Why is this so hard? Training seasoned clinicians in communication skills

Podcast Transcript

Adrienne Boissy:  Welcome to another episode of studies in empathy, a Cleveland Clinic podcast exploring empathy in patient experience.

I'm your host, Adrienne Boissy, chief experience officer here at the Cleveland Clinic in Cleveland, Ohio and I'm very pleased to have Dr. Amy Windover here who is the director of curriculum and faculty development for the Center of Excellence and Healthcare Communication. That's quite a mouthful. Welcome.

Amy Windover:   Thank you.

Adrienne Boissy:  I'm so thrilled to have you.

Amy Windover:   Thank you for having me.

Adrienne Boissy:  So, tell me a little bit more about who you are, and how you came to be in this role.

Amy Windover: Well, I'm a clinical health psychologist, and as part of my training and fellowship was asked to work on communication skills training for medical students at another medical school.

So, when I came here to the clinic, they were just starting with the Lerner College of Medicine, and that was a wonderful opportunity to kind of expand my role in that area and then, you actually approached me at a later point in time when there was really a lot of interest and attention to wanting to support the staff in the way of improving communication.

Adrienne Boissy:  So, what Amy's alluding to is, there's actually this really great story about, I kept hearing about this amazing communication skills expert in the medical school named Amy, and after months, and months of hearing how spectacular she was, I finally decided to go and meet her as I became tasked to go look at communication skills training for staff positions.

And so, I had made this appointment in her office and I showed up. I remember we had some conversations like, do you think you'd be willing to help me try to figure this out? And she was like, “Who are you?”

That's essentially how it went. And then of course, later we were so blessed when you finally took charge of what was going on. So, it was really a funny first start.

All right, so what's the difference though? Because I often, when we talk about communication and healthcare, I hear people say, oftentimes they're really talking about communication for med students, right?

We'll just train the med students over there, and then we'll be all set for the rest of their career.

Talk to me about the difference though, in your experience between training medical students in relationship centered communication and practicing staff physicians.

Amy Windover:   Well, that's the beauty of what the Cleveland Clinic really asked you and your team to do, is to develop resources to support staff physicians, because it really hadn't been done that way and supported at such a high level before.

In medical school, for several years, they had really been working hard to integrate more, and more communication skills training, recognizing that it is the most common medical procedure that a physician will ever perform and the value just is exponential.

And so, a lot more time and attention is paid in medical education to that training. And the students, you know, love it and it really resonates with them.

They're new, and they're very much focused on why they got into medicine in the first place and their call. And so, it just ... it works for them.

It resonates with them, and they get really involved, and they love it because it's also some of the first opportunities they have to interact with actual patients, whereas the staff, they've been doing it 20, and sometimes 30 or more years and they're actually quite effective already with their communication, so much so that it's more unconscious.

They're able to kind of function on autopilot in terms of their communication anyway, and it allows them to be more efficient in other ways and effective in other ways. So, the idea that they would be asked to take a foundational communication skills course could be rather upsetting or annoying to say the least.

Adrienne Boissy:  Yeah, no.

Amy Windover:   And I know you encountered a lot that.

Adrienne Boissy:  I remember when we started. So, the history here is seven or eight years ago, after we had gone transparent with communication scores across the enterprise, we felt very strongly that you also needed to have tools to help people get better.

So, it wasn't just about transparency, or shaming or on the scores. It was, we're here to help.

Amy Windover:   Right.

Adrienne Boissy:  But at the time, we didn't have any tools, right? And we really advocated to say, you can't highlight people's blind spots without having tools for them.

And so, the organization really made a commitment through the office of patient experience and the development of the center to create those tools.

So, some things I reflected on though when we were early in the journey is, there was a lot of, I would say reticence on the part of staff physicians to engage in the training sometimes, because they were already effective or thought they were already effective and others said, “Well, this is something the med students need. I don't need.”

We navigated that, as I recall, by trying to say, all boats can elevate, right? We didn't just take the least effective communicators, at least in the patient's eyes and try to raise them. We tried to raise everybody.

Did you think looking back now that that was an effective strategy?

