Daryl Oakes: I'd like to welcome everybody, and say good afternoon. And thank you for joining us for this July session of the Stanford CME Leadership Virtual Journal Club. I am Daryl Oakes.
Ruth Adewuya: And I am Ruth Adewuya.
Oakes: And we will be your host today for this session. And this is a series of journal clubs with a format of a live facilitated webinar. And with pre-assigned topics and articles for discussion each month, we will ask the registrant's to submit their questions in advance of the session. And there will be opportunities to add to the discussion during the session via the live chat. And the goal of the program is to provide practicing positions in all levels of leadership, some insights and management skills to help them be more effective in their clinical environments.
Adewuya: Yeah, and so today's discussion will really focus on communication and leadership, and really think that strong communication skills not only builds trust, it eases tensions that may occur with patients and staff and providers, but also increase positive patient outcomes and help clinicians boost their professional satisfaction. So we are really excited to dive into this topic today. And if we can go to the next slide?
Oakes: Yes, I had a little issue with the slide. So I'm going to fix that just one second, please.
Adewuya: No worries as that is coming up, I just wanted to remind people that this webinar is certified proceeding as an accredited education. This slide shortly will show all of the language for that, but there's no action required for you right now to claim CE for this just stay tuned. And one to two business days, you will receive an email from us and you can just follow the instructions that you get on that email to be able to claim CE.
Oakes: And that should be the languages that available. Okay.
Adewuya: Excellent. Thank you so much. And then we can go to the next slide now. And so the format of today's session is that Dr Oakes will provide you with an overview of the three articles that we will be talking about today. Then we'll enter into some time for Q and A panel discussion with some of our expert guests panelists today. And so with that, I will turn it over to Daryl to go ahead with the article presentation.
Oakes: Thanks, Ruth. The first article we will discuss is Leader Communication Styles and Organizational Health by Joel, researches suggested a link between leader communication style and effectiveness and employee satisfaction in organizational productivity. And effective communication is really vital to building trust, to aligning efforts and to inspiring positive change. The lack of effective communication in organizations unfortunately can result in misinterpretations, miscommunications, and missing important information. It can damage relationships and ultimately it can result in important barriers that interfere with progress. So in order to explore this issue, Hicks conducted a structured review of the literature to identify the most effective communication styles for organizations.
He describes two primary leadership communication styles. The first is person centered communication focuses on relationship building and tends to be a communication style utilized by transformational leaders. Person centered communication involves a partnership between the leader and the employee and requires mutual participation, feedback and reflection. And this communication style is observed in very high quality, high respect, employee leader relationships. The second leadership communication style is positioned centered communication is hierarchical, formal and task focused. In this model, the leader communicates primarily through rules, commands, maybe even threats and regulations.
This type of communication is utilized in more transactional leadership models. And the leader employee relationship in this model is more low quality and has lower levels of trust. Hicks, found that certain strategies were associated with highly effective communication. And these include empathic non-defensive listening, active listening with an eye contact and using both verbal and non-verbal affirmations Self-disclosure characterized by an open, honest, atmosphere of partnership and effective sharing of critical information, which is particularly important during periods of major change. And finally editing the ability to carefully curate language, to promote a calm and stable environment. And these communication strategies are associated with decreased stress and conflict in an organization and increased employee trust, knowledge sharing, and problem solving. And they lead to greater employee satisfaction, loyalty and retention.
The take home point to this article or that person centered communication is associated with transformational leadership styles and associated with a higher quality leader employee relationships, than is seen with position centered communication. And effective communication strategies, including empathic and active listening, self-disclosure and curated language are associated with better employee satisfaction and organizational outcomes.
Our second article is Bringing Value: Honing the Fine Art of Communication by Eugene Fibuch and Jennifer Robertson. Although many leaders think they are communicating well, they occasionally maybe missing the mark and this article explorers both what factors can interfere with effective communication and what strategies leaders can employ to be more effective in their communication of their message. The Fibuch and Roberts identify multiple barriers to effective communication. And first they say that the recipient may simply just get overloaded by the information that is given and may miss the intent of the message. And this can particularly happen when a lot of information is offered at once, or if the information is poorly organized.
