Cleveland Clinic’s Chief Experience Officer Dr. Adrienne Boissy on Embedding Empathy Into Health Care Training

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Female: Welcome to C onversations on H ealth C are with Mar k Masselli and
Margaret Flinter, a show where we speak to the top thought leaders
in health innovation, health policy , care delivery, and the great minds
who are shaping the health care of the future. This week Mark and
Margaret speak with Dr. Adri enne Boissy , Chief Experience Officer of
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the Cleveland Clinic. She's presiding over the 10 Annual Patient
Experience Summit , which brings together experts from across the
health industry, hospital a dministrators, clinicians and patient
advocates, examining the need to develop better empathy training for
clinicians and health care.

Lori Robertson also checks in the Managing Editor of F act Check.org
looks at misstatements spoken about health policy in t he public
domain, separating the fake from the facts . We end with a bright idea.
It's improving health and well being in everyday li ves . If you have
comments, please email us at [email protected] or find us on
Faceb ook, Twitter, iTunes or wherever you listen to podcast. Y ou can
also hear us by asking Alexa to play the program C onversations on
H ealth C are. Now stay tuned for our interview with Dr. Adrienne
Bois sy , C hief E xperience O fficer at the Cleveland Clinic here on
C onversations on H ealth C are.

Mark Masselli: We're speaking today with Dr. Adri enne Boissy, Chief Experience
Officer of the Cleveland Clinic Health System. She's a neurologist and
staff physician in the Cleveland Clinic - Mellen C enter for multiple
sclero sis. Dr. Boi ssy also leads the Center for Ethics Humanities a nd
Spiritual Care . She previously served as Medical Director of the Center
of Excellence in Healthcare Communication . She earned her master's
in bioethics from Case Western Reserve, her medical d egree from
Penn State University College of Medicine, and completed her
neurology residency and fellowship at Cleveland Clinic. Dr. Bois sy
welcome to C onversations on H ealth C are.

Dr. Adrienne Boissy: Thanks for having me.
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Mark Masselli: I see that you're presiding over the 10 Annual Patient Experience
Summit , the largest independent patient experience summit in the
world. I'm wondering if you could talk to our listeners about the
evolution of the science of patient experience and why empathy plays
such a n important role?

Dr. Adrienne Boissy: Well, patient centered care really started really way back when , when
the Institute of Medicine had published a report, it was called the
C rossing of the Q uality C hasm. T hey talked about six efforts that
health care n eeded to make to make health care more efficient, safe,
equitable, and more patient centered. T hey defined it at that time as
care that's respectful , the patient preferences, needs and values and

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ensuring those values guide clinical decisions. I f you resea rch even the
number of studies on empathy, or patient centeredness, specifically,
you come up with about 1800 articles since the 1960s. Y et, I still hear
stories at times from journals not accepting articles that are focused
on the patient experience, beca use they don't think it's scientific
enough. T hat's pretty worrisome, as you're seeing decades and
decades of li terature coming out, that talk about the power and the
impact, empathy and real conversations can have on patient reported
outcomes, medical out comes, safety, quality. W e need to get real that
it's not the soft thing, but it is backed by decades of science.

Margaret Flinter: In a recent TED T alk you expressed some concern that the empathy,
which we believe is so powerful is perhaps too often dismi ssed as a
soft skill in health care. Y ou ’ve said that empathy needs to be
operationalize d . T ell us what you've learned in your own practice at
Cleveland Clinic about the importance of empathy, and in particular,
maybe the measurable impact empathy has had and it’s having on
patient outcomes ?

Adrienne Boissy: I mean, even the fact that you're still hearing empathy called a soft
skill , drives me kind of crazy . I t's not a soft skill, it is the hardest skill
that we do, telling someone you've never met and you’ re meeting in
the first time in the ER that they have ALS, or telling a patient who
thinks they have one diagnosis that in fact, they have another. These
are not soft conversations, these are exceptionally uncomfortable and
they’re intimate and they're fra gile. I was seeing patients in a very
busy practice, I was double booked a nd I would do my best to be
empathic but trying to b e efficient with time as well. I n many
situations where -- and I was trying to have a conversation about their
medical care , a nd I realized that the patients, I'm a multiple sclerosis
specialist , and the patients I was seeing, some of them didn't actually
have MS.