Amy Windover:   Absolutely, because I wouldn't want to imagine a course where people who were all "Poor scorers”, which is an unfortunate way to look at folks anyway, but where they would all be in a course together trying to improve communication ...

Adrienne Boissy:  That's right.

Amy Windover: ... giving feedback to each other doesn't make any sense.

Adrienne Boissy:  No.

Amy Windover: And there really are a lot of people doing a lot of effective things in terms of communication, why not leverage that expertise and really bring it out in the day?

So, as facilitators, if we're doing our job right, we aren't teaching them a lot of things they don't already know. Rather, we are just bringing attention to, and pulling out the experiences and best practices from the group.

So, it was surprising to me though how many people came in skeptical, and were so quickly willing to transform the way they think about communication, and really participate actively, and work with the skills and take their communication up a notch regardless of how good at they already was. My respect for staff physicians grew immensely...

Adrienne Boissy:  Yeah.

Amy Windover: ... watching them, and they want to be the best they can be in every way shape, and form

Adrienne Boissy:  That’s right.  So, let's pause there for a second because I think this is a really interesting point. Oftentimes, I hear there's sometimes a perception that physicians don't care, we're just too rush so, we're just rushing through things.

And how we communicate, we're not spending any time thinking about and it sounds like you were quite surprised to find the opposite. So, I'm curious.

Tell me a little bit more about that, but also, what do you think we did that was effective in getting them engaged? Because although most walked in, I think willing to learn, there were some that probably didn't.

So, what environment did we create? What did we intentionally do to make sure that we got them engaged?

Amy Windover:   The word intentionally, I think is a really important word, because we wanted to create a safe supportive environment where we did acknowledge their experience and their expertise.

We weren't seeing them as blank slates walking in, and we're gonna fill them up as sages on the stage and have them walk out. We really did want to make it learner centered, where they have experiences, and expertise that we all can learn from and share.

We wanted to model all the skills as best we could as facilitators to those participants, and at this time, it was mainly physicians, but it's expanded beyond that and a large part of that, I think was being empathic.

Being present in the moment, and just being able to respond to their thoughts, and emotions, allow them to voice their feelings about things, and hear them, and reflect them in a way that they know that we heard and understood them.

Adrienne Boissy:  So, let's talk concretely about that though, because I think there are some really interesting things we learned as we were doing it that we implemented very early in the course. Yeah. I'll tee up some examples that I can...

Amy Windover:   Sure. Good

Adrienne Boissy: ... think of and then please, add your own color. Number one, we fed them.

Amy Windover:  Right.

Adrienne Boissy:  Especially for residents, there's no more time to sit down, and actually eat and although it sounds kind of silly, for some, particularly the emergency residents we trained, I remember there's this profound sort of notice that we all took of how much they actually ate.

Yeah, I don't think they were stopping to eat. We would also ask questions real early in the course around, “who was on call last night?” To try to understand where people truly we're walking in.

Amy Windover:  Mm-hmm (affirmative).

Adrienne Boissy:  And then I know there's a variety of exercises that we do to understand, have you had this course before? How do you feel about it? Do you hate it?

Do you think you're really good? To understand where people were so we could figure out where we actually needed to go. Talk to me about others observations.

Amy Windover:   Yeah, we were bringing in people from all over the enterprise. We wanted a diversity of specialty in each day.

We kept the course sizes very small to no more than 12 participants, again, to help create the safety, and really be able to focus on the individuals as people and to help give them an opportunity to connect more with one another.

I think the meals were important so that they had time to make those connections with people although, it was very foreign to many of them. And I think they found that initially somewhat comfortable until I realized, we weren't expecting anything but just food and conversation.

Adrienne Boissy:  Yeah, before we get started.

Amy Windover:   Before we got started. The other things that we do is warm ups. So, oftentimes people refer to these things as ice breakers and really, recognizing that it's something we have to warm up to these things.

There are some extroverts out there that can jump into the day, and just make themselves vulnerable and learn a lot. That's certainly not me, and I think the majority of people, we need time to warm up.

And so, being able to share a little bit of who we are in ways that don't feel vulnerable, and then moving to the more vulnerable, can be helpful.

