Abstract
When I think about empathy, examples from my personal life come easily to mind. I think of the soothing sound of my mother’s voice as she hears the break in mine as I am about to start crying. I recall looking into the kind eyes of a friend who is hearing a difficult part of my story for the first time. I see the wrinkle at the corner of my son’s eyes just before the laughter. Empathy in medicine is more complex and can be rather elusive. It is less personal because I don’t have a day to day relationship with patients, and more personal because I want to alleviate their suffering. Having been a patient myself, I have been the recipient of beautifully timed and placed empathic gestures and words. But, I have also experienced the downside of health care, the rushed, uncaring, somewhat bitter moments that probably had nothing to do with me, and everything to do with pressures on the person delivering it. Done well, expressions of empathy can be healing and much appreciated; done poorly, it feels deeply distressing and personal and is almost always something you remember vividly and talk about with strong negative emotions.
Why do the negative memories often bubble to the surface first? It’s certainly not because they are more common, yet they dilute and sometimes cancel out the times when empathic gestures and words were genuine and well placed. As a physician, I hope the memories I have created with patients are positive and were communicated in a way that was healing. There is no question I have made mistakes and faltered along the way. Unlike my personal experience of recognizing and receiving empathy, there weren’t a lot of mentors in my clinical training who helped me identify opportunities and strategies for improvement.
I entered the field of medicine with the intention of being a life-long learner and I enjoy learning new things. The idea of including communication skills as part of this process wasn’t on my radar until I became faculty. What I have learned through my training, first as a course participant and now as a communication course facilitator at the Cleveland Clinic, has revolutionized the way I build and maintain relationships with patients and colleagues. I now appreciate the value of reflective practice and opportunities to improve using guided feedback and repetitive skills practice. Learning new skills and having the ability to practice them has made me a better communicator and certainly a better physician.
The story of how the Cleveland Clinic began and sustains communication skills training in empathy has been told several times before. What I hope to offer is a different perspective, one viewed from the lens of a trainee who then joined the Clinic as faculty. I have spent my entire training and professional career at the Cleveland Clinic. My medical school experience was probably not dissimilar to many clinicians; my communication style was an amalgam of who I am as a person, what makes up my individual personality, and the physicians I worked with who I viewed as being good communicators. There was definitely a lot of mirroring, I would take what I liked and reflect it back as well as I could. I had no idea at the time what made these clinicians “good” communicators, it was simply a feeling, an innate sense of what was right and what worked with patients. What came a lot easier was recognizing what didn’t work, both in my own actions and words and in others.
In 2006, the idea of teaching empathy to physicians was brought to our CEO Dr Cosgrove’s attention after a presentation he delivered at Harvard University. Interestingly, the student involved in the story was not sharing her experience as a member of an elite few who attend the business school, rather she was sharing her experience as the family member of a patient. The question posed was around whether the Cleveland Clinic had resources to help caregivers be more empathic. At the time we had none, and this realization was a turning point for the organization. The year 2006 was my second year of training in Internal Medicine. If we had organized education around the practice of empathy, I don’t recall any of the details. After all, weren’t we all inherently empathic? Otherwise, we would not have gone into the field of medicine. Residency was the time to hone our clinical skills and become experts in our field of choice. Challenging communication experiences were followed by the endless stream of patients needing to be seen with little reflection on what had gone wrong and no time, strategies, or opportunities for improvement. Being empathic was supposed to come naturally and be nurtured in the environment of caring for the suffering. The overarching problem with this approach is 2-fold: improvement is impossible without feedback and practice, and the ability to project empathy is difficult to assess in a medical school or residency interview. Not everyone is equipped with the capacity and skills needed to show they care.
The Office of Patient Experience (OPE) was established in 2008 as a response to the CEOs initial call to action to teach and improve empathy among our caregivers. The first line of the mission statement is to build a culture of empathy. The Center for Excellence in Healthcare Communication (CEHC) is part of OPE and was established about a year later to operationalize the mission statement. The CEHC was charged with providing enterprise-wide communication training and support to physicians and advanced care providers. The training model is designed around building relationships with patients and research evidence that demonstrates the benefits to patients and providers from doing so. As a trainee, I was most familiar with the traditional physician-centered approach: the notion that physicians know best and it is our job to help patients get there and see it our way. Relationship-centered care is about creating therapeutic connections between clinicians and patients with the end result that the experience is enhanced for everyone.