I wanted to be a good neurologist , s o I was honest with them right out
of the gates, and I said, the great news is you do n't actually have M S .
I nstead of getting the big hug that I thought I would get, they get
really mad. What I realized in that was, they were n’t looking for me to
get the diagnosis right, they were actually looking for me to see them
in their totality as a human, and the label of MS became an identity.
W hat was underneath that was even though they didn't actually have
MS, they had suffering. Here was all this suffering that we had neatly
applied a label to, what I was actually doing was ripping out their
ide ntity. I t taught me that people need to be seen as a human before
they'll trust you with making a significant change like that. Now I
spend a lot more time up front, I empathize, I asked about trauma
a nd how they're coping with the disease b efore I dive in to any of the
medical jargon and specifics . T hat has changed my practice .

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Mark Masselli: I was just thinking about the ch allenges in primary care of how, as you
say, to connect with the human sitting across from you with suffering
and also the economy of a practice you might be in there for 15
minutes with a patient . Y ou've got an EHR in front of you, your
colleagues are burning out. At Cleveland Clinic, you've launched a
number of efforts to improve patient engagements a nd we're just
wondering how technolo gy and online social networks, like patients
like me help improve this patient engagement?

Adrienne Boissy: Y eah, when we talk about engagement, I think we have to be really
careful about what we're talking about. I t's used interchangeably,
even with exper ience, and they're not the same thing. One of my
favorite examples is you can have the experience of riding a
rollercoaster a nd you could be screaming, throwing your hands up as
you're going down the hills, and then by the photograph afterward, or
you just sit there with your hands crossed and go through the ride.
One person on that ride is really engaged with the experience, and
the other is not. E ngagement is about engagement with something.

A lot of people use these patient portals as an example to say, o h well
the patients engaged because our hospital has patient engagement
because 30% of our patients use the patient portal. But if you've
never actually logged in to check your labs that are available to you in
the portal, we're not maximizing what patien t engagement is
supposed to be. I think to get to truly engaged patients, it's really
about behavior, which means they should be completing an advanced
directives . T hey should know what meds they're on and why , r eal
tangible behaviors that a patient can ma ke to demonstrate
engagement. But to fully empower a patient, health care has a
responsibility to give them some capabilities back like access to their
data, speedy access to appointment, transparency across , availability
of their records anytime anywhere, and really control.

C onsumers have control , p atients don't. They also h ave fear which
will forever differentiate them. P atients like me started as a --
because one of the brothers of the Haywood family was diagnosed
with ALS. T hey were struck by the pauci ty of resources available for
patients. T hey developed patients like me, it's a organization and
there are many others like it that are trying to create communities,
right , where healthcare can't go , b ecause those are patients who have
the same disease con necting with those patients . I n some sense it’s
the empathy community , a nd so it's , I think, done a beautiful job in
terms of elevating that . T hey've also been very effective at being
transparent about how they use patient data, which is a hot topic
these days. T he data can be used for research, and patients with that
level of transparency clearly resonate with it. I think that's why you're
seeing the explosion of spaces like that.

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Margaret Flinter: But Dr. Boise it would seem, we cannot hardly pick up a jo urnal
without reading about clinician burnout reports that it's at an all time
high and some pretty devastating consequences to those individuals.
Cleveland Clinic has such a great reputation as a high performing
health system, but I doubt immune to those same stressors. What
have you done there that we might all learn from that you think is
having or has had an impact on preventing preferably or reducing
clinician burnout? Are there programs that you found to be
particularly effective in preventing or redu cing burnout ?