Adrienne Boissy:  That's right. So, warm ups can be really superficial. Do you like ice cream or cake?

And then, as you're highlighting, they can progress in terms of their weightiness to things like, how many of you saw a patient die or had to tell a family that their loved one had died over the last week, over the last month?

Amy Windover:  Yeah.

Adrienne Boissy:  So, any other examples you wanna highlight for our audience on the warm up you think is highly effective?

Amy Windover:  I think one of the warm ups that we used the most or I have found the most effectiveness from has to do with feedback, and asking them, to what extent are they comfortable receiving helpful feedback?

And they'll stand on a continuum from, not at all to, bring it on, the more the better. And we get a lot of interesting, helpful ideas and then, we ask them to line up along that same continuum in terms of the degree to which they're comfortable giving helpful feedback.

The reason I found that exercise so helpful is a large part of what we're doing in the day is, sharing feedback with one another, and we are also offering them structure that they may try that has some evidence to support its efficacy in helping people actually, make changes based on our feedback.

And so, even for people who are excellent in communication and weren't really open to the course, we were giving them a common language, and a structure to provide feedback and it would improve their teaching, for example, and that was something that everybody really resonated with.

So, it just allowed us to acknowledge an elephant in the room about the day that we are going to do a hands on skills practice, and that we wanna be sensitive to all the different perspectives about giving, and receiving feedback and just take it up a notch wherever we are.

Adrienne Boissy:  Yeah. So, two things strike me. One is this idea that, I think in healthcare or in learning environments assume that everybody always wants feedback.

Amy Windover:   And you've had a few examples where, which is, it was not appreciated.

Adrienne Boissy:  Right. How comfortable are you receiving, and giving and around what, right? Because the more targeted the feedback is often, the more helpful. So, that's fascinating.

And the other idea is around, really attending to where they are coming in, in terms of their learning goals as well.

Amy Windover:   Mm-hmm (affirmative).

Adrienne Boissy:  Okay, so for context, you know, at this point, you've probably trained in totality, eight, 9000 clinicians, including staff, physicians, APPs, MPs, et cetera, and some of those are here, and some across the country and the globe for that matter.

What do you think in all of those conversations, and all of those trainings is the biggest barrier to empathy for our clinicians?

Amy Windover: I come back to time, and task pressures and even one step further, sometimes feeling as though, how do they have anything more to give when they feel like they're already giving enough and who has their back?

So, I think for us to as human beings, be able to do what is already hardwired in us, right? Being empathic, being compassionate, we need to feel that from other people, whether it's our leaders, or from our peers or from ... It doesn't really matter.

And it's not always there. Even more so I would say, while we need it from others, we need it just as much, if not more from ourselves.

And while there's a whole lot of focus right now on empathy for others, empathy for self sometimes still is seen as, “Oh, well, that's, that's really a soft thing and that's self-indulgent.”

And in reality, if we don't take care of ourselves, if we don't convey empathy and compassion toward ourselves, I think we are less capable of doing that for others unless we're able to accept it or receive it when we get it from others, because oftentimes, it isn't that that empathy doesn't exist from others. It's that, we're just not open to it.

We don't trust it maybe. It doesn't feel genuine. So, I think there's work on all sides of it, and in this climate, with burnout being here, we found in research, over 35% of physicians are experiencing burnout.

I know and for the same time frame, it's over 54% across the country and so, some would say, “Oh, that's really great.” I'm sorry, but 35% is not acceptable. We can and should do so much better.

And I'm really grateful for the resources that are being devoted to staff experience, and caregiver experience, and patient experience because they all overlap and flow together in many ways.

Feed off of one another so that we can continue to reduce that level of burnout. I think some of the communication skills training courses that we have, and we'll continue to offer, and especially some of the empathy skill building that we have to offer, can help everyone be more self-empathic or compassionate and empathic towards others.

Adrienne Boissy:  A couple of thoughts running through my head as you're talking. One, when I think about barriers to empathy that we learned from training the thousands of clinicians on that.

Most physicians and clinicians are actually trying to do their best at expressing empathy. It's not always this inherent deficit, but their way of expressing empathy often is not the most effective.

