Cleveland Clinic’s approach to burnout focuses on relationships

You can try, but it’s not easy to find a physician who wants to add another commitment to an already busy schedule. At the Cleveland Clinic, a one-time training session in relationship-centered communication skills improved patient satisfaction scores, physician empathy and self-efficacy, and reduced physician burnout through three simple phases.

The training, “Relationship: Establishment, Development and Engagement” (REDE), took place over one eight-hour session, comprised of interactive didactics, live or video skill demonstrations and group practice sessions.

More than 1,500 of the 3,220 physicians at the Cleveland Clinic participated in REDE, offered by the health system’s Center for Excellence in Healthcare Communication. Before taking the course, only 20 percent of physicians “strongly agreed” that it would be a valuable use of their time. But after completing the course, 58 percent “strongly agreed” that it was valuable to their daily practice.

The Centers for Medicare and Medicaid Services (CMS) requires that physicians publicly report patient experience scores in the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) for inpatient care. And for outpatient care, they are required to report patient experiences in the Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CGCAHPS).

Because physicians want patients to be satisfied with their care, and because HCAHPS and CGCAHPS scores are required for payment, physician practices and hospitals are looking to improve those scores every chance they get—yet there are not many proven methods available.

The Cleveland Clinic's approach, with the REDE model, that focuses on improving patient-physician communication and the theory appears to be paying off. For participating physicians, CGCAHPS scores were a little bit higher, specifically on the survey items for “Conveyed clear information” and “Knows patient’s medical history.” HCAHPS scores were also higher for physicians who took the REDE training, particularly in the category of respect for patients.

Considering physician wellness, physicians reported increased self-efficacy across 13 domains and scores on all three domains of burnout—exhaustion, depersonalization and personal achievement, according to results published earlier this year in the Journal of General Internal Medicine. When the participating physicians were checked up on three months after the program, improvements in all measures except emotional exhaustion were sustained.

Physicians know that the better relationship they have with their patients, the more able they are to treat their patients’ illnesses and keep their patients healthy. That’s why the REDE model is a framework for teaching and evaluating relationship-centered communication.

The training organizes a collection of validated communication skills into three primary phases: establishment, development and engagement.

Making a personal connection with a patient involves creating a safe and supportive atmosphere that allows the physician and their patient to foster trust and collaboration. One of the techniques the model employs is the “emotion bank account,” as detailed in a 2014 article published in the Journal of Patient Experience. Each time an emotional connection is made, physicians can think of it as a deposit in the emotion account with that patient. As the account builds, the relationship becomes more sustainable.

When a patient has to wait to see their physician, this is considered a withdrawal, but if the account has been built up then this withdrawal does not send it into the red.

In this first phase, physicians are taught to collaborate with their patient on setting the agenda for the visit. This technique makes sure the patients feel involved in their health care and also helps physicians avoid presumptions about a patient’s specific concerns.

Introducing the computer is another technique that minimizes the distraction of the computer’s presence in the room. The current state of electronic health records (EHR) means that the computer must be present, and so explaining its purpose and how it will be used can set the patient at ease.

Every opportunity to convey empathy is encouraged in this first phase of REDE. Physicians learn to better demonstrate empathy orally using the SAVE technique:

• Support: “Let’s work together …”
• Acknowledge: “This has been hard on you.”
• Validate: “Most people would feel the way you do.”
• Emotion naming: “You seem sad.”

Once physicians learn how to establish a safer and more supportive environment, the next step is to grow the relationship by getting to know who the patient is and to understand symptoms in the correct context.

Three techniques are emphasized in this phase:

• Reflective listening: This includes making direct eye contact, leaning forward, nodding and using verbal continuers such as “I see,” “Go on” or “Sounds like …” Physicians are encouraged to avoid expressing judgment, getting distracted or redirecting the patient, and to express appreciation for the patient’s sharing.
• Bring out the patient’s narrative: The best way to do this is to use transition statements to orient the patient to the history of their current illness. Open-ended questions can initiate this conversation and continuers such as “Tell me more” or “What next?” can bring out key events or situations that can help in diagnosis.
• Explore the patient’s perspective: This technique is taught using VIEW, which is understanding how the patient’s illness disrupts Vital activities, eliciting the patient’s Ideas about what is wrong with them, finding out what their Expectations are and understanding their Worries.

The final phase of the REDE model involves the education and treatment portion of the patient visit. Engaging the patient in dialogue rather than in monologue can enhance health outcomes by improving patients’ comprehension, recall, capacity to give informed consent, self-efficacy, treatment adherence and self-management of chronic illness.

Physicians are urged to share with patients their diagnosis and detailed information about their condition, collaboratively develop a plan through dialogue, provide closure through ending the visit with a review and conveying respect for the patient’s honesty and participation throughout the visit.

Though further study is needed to cultivate the sustainability of the REDE model’s ability to increase patient satisfaction scores and reduce physician burnout, the developers of the program say they believe enhancing the patient-physician relationship will improve patients’ health outcomes and doctors’ well-being

The “Listening with empathy” module, part of the AMA’s STEPS Forward™ collection of practice improvement strategies, offers more on effective patient-physician communication. There are seven new modules available in STEPS Forward collection, bringing the total number of practice improvement strategies to 42. Several of the modules were developed thanks to a grant from, and collaboration with, the Transforming Clinical Practices Initiative.