Adrienne Boissy: W e've cared about burnout for some time, but I really learned about
it the most when we were launching communication skills training for
clinicians. In the training , all the sudden, you had these small groups
of clinicians, w ho began sharing this vulnerability in the safe space
that we had created, they began sharing the story that just made it
incredibly hard to imagine how they show up for work the next day. It
struck me at the time that what was therapeutic about the traini ng
wasn't necessarily that we were doing reflective listening or anything,
but that we were creating a space for those stories to be told . T he
sensation of what it feels like to have empathy ref lected to you, a nd
when you do that, the clinicians never forg et it.

We hold them accountable for patient satisfaction scores and tell
them to be more empathic, but who's being empathic to them ? T hat
question drove everything we developed since then. I t's important to
note that burnout is not an individual problem, s omething about the
health care system is not supporting these amazing clinicians to be
their best. T hese individual fixes, resilience courses for me, or yoga
training, that is a bit off enses, because I studied minutiae for years to
become a doc. W e need to acknowledge and make sure we're talking
about the system and how the system can change. I spoke about a lot
of solutions , m any of them seem like common sense, having
pharmacists do refills for patients who are already established.

Having pharmacist help w ith pre - authorization or some of the
paperwork that often clinicians get left to do, implementing scribes
and virtual scribes so that we're not just typ ist. W e also have to look
in health care , s o some of the things that we've done which other
organization s could easily do, would be to recognize the moments
that matter for clinicians and patients. Jonathan B artels out of
University of Virginia came up with this beautiful concept, the pause,
which is just to take a breath when a patient dies, or ritual calle d the
pause, take a moment and recognize the power you have. We began
on our walks , s o when a patient donate their organs, all of the
caregivers line up in the hallways to honor that patient and the
sacrifice they're making to save other lives.

When there' s a trauma in our ER , or somebody is hurt, you can call it

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code lavender, and a team will arrive on the unit to provide care to
the caregivers. I think it's about attentiveness to the moments where
you can create meaning, because burnout is associated with the loss
of meaning for people . Y ou have these amazing people that want to
be caring and healing , and t hen we make it so hard for them to do
that. You hear a lot of talk about the HER, I would say it's not the EHR
per se , i t's the lack of intuitive ness th at it's not making my job any
easier , r ight? It's taking two extra hours to document at nighttime .

Margaret Flinter: L ots of clicks .

Adrienne Boissy: Yeah , and it -- I wouldn't mind the clicks, quite honestly, if it helped
me do what I'm there to do. But h ow does the EHR help me
understand what's most important to the patient , r ight? We're talking
about patient centered care and empathy. I haven't met an EHR that
does that yet . Y ou wouldn't get so much frustration i f I saw the
reward of a deeper connection with the patient I'm trying to impact
and walk on their journey with .

Mark Masselli: W e're speaking today with Dr. Adri enne Boissy , Chief Experience
Officer of the Cleveland Clinic Health System . Y ou've already talked
about the work that you've been doing on communication skills for
physicians and it really came out of the Cleveland C linic's own
experience with this diagnosis, medical errors, even deaths after they
review thousands of patients concerns, and recognizing that the
health system itself has to d o some things to make sure that there's
access to data , access to appointments, there's transparency cost . I’m
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wondering in your 10 conference, have you segue d over to sharing
some of this with group practices, smaller entities than the hospital
systems, if there's any training protocols you've developed that might
assist those clinicians in becoming better communicators?

Adrienne Boissy: A bout a decade ago at the Cleveland Clinic, Toby had declared a
patients first and he had elevated the first chief exp erience officer in
the country to represent patient experience at the executive team.
O ne of the first things we did was developed service recovery training.
T hat was for 40,000 people, we put them all in a room over a year and
a half, we trained t h e m in t hat. W hat we realized from that though,
was that the conversations clinicians had can't really be fixed by
models that work in hospitality. I f I smile and say thank you, or my
pleasure, that feels very superficial to most clinicians. W e wanted to
evolve co mmunication skills training, that works on -- it's called the
ready model framework, relationship , establishment, development,
engagement . H ow do you do that? What does it sound like? E mpathy
is simply meeting the emotion where it is in that other person a nd
taking the time to do that. W e've trained about 9000 clinicians, as
well as across the globe. W e certainly are happy to share that model.
E mpathy doesn't take much time. Like how long does a hug take?