Can you think of a time or a story or an example of that? I mean, I think of somebody saying, “Well, don't worry about that. It's gonna be okay.” This only happens one percent of the time, which is a nice reassuring statement, but not necessarily an empathic statement or an attempt at a reassuring state.

Amy Windover:   Right.

Adrienne Boissy:  Right, and all the person here is, “I'm in the one percent. I must be.”

Amy Windover:  That's right.

Adrienne Boissy:  So, morphing some of that language, I don't know if you can think of any other examples.

Amy Windover:   Things like, “yeah, don't worry, we're gonna take care of you.” You know, it's the, “don't worry”, or “I understand.”

Adrienne Boissy:  Yeah.

Amy Windover:   And that was a big one.

Adrienne Boissy:  The proverbial. You don't understand, right?

Amy Windover:  It can actually really trigger a patient to feel less cared for.

Adrienne Boissy:  Mm-hmm (affirmative).

Amy Windover: Even the word, “I'm sorry, ” it's challenging. There are times where we can genuinely apologize. Certainly, we need to apologize when there is need for service recovery.

When there isn't a need for service recovery, I think we run the risk of triggering people by saying that because oftentimes we say, I'm sorry when we want everyone to just be okay with us or not be at odds with one another, and it doesn't feel genuine.

First of all, I'm using the word I, right? ”I am sorry for you.” So, it can come off patronizing and there's research that suggests this beautiful study that was done that suggests that I wish statements can be just as if not more effective, especially in delivering bad news.

So,”I wish we had better alternatives.” It can sound better?

Adrienne Boissy:  Yeah, those are some great examples of I think what we saw.

Amy Windover:   I would have to say we did a video called “The words matter” that is available publicly on YouTube that really highlights the types of things we say, and how they can be helpful, and how they can be hurtful and it's the through the lens of actual caregivers who work in the healthcare who have been patients themselves.

And so, it's something that can be maybe helpful for people if they're looking for resource.

So, is that it though? I love that you brought that up, because oftentimes, I feel like empathy doesn't have its true depth until unfortunately, sometimes we've suffered ourselves that it takes on a new depth for people when that happens, when your mom becomes a patient, when you become a patient, when your child is a patient then, the light bulb goes off.

But I don't wish that upon anybody. I don't want them to have those experiences.

Adrienne Boissy:  What's your reflection on that? I mean, do you think there's anything as equally powerful? Is there some other experience or light bulb that goes off for people that that makes them?

Is it experiencing what it feels like to be, to have those empathic statements land on you that…?

Amy Windover:   People can't see my face and my quandary here. I struggle with this so much, because I do think experience does play a large role in our ability to empathize, and it expands our perspective.

At the same time, we know that the brain has mirroring pathways and mentalizing pathways and so, there's an effective, and cognitive empathy and certainly, we can experience affective empathy with the mirror pathways.

So, I remember when I was in high school and fighting with my family in front of my extended family. I had a two-year-old nephew, and I was really mad, and slammed the door for effect, and really wanted to make a point and he just started bawling.

And I remember thinking in my high school, “Yes, yeah, he's on my side.” But he was just responding to the emotion that I was bringing, and felt feeling bad for me, and my tears and all mirror neurons. Not helpful to him at the time I might add

Adrienne Boissy:  Mm-hmm (affirmative).

Amy Windover:   Right?  So, we have to be mindful of how those mirror neurons can cause us to offload our emotions on to others, at times, unintentionally and unhelpful ways or for understanding.

Mentalizing pathways, though, require us to have a little more context. So, someone might tell me they're anxious, but if I can't see it, if I can't understand why they would be anxious, it's gonna be harder for me to have a sense of what that experience is like.

Adrienne Boissy:  That's right, and those are also stronger. I saw on studies if you know the person, right?

Amy Windover:   Oh, yes.

Adrienne Boissy:  If you...

Amy Windover:   Oh, yes.

Adrienne Boissy:  If I watch something happen to you and then you are a stranger to me versus I watched something happened to you, and I had some context of our relationship or connection, the brains neural biological reaction is different.