Second, if the communicator fails to recognize and account for the possible emotions that their message may elicit, their message may actually get lost in the recipient's personal internal reaction. So it's really important to anticipate how the person receiving your message will hear the information and acknowledge that experience when delivering the message. Third different gender and cultural perspectives can mean that a recipient of the message may have a response the message that is quite different than what is intended by speaker. So awareness of these other's perspectives is important to avoid miscommunication and sometimes even frustration.
And finally selective filtering. This can occur in a couple of different ways. First, a recipient may simply hear only parts of the message because they will be primed by their past experiences or their motivations and interests to hear things in a particular way and end up in another scenario, a filtering can occur when a person is delivering a message to a person at much higher status, and the message may be selectively filtered due to the desire for that message to be received favorably. And this filtering may somewhat distort the information that's given. And this is important because leaders need to maintain an awareness that the information that they receive may be inadvertently filtered in this way. And so if they want to avoid missing a hearing critical negative data, they need to be aware of this so that they can get the right information to make good decisions.
And as we think about ways to be more effective in our communications, it is really critical to consider how our listeners are receiving the information we provide. When we prepare our messages as leaders, we often spend the most time focusing on choosing the exact words we will use to convey our meaning. But interestingly, only about 7% of our message is communicated by the actual words we use. In fact, it's really other factors such as our voice tone, tempo and modulation that have a much more significant impact on the effectiveness of the message being conveyed. And among the most powerful influences on what people actually hear of what you say are related to the non-verbal cues we use as we present the information, it may be our posture, our body language, and actually most significantly our use of eye contact.
So next time you were giving an important presentation. Remember, you need to pay attention to how you say what you're saying as much, if not more than what you were actually saying. In addition to understanding the importance of nonverbal cues, Fibuch and Roberts point out that personality style also affects how we give and receive information. Although there are a number of different personality and communication inventories in this article, they identify four main types of personalities, the doers, the feelers thinkers, and planners. In each of these have their own approach to the world and preferences for communication. Doers are very action oriented and are drawn to big ideas. And with them, you want to keep it short and to the point.
Feelers are people oriented and will be interested in how the idea impacts the team, they'll be interested in fairness and the process. Thinkers are data oriented and they will want the facts and the numbers. And they'll be interested in the analysis to support your ideas and your decision-making. And finally, planners are more concept oriented. They're often hardworking, like punctuality and have a really high attention to detail. And they may be more focused on what tasks are going to be required to operationalize the idea. So to communicate effectively, you need to really understand your own style, but you also need to recognize and adapt to the communication style of the person you're talking to. And remember that as much as you think your style may be the right way to be in the world, the people who have different styles feel equally the same about their style. It's important to respect all ways of approaching these things and also recognize that if you want to avoid unnecessary miscommunications, it's good to know your own style and also know the person's style that you're talking to.
Their take home points here are that it's important to be aware of communication barriers, such as filtering, emotion, information overload, and perspective differences. It's important to recognize that what you are communicating may be impacted by how you communicate it. And it's important to understand that communication style of your audience is important and you need to be aware of it so you can tailor your message to match their style.
And our last article is by Edward Baker and colleagues, and it is called Listening to Understand, a core leadership speaker points out that listening is a critical predictor of successful leadership and allows for the building of a relationship and trust in an organization. Effective listening however requires some preparation and among the things we need to be thinking about when we're preparing to listen is how we're going to provide our full attention to whoever's speaking. And this can be very challenging in our busy work environments, but requires us to make some additional effort to do this. It's also really important to be aware of and set aside our premature judgments. We sometimes listen to someone, but mostly for the opportunity to be able to say our own thoughts. And so it's important to notice our preexisting assumptions and ideas and hold them to the side to make room so we can actually hear what the other person is saying. One way to do this is to, as Baker says in this article is to cultivate a mental posture of genuine curiosity. And I think this reminds me of the quote, “Seek to understand not to be understood.” This is the idea. Just try to keep an open mind first and then maybe people will be able to hear what you have to say.