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How long does it touch on the hand take ? I t takes se conds.
O ftentimes you hear buzzwords of empathy in 15 seconds, or 30
seconds , a nd the truth of the matter is, if you're doing it time stops,
and even if you had 15 minutes that one minute will be something the
patient will never forget.

Margaret Flinter: Y ou're presiding over the patient experience summit, you've got an
improvisation coach from the famous Second City comedy troupe.
You have a fellow named Chris D ancy, who's been called the most
connected man on earth really focused on how technology gadgets
can improve health . But I think my favorite of this is your event called
Death Over Dinner , where attendees join ed together for a meal, and a
really frank conversation about how do we address death and dying
with our patients . T alk a little bit about the variety of presenters, what
are you most excited about?

Adrienne Boissy: We always begin and end the conference with patients , t hat's a non
negotiable for us. Actually, when the conference started almost a
decade ago, we had C harity Till e man n - D ick come, wh o recently
passed . S he was the opera singer who had a double lung transplant
twice. She sang beautifully about 10 years ago, and then it's
unfortunate that now here we are 10 years later, but having just
recently passed. I t's trying to literally elevate vo ices like hers, both the
profound beauty of empathy a nd the power that it can have . Death
o ver D inner is the brainchild of a wannabe architect , name is Michael
Hebb [PH] . H e came with his idea many years ago around -- he's done
this for Barack Obama and ma ny other high profile events where
people came together over a table to have really important
conversations in an era where everybody's got a phone, are we still
talking to each other about the things that matter most ?

W e have collaborated with him to deve lop a D eath over D inner for
Health Care , meaning if you as a health care provider could have this
conversation over dinner about your own imagining for your life and
the end of your life , c ould you then be a more effective enabler of a
conversation with a patient? I think it's very powerful. We're going to
expose people to the concept of the conversation with death over
dinner. I mean, the event is most exciting for me, because actually
when I started this work a decade ago, I felt actually quite alone.
Som etimes it'd be really hard to keep pushing to amplify empathy i n
today's world . T here's always something newer in technology that's
coming , a nd how do you keep saying this stuff matters ? I think when
the movement was first starting almost a decade ago, it just felt
lonely for me. T his event, when you're staring at thousands of people
that are coming together to elevate this global conversation, I feel a
little less lonely.

Mark Masselli: Thank you so much for speaking today with us Dr. Bo issy , Chief

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Experie nce Officer at the Cleveland Clinic Health System . Y ou can
learn more about her work by going to Cleveland C linic.org o r you can
follow her on Twitter @ b o issy ad . Dr. Bois sy thank you so much for
advancing the quest to build empathy and better communication s
into our profession and for your commitment to innovation and care
delivery to improve the patient experience and for joining us on
C onversations H ealth C are today.

Adrienne Boissy: T hanks so much for taking the time to speak with me.

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Mark Massel li: At C onversations on H ealth C are we want our audience to be truly in
the know when it comes to the facts about health care reform and
policy . Lori R obertson is an award - winning journalist and Managing
Editor of F act C heck .org a nonpartisan, nonprofit con sumer advocate
for voters that aim to reduce the level of deception in US politics . Lori
what have you got for us this week ?

Lori Robertson: Democratic presidential candidate Beto O’Rourke advocated universal
background checks for gun purchases, claiming t hat state laws
mandating universal checks, “Have been shown to reduce gun
violence by 50%. ” B ut academic research doesn't support that .
O’Rourke’s campaign said the statistic came from every town for gun
safety , b ut the gun control group told us it has upd ated its
background material on the issue in light of rigorous new research. A
study published in the J ournal of General Internal Medicine in March
found that universal background checks are associated with about a
15% reduction in firearm homicide. The st udy looked at homicide and
suicide rates in all 50 states and analyze the relationship between
various firearm laws including universal background checks. But the
study stopped short of concluding that the decline was caused by
those laws.

