that it could be the same emotion perhaps that people are responding to, but their articulation of it around the table can be quite different.

Katie Neuendorf:  That's right. Yeah.

Adrienne Boissy:  But they could all work. Right?

Katie Neuendorf:  Yes.

Adrienne Boissy:  And it has to be authentic. Something else. You can't just say, "Say this," and then it will work for docs. It doesn't work.

Katie Neuendorf:  Right. Giving them the construct of what an empathic statement is then allows them to figure out what words would they put to that within the construct.

Adrienne Boissy:  I love some of those play ... having different people give their own empathic statement to the same emotion, some of the improv exercises. What's your favorite one?

Katie Neuendorf:  Oh right. I never answered that.

Adrienne Boissy:  No. That's why I'm here, actually, is to make you answer the questions.

Katie Neuendorf:  Oh, that's a hard one. I think that my favorite improv exercise is the basic one, which is the “Yes, and” exercise. And it's taking people through a conversation where first you have a conversation about something and everybody responds with no.

So Adrienne, you'll say something, and I say no, and then you say…

Adrienne Boissy:  That's actually usually how our conversations go.

Katie Neuendorf:  … that’s exactly how it goes.

And then we switch it to, "Yes, but," and then we switch it to, "Yes, and," or, "I appreciate you said that because," and it really highlights for people the number of times we're in, "Yes, but," conversations. We often avoid no conversations. We can find ourselves in, "Yes, but," conversations over and over, and that is just a no conversation in disguise for a lot of people.

So that one is the one that if I could have everybody go through an improv exercise, that would be it.

Adrienne Boissy:  That would be it?

Katie Neuendorf:  Yeah.

Adrienne Boissy:  Well, I want to thank you for spending your time with us today. We started by talking about how it takes a special person to do what you do, and that's absolutely true. You are a very special gift that we have here, and I think to the broader community at large. Thank you.

Katie Neuendorf:  Well, thanks.

Adrienne Boissy:  This concludes Studies in Empathy podcast. You can find additional podcast episodes on our website, my.clevelandclinic.org/podcasts. Subscribe to Studies in Empathy podcast on iTunes, Google Play, Soundcloud, Stitcher, or wherever you get your podcasts.

Thank you for listening. Please join us again soon.