So listening well is actually it's own art. And although we tend to think a lot about the fact that we listen to hearing information and for content, it's actually very important to learn, to listen, to hear the message that's being conveyed underneath the words. This may be meaning and intent, or it may be that they're feelings and values that motivate the person that are embedded in the message. And these are important to tease out and Baker has a fun quote from the movie, the Big Z. And he says, “It's not what he says that it's so important. It's what you hear that counts.” So I think his point being that really you need to listen for all the messages and the communication, because this is really where the art is in being an effective listener.
So one way to be an effective listener is to develop our deep, deep listening skills. And this means having awareness of our own natural conversation style and understand how it may be different from others. You need to maintain that active posture of attention, and also active awareness and curiosity to learn, so that openness. It's also helpful to listen very carefully to specific words and phrases that are being used by the person you're speaking to, because it can be very useful to reflect those specific words back to the speaker when possible. And with deep listening, it also means that you are listening for questions that are embedded in the conversation. And you may want to take the opportunity to ask those questions when appropriate.
And it also requires a reflective responsiveness. So as you're listening, you ask clarifying questions. You paraphrase what's being said, you reflect back the words and the feelings that are being expressed and you summarize the content and you will find if you do this well, the person will really feel heard. And this builds trust and makes the person more open to hear new ideas, maybe your ideas or suggestions. So in summary, the take home points from this article are that listening is a critical leadership skill, effective listening involves focusing not only on the content, but also paying attention to the meaning and feelings behind the words and listening strategies, such as asking clarifying questions, paraphrasing, reflecting back ideas, and summarizing can improve understanding and really help people feel heard.
So that brings us to our expert panelists and I will let Ruth introduce them. We are excited to have two discussants of this really important topic here today.
Adewuya: Excellent. Thank you so much, Daryl. And thank you for that great summary of the three articles that we'll be discussing today. Really looking forward to our panel discussion and the Q and A that will take place shortly. So I'll begin by introducing our expert guest panelists, starting with Dr Barbette Weimer-Elder, and she has 35 years, over 35 years of leadership experience and has extensive experience in organizational development and executive management in health care. She's currently the director for the Physician Partnership Program and is a service excellence physician coach here at Stanford Health Care. She has co-developed the advancing communication excellence course here at Stanford in partnership with the Academy of Communication in Health care. And that course is focus is really mastering empathic communication skills with the goal of improving the patient experience as well as enhancing professional satisfaction. So Dr Weimer-Elder, thank you so much for being with us today.
Dr Barbette Weimer-Elder: Thank you so much. And yes, exactly. We're here to make a culture change for health care in the future and building a relationship centered culture. And that's going to take all of us individually, teams as well as the organization to focus on what do we need to get there? And today's topic is really important because I believe all of us are leaders and have the potential to make this change through our behaviors. Thank you so much.
Adewuya: Excellent. Thank you so much for being here. And also I'd like to introduce Dr Kelley Skeff, who is the co-director for the Stanford Faculty Development Center for Medical Teachers here at Stanford University. He is the George DeForest Barnett professor in medicine, and he is a distinguished educator with numerous honors and awards such as the Distinguished Medical Educator Award, made the Association of Program Directors in Internal Medicine, the [Goss] Award for excellence in teaching, and more recently the RISE Award for outstanding contributions to Stanford students and other trainees. He is also a member of the Macy Foundation National Advisory Committee. Dr Skeff, thank you for joining us today.
Dr Kelley Skeff: Thank you so much Ruth and Daryl for this invitation. It's an honor. I wished I could see everybody that's on this call because it's truly an honor to have some time with you to talk about something that's so important to all of us, and that is how we connect with each other. And so I'll try my best in the next time that we have together to draw on the research that we've done on teaching and the work that we're doing with the patient physician communication and the very important issue of physician distress that sometimes comes from how we're talking to each other. Thank you so much for being here.
Adewuya: Excellent. Thank you so much. I'll start with a general question to both of you before we dive into some specific questions from the articles. And I'll start with you, Dr Weimer-Elder, where do you see a physician leaders most often making mistakes in their communication efforts?
Weimer-Elder: I think in listening, really aren't listening to understand or listening to respond.