There have been attempts in c ongress to require universal checks,
which would cover private sales by unlicensed individuals, including
some sales at gun shows and over the internet. But the policy has
failed to gain enough support to pass . R esearch released by every
town in 2015 found, “N early 50% fewer police murdered with guns,
women shot to death by intimate partners in states with background
checks. ” But determining that states with universal background
checks have lower rates of certain types of violence is not the sa me as
proving that universe background checks have been shown to reduce
gun violence by 50% , t he phrase used by O'Rourke .

D avid Hem e nway, D irector of the Harvard Injury Control Research
Center and the Harvard Youth Violence Prevention Center told us it is
notoriously difficult for researchers to tease out the effects of various
gun policies in states that often have a combination of poli cy . A 2017

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paper Hemenway co - authored reviewed the available peer reviewed
research on gun control laws from 197 0 to 2016 it, “F ound evidence
that stronger firearm laws are associated with reductions in firearm
homicide rates. But a reduction in viole nce of 50%, “S eems much,
much too high to me .” Hem e nway told us . T hat's my fact check for
this week. I'm Lori Robertson, Managi ng Editor of FactCheck.org.

Margaret Flinter: F act C heck.org is committed to factual accuracy from the country's
major political players and is a project of the Annenberg Public Policy
Center at the University of Pennsylvania. If you have a fact that you'd
like checked, email us at C HC radio.com , w e'll have FactCheck.org’s
Lori Robertson check it out for you here on C onversations on Health
Care.

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Margaret Flinter: E ach week C onversations highlights a bright idea about how to make
wellness a part of our communities and everyday lives. Sub - Saharan
Africa leads the world in maternal and infant deaths each year.
According to an annual report from Save t he Children a n estimated
397,000 babies died at birth in that region in 2013 , and s ome 550
mothers died pe r day as well. Most of the causes have to do with lack
of access to medical care in these low resource regions , a nd often the
local midwives lack formal medical training to prepare them to
conduct interventions i n the event of a life threatening event like a
hemorrhage or an infection.

Anna Frellsen : We know that 90% of all the deaths that we see today could be
prevented if the mother had had access to this really basic skill care
during the childbirth .

Margaret Flinter: Anna Frellsen is CEO of the Maternit y Foundation, their organization
has created an intervention for midwives living in low resource areas.
It's called the S afe D elivery A pp , a nd it provides comprehensive
training for midwives that teach them and guide them on what to do
in the event of a bi rthing crisis.

Anna Frellsen: This is really a matter of building the skills of the health workers who
are already out there and empower them to be able to better handle
the emergencies that may occur during childbirth, such as the woman
starts bleeding or the newborn is not breathing and so forth. First and
foremost, it's a matter of finding a way that we can reach to help
progress and build the ir skills .

Margaret Flinter: Frellsen says the real promise of the Safe Delivery Application lies in
its ability to provide ongoing obstetric and neonatal training. The Safe
Delivery App has been designed to be culturally relevant and easily
understood. It's received the United Nations approval for wider
deployment. The Maternity Foundation plans to have the Safe

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Del ivery App in the hands of 10,000 health care workers across the
region by next year. A low cost culturally sensitive mobile app that
offers immediate guidance and assistance to midwives and health
workers empowering them with ongoing support and knowledge that
can improve birth outcomes , n ow that's a broad idea.

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Mark Masselli: You've been listening to C onversations on Health Care, I’m Mark
Masselli.

Margaret Flinter: And I’m Margaret Flinter.

Mark Masselli: Peach and health.

Female: C onversations on H ealth Care is recorded at WESU at Wesleyan
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