Thursday, March 5, 2015

A Prescription for Better Communication

Sara del Nido - for website - 400 x 580As the daughter of a surgeon, I grew up hearing about life in the halls of a hospital. My father worked long hours, but never tired of recounting the day’s (usually hectic) events to me and my siblings. On many occasions, his stories would end with the same conclusion: the most important trait of a great doctor isn’t technical savvy, nor even scientific expertise – rather, it is the doctor’s people skills that make all the difference.

Having internalized and carried my father’s lesson for well over 20 years, it was with particular interest that I read a recent New York Times article about “inattentive care” – that is, the set of inconveniences and hardships, large and small, that patients experience in the course of medical treatment. In describing inattentive care, the article gave the particularly resonant example of poor communication between doctors and patients, from routine interactions to tough conversations about bad news or outcomes. Scrolling through the comments on the article (the online version generated over 860), one in particular stood out to me: “If doctors have trouble speaking with their clients, they are even worse at consulting with each other!” Other comments alluded to the same overall problem: a lack of communication between all members of the medical support team, and the impact of that lack of communication on patient care.

This is a problem relevant to those of us interested in conflict management, as well. As a student in the Harvard Negotiation and Mediation Clinical Program, my partner and I interviewed over 30 doctors, nurses, medical assistants, and other staff members at a set of health clinics in Boston, about the “difficult conversations” that they have on an everyday basis. We focused specifically on difficult conversations between team members, rather than with patients. We heard recounted conversations about scheduling and coordination, about clinician workflow or the implementation of new systems, and about sharing patient information, especially across different roles within the medical hierarchy. Above all, what became clear over the course of the project was that many medical professionals at the clinics felt that they lacked sufficient training and practice in key communication skills that, if honed, would allow them to improve their practice. Moreover, they felt that even if they possessed the skills, structural constraints such as limited time and rigid hierarchies might prevent important but challenging conversations from happening at all. Eventually, my partner and I used the stories we heard to develop a customized training for medical staff on how to skillfully engage in difficult conversations.

An undercurrent of what we heard in our interviews was that medical staff are already overworked and squeezed by a variety of stakeholders. Indeed, I noticed this dynamic manifest itself in my father’s stories (and read a particularly heartbreaking account of its impact on patients in one doctor’s words). All members of the medical profession juggle an incredible number of different roles and responsibilities – from direct medical care to documentation in electronic medical records to the management of the type of political spats that arise in any organization – all in the shadow of potential consequences that are far more serious than most of us even think about on a day-to-day basis. On top of that, the healthcare landscape is changing as a whole, which is creating new management challenges and financial pressures for hospitals and practice groups of all sizes.

So at this time of transition and upheaval for healthcare institutions, and in the midst of medical professionals’ already long and growing list of other responsibilities, why spend valuable resources developing communication skills? Why should communication be on the priority list at all?

The complex macro- and micro-dynamics inherent in the modern health care system make better communication a necessity, not an option. At a practical level, the need to navigate and comply with complex regulations around medical care remains an ongoing and evolving challenge both for individual practitioners and for institutions, and in fact, it is this challenge that prompted our HNMCP client to identify the need for better handling of difficult conversations. For instance, if doctors need to extend their hours in order to accommodate more patient appointments, who is going to inform them of their increased responsibilities? What if the doctors push back? What if the team members don’t even see themselves as a team, but rather as individuals existing in separate silos of a patient’s treatment plan? Team members might notice instances of “inattentive care,” but without communication skills or a structure that allows for conversations to take place, how will they provide each other with constructive feedback? The efficiency consequences of handling these questions poorly, or not at all, actually began to impact our client’s bottom line, and it was this that persuaded them to devote serious time and resources to skill development.

Since the passage of the Affordable Care Act, many hospitals have also realized that from an economic standpoint, collaboration and consolidation of operations makes the most financial sense (at least for the institutions – for patients, such consolidation has empirically led to price increases in many cases). As long as the tectonic plates of the healthcare marketplace continue to shift towards an “accountable care organization” model, the communication consequences of consolidation and mergers will remain a parallel challenge – particularly given that physicians’ training typically does not emphasize team-based decisionmaking, let alone managing structural complexity. For instance, small and solo medical practices are gradually disappearing, being absorbed into larger institutions; these physicians find themselves working in an environment that might be entirely new to them, with its own rules, incentives, and norms. Attentiveness to and active management of differences in “culture,” a related concept that might include communication styles, has been shown to make a business merger 26% more likely to succeed. But without providing practitioners at all levels of the medical hierarchy with the skills and techniques to communicate about challenging dynamics, they will lack the tools they need to engage in active management.

So what does this all mean for preventing “inattentive care”? And where does it leave us, as ADR practitioners? One of the greatest and most heartening surprises of our HNMCP project was that even after long days of physical and emotional stress, individuals from across the medical hierarchy – surgeons, physician assistants, nurses, medical assistants – willingly attended our three-hour training on difficult conversations, eager to discuss their most challenging situations and hungry for new communication tools and techniques. To my HNMCP partner and me, this was a powerful demonstration of the extent to which individuals who have chosen to devote their lives to providing medical care are already driven to self-improve, learn more, and achieve even better outcomes at work. Of course, this might not be true in every single case. But if we start from the assumption that medical professionals are trying their hardest to provide the best care for patients, we must recognize that the ADR community has expertise to offer in terms of what my father called “people skills”: effective communication and management of difficult conversations. It is the job of healthcare institutions to make this important work a priority. But ADR practitioners have a job, as well: to see and seize opportunities to share these critical skills with medical professionals.

Sara del Nido Budish ’13 is the Clinical Fellow at the Harvard Negotiation & Mediation Clinical Program.