Adewuya: That is correct.
Weimer-Elder: I think that we have this great communication tool called listening and it's underdeveloped. What I've learned in the last really 40 years of being a nurse, of being a leader in the military is most of the time it goes down to either not hearing the message that was sent, holding it in our brains differently and not really asking to understand what the message was. So listening is our most powerful tool and it's a brain function, which interestingly enough, we all listen to and for information differently. And we now have assessments that I use in my coaching practice to help people grow in their self-awareness, because if I'm aware of how people are listening and non-verbals tell us how the person is listening. For example, a reflective listener will look down and they'll actually need time to think, whereas a connected listener, as I am dominant in love eye contact not everybody is like that.
So we're starting to learn differences in style. And as Kelley said, with our research, we're learning more and more about those patterns that are our DNA and our styles in personality styles in the articles that we talked about and what are different that are learned skills. So listening is a skill that you can build listening intelligence. And so it's exciting some of the research that's coming out in listening.
Adewuya: Thank you for that, Dr Skeff, any thoughts to add there, even context around some of the research that was referenced?
Skeff: Right. Thank you so much. I as Barbette says with listening, there are particular skills we can gain. And in our work, what we've been recognizing is that probably the most important issue is the issue of versatility. In so many ways, we start to try to study what's the best way of doing something? That's been our scientific model. What's the best way? When we're dealing with human beings who have multiple different ways, the best way may differ from person to person. And so the thought for you and me, and as we began to study teaching, was that I found myself wanting to ally my teaching with the philosophers that I believed in, which meant that I was leaving out a whole bunch of other brilliant people. So the challenge is that how can we have versatility when we've been training people to try to train ourselves to be the set alike?
So our training, in fact, and now our use of cell phones and others I'm worried has actually diminished the versatility that we started with my sense is that we were probably pretty good listeners at the beginning, but then we were taught a series of facts that when our listening to say whether what the other person says fits with our facts. And so instead of just listening for whatever we hear, we're trying to match. So the challenge for me has been to recognize that I have my own belief system and that if you agree with me, I really like to listen. And if you don't agree with me, I don't like to listen quite as much. And so as a physician leader or as a physician or as any other care provider, the secret may well be to say, can I be versatile enough to hear how somebody else wants to hear thing? And then practice doing what they want rather than practice doing what I want.
Now Barbette's pointing out that we're trying to find common particular skills to deal with, but I think for intellectual, I'm going to give everybody credit on this call now because we are a group of intellectual people who want to not only master the skill, but to have the understanding of the principle behind using the skill. So it's listening for a purpose. If I want to listen, because I need to know more about you, I'm going to listen differently than if I'm wanting to listen to just see if you give me the particular facts I want. Some of the chat folks, some of the people on chat, have been pointing out some wonderful things about caring that the physician is with the patient who cares. The physician cares, has an easier chance of listening, than the percent who doesn't care. Now, all of us care, but the issue is what are we doing in a world that's full of so many different distraction for caring when physicians treat each other without much respect how'd that happen? We didn't start that way. So I'll stop.
Oakes: I just have to respond to the concept of really thinking of listening in to as an individual needs and that there are differences. I think in sort of our scientists are the mindset. We talk about personalized medicine with very specific responses. We were recognizing that at molecular levels, patients will respond differently. So also this applies to these interpersonal attractions too. And as Barbette, you pointed out, people may have different preferences for how they take an information and listen, and Kelley, understanding that we often filter out or don't hear the things that don't fit with our mode of our model for taking in information, so.
Adewuya: Yeah, I thought it was such an extremely powerful way to respond to that question in terms of communication, because I think the initial instinct is to say, okay, this is how you should say things and what you should say as a response to the question of what are the mistakes in communication efforts? So I thought it was extremely powerful that both of you, your response was listening and not having to do something, but just actually say something, say the right thing, although that's part of it, but it was taking a step back and listening and understanding how we listen and the versatility around that. So thank you both for synthesizing that and highlighting that as an area that we should be thinking of. And we should be looking at, I want to continue on, oh, go ahead.