The day-long foundational health-care communication skills course has gone through several iterations over the years but the focus has remained the same. We value the individual needs of our learners and provide a safe environment through which to practice communication skills. There is a deep parallel between our model of education and the skills that we expect our providers to adopt with their patients. In fact, they are the same skills. At the heart of the course is the vital importance of empathy; it is the common thread among all the skills and a great deal time is spent on recognizing and responding to emotion with verbal and nonverbal expressions of empathy. A detailed description of the course has been published elsewhere (1). After completing fellowship in Pulmonary/Critical Care, I joined the Cleveland Clinic as a faculty member. Part of my orientation (also known as onboarding) involved taking the full-day communication skills course offered by CEHC. Woven throughout my training were unplanned experiences as a patient, and these certainly had changed the way I was now communicating as a physician. I remember sitting in the course and being impressed at how new hires were invited to talk about and reflect on their communication experiences, the good, the bad, and the ugly, in a safe supportive atmosphere. I finished the course with a renewed sense of what I did well and what I could work on.
In 2013, communication skills training went from a requirement for all new physicians to the clinic to 1 for all staff physicians. Whether you worked here for 3 or 30 years, you were enrolled in the course. New and existing trainees were also a part of the mandate and importantly, the content of the curriculum across the enterprise was exactly the same. Toward the end of the year, I was invited to become a course facilitator along with 50 other physicians. Over the next 7 months, we trained roughly 3000 physicians in the foundations course. This was a major undertaking and required full support of hospital administration. Our overreaching goal was to improve the experience of care for both patients and providers.
It seems obvious that a course designed to improve provider and patient experience is a good idea but all well-intentioned ideas need evidence to be accepted and sustained. In order to examine the impact of our skills training, data were obtained and analyzed over a 7-month period from physicians who attended the course versus those that did not (1). Factors explored included empathy, burnout, course satisfaction, and self-reported communication efficacy. The study groups each consisted of approximately 1500 practicing physicians. Clinicians were satisfied with the course overall and reported that the content was relevant and time spent was valuable. Additionally, they felt the skills were easy to incorporate into their practices, and an overwhelming majority (>90%) said they would recommend the course to colleagues. Empathy, as measured by the Jefferson Scale of Physician Empathy, improved following the course and this effect was sustained over 3 months after training had taken place. In addition to improvement in empathy scores, participants reported decreased feelings of burnout, a major concern in the profession right now. The impact on patients was also measured and relationship-centered skills training was shown to improve patient experience scores.
To date, over 4000 physicians and 1000 advanced care providers have participated in the communication skills training. All new trainees are enrolled in the course, and the Cleveland Clinic Lerner College of Medicine has adopted the model as part of its undergraduate medical education curriculum. I am proud to be 1 of over 50 clinician facilitators who teach the course. Once providers have attended the full-day foundational skills course, they are eligible to attend a number of advanced communication courses. All courses are designed using the same platform and provide brief didactics followed by skills practice. Examples of advanced courses include delivering bad news, patients with chronic pain, family meetings, and discussing code status/end of life conversations. Half-day booster courses have been designed as a way to review and focus on individual relationship-centered skills. I have participated in and facilitated a number of these courses. This work continues to enhance my communication skill set and provide opportunities for ongoing reflective practice.
In a way I feel my empathy journey is just getting started, there is so much more to learn. We need to involve patients in the process of how we incorporate empathy training in medicine. In as much as empathy in our personal lives and empathy at work is often viewed as separate, there is great value in exploring what is similar. We need to take better care of each other and convey empathy to our colleagues in the same way we do with patients. It is also important to recognize that showing empathy is not always easy, admitting this should not be viewed as shameful rather a crucial reason to continue the conversation. I will continue to make mistakes but I am now empowered with the mindset and skills necessary to improve. Any negative health-care memories will hopefully be washed away by the moments when what we wanted to convey came across in the right way, in a way that is healing and hopeful. In the end, we are working toward cultivating our humanity, seeing each other as people first before being defined by our technical roles in the patient experience.