Amy Windover:   And that's where I really I'm a strong believer that empathy, and we're seeing so much research supporting the use of empathy is wonderful and invaluable in the context of a personal connection or relationship.

Even a healthcare relationship that may be a little different from, say, friendship, makes it exponentially more powerful.

Adrienne Boissy:  It's all goes back to relationships.

Amy Windover:  Yes.

Adrienne Boissy:  So, you talked about self-empathy and I wanna recognize, though, that a lot of healthcare providers, clinicians, caregivers are not the best at actually caring for themselves.

And everybody says it, and we all talk about resilience and how we should go to yoga. But, what have you found either for yourself or seen in others?

What tips do you think are great examples of self-empathy? What does that look like in your experience?

Amy Windover:   I think some of the best examples, it sounds so cliché to say self-affirmation. And then when I finally was forced to do what I preached, I found them to be really effective and helpful.

And one of mine was simply saying, “I am perfectly imperfect, and I'm okay with that. I'm worthy, I am a valuable human being.” And when things come up, being able to say those things and own that for myself actually, lessens the chance of my unloading the emotion on to other people, and allows me to move forward in a way that can be more helpful to contributing to my team at work or my family at home.

I also have found that, exercise is really valuable but not everything. And the other piece is just being able to have some time to center our thoughts, and your mindfulness is kind of a hot word right now and yet, I found being able to pull out my calm app, and go through just that 10-minute brief meditation in the morning, is extremely beneficial and changes the day a lot.

The other practice I have with a friend of mine is, we exchange three things that we are grateful for at the end of the day by text, and just kind of hold each other accountable to that.

So, those kinds of things are really helpful, and every now and then we change up like "Okay, my gratitude is getting a little generic. I'm gonna start being grateful for people at work, or what they're doing at work, or I'm gonna be more grateful for things about my family," just to try to again, expand our perspective.

But if we don't have time to just be present, and really allow ourselves to be open to our thoughts, it's hard to even know what to be self-empathic or compassionate towards.

Adrienne Boissy:  That's right. That's a great point. I love the gratitude. The three things. I know it's something Sheryl Sandberg talks about as well, this idea of just a simple gratitude, and we do it with my kids before bedtime.

Amy Windover:   Oh, it's a wonderful thing with kids.

Adrienne Boissy:  Yeah. We could go on and on talking. What one thing do you think all of our listeners who are trying to build better experiences should be doing to really transform the patient experience or maybe the human experience, which we've spent some time talking about?

Amy Windover:  It's such a big question. I think if I were to say one thing at this point it would be again, really focusing on modeling what we want other people to practice, and that's not easy, and being willing to be vulnerable, and transparent about when it's working, and when it's not and to be able to support one another in that.

I also think that we need to keep going with the research that supports these things so that our organizations are able, and willing to continue to support these things financially.

We have this model, patients first at the clinic and it is so helpful to just use that as our kind of guide. I know people refer to it as our North Star, and it's memorable.

Unfortunately, and as we've learned, there are many people that then feel like, "Well, then, I'm second," and in their minds, it's almost as if they're last. And I loved a phrase that I think it was somebody in marketing who came up with: patients first, caregivers always.

Oh, it's just beautiful because it really does speak to how we need to be taking care of one another so that we can take care of patients.

I know our organization is making a very concerted effort to do more of that, and really focus more on teaming, and civility, and teams, and collaborations and being more vulnerable.

Adrienne Boissy:  I wanna end on a note of gratitude for you. I know a lot of your work most recently, has connected the work we've done in relationship centered communication and empathy.

You've expanded that portfolio of resources to end of life and, how do you set boundaries with patients in opiates? And, how do anesthesiologists express empathy?

It's really been an arsenal of tools for our people, and you've tied that to meaning, and burnout and significant evidence-based work to demonstrate the impact.

I'm really grateful that, after you kicked me out of your office the first time we met....

Amy Windover:   Now, now

Adrienne Boissy:  ... that wasn't the end and really just the beginning. So, thank you, so much for joining us, Dr. Amy Windover.

Adrienne Boissy:  This concludes studies in the empathy podcast. You can find additional podcast episodes on our website, my.clevelandclinic.org/podcasts.

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