Skeff: Ruth your comments struck me about two writers that the audience may be familiar with. But if not, I want to mention them. Simon Sinek and Daniel Pink, are both wonderful writers that have different meaningful to me and speakers as well. As Sinek points out that if our question is, “Why are we sitting there listening? Not what do we listen for? How do we listen? But why are we listening?” That the what and the how can be practiced if one remembers the purpose of the why. And Daniel Pink pointed out that if you have two different groups of people who are trying to mastering their skill, and with one group, you keep reminding them of the purpose of the skill and another group you keep giving feedback about whether they're doing the skill right. It's a group that remembers their purpose, that master the skill faster that if we remember as leader, that the purpose of our listening skill is to improve the people with whom we're working. Then the idea of listening makes more sense than if whether we're using the right behavior.
So I like both and would recommend to them too as that either watch them on YouTube or read their books or whatever, that Sinek and Pink I think have hit something that I tend to forget the why of what we're doing.
Adewuya: Yeah. Excellent recommendations. Thank you for sharing that as well. I want to continue that thread of listening to understand, and the question that an audience member asked about the article that we discussed today, and I think Simon Barbette you also highlighted this, that once awareness, one's own presence. So the question is the article talks about how it's important to maintain an awareness of one's own presence in the conversation to be able to listen effectively. You need to be able to develop the capacity to monitor the quality of your own presence in real time, what to overlay this with the pandemic and all of us having to shift to this virtual meeting, virtual communication, it's now common. How do you maintain that awareness of your own presence when you are limited to a virtual space, any thoughts on that?
Weimer-Elder: Absolutely. It's so important coming out of this pandemic to think about the strategies that I need to practice could be a physician. Now, every physician at Stanford now 30% of their practice is done virtually now. And it expedited overnight. Some people that I coach were up to 99% of their patients, they were seeing virtually. And what it made us think about is normally when you go into a patient's room, you knock on a door and maybe have a way to prepare with intention. The challenge today is the efficiencies, the effectiveness of a physician seeing 20, 40 patients a day is how do I pause, take a breath and remind myself that I need to put on my oxygen mask first. So do I have a water bottle here? Am I taking a sip of water? That sounds very simple, but for some physicians, they don't even take a sip of water.
That's not normal. So to acknowledge, how am I preparing myself to be with another human being physically, I'm talking about Maslow's hierarchy of needs. So taking that moment to be prepared physically, psychologically, you may just have had a very difficult conversation with preparing. So preparing with intention, a lot of physicians now have a little sticky. So when they come out of one virtual visit, they prepare with intention and they focus on that. “How do I take a breath? How do I think about for a second? What I'm bringing this patient?” Because Kelley talked about it's our hearts that brought us here.
That's how we began this journey to be a physician or a clinician or a provider. And what keeps us here is constantly reminding ourselves is I'm with another human being. And the word doctor means teacher, interestingly enough, from the Latin. And how do I prepare myself before I even go into that room and virtually connecting with that other human being? So we at Stanford have, and we can refer you to this is the telepresence five. And here at Stanford, we are co-creating a course to talk about how do we do this in a virtual environment? And that will be done virtually. And we have currently 25 faculty that are certified in this methodology. And we have 18 physicians that are co-creating this with us because we're learning together.
As Kelley said, I don't know the answer, but by listening to the physicians that are practicing, we are learning their best practices and we are publicizing them. I think we need to create more space to what we're learning as physicians crave this opportunity to be together, to share their strategies. And Kelley, you brought this up about feedback is we need opportunities for safe environments to give each other feedback about our practices and what's effective and what we might modify or change. So that feedback needs to be a culture and we need to create new ways. And technologies here is exciting, right? We have new ways to communicate, to augment what we already have.
Adewuya: Excellent. And I think that's such a great segue to my question for Dr Skeff, around feedback and the work that you've been doing in that space. So we know that giving feedback, it has been identified as perhaps one of the most commonly lacking skills among leaders. What do you see are the major pitfalls or mistakes that we can make when we are trying to provide challenging feedback to our colleagues?
Skeff: Thanks, Ruth. I'm going to try to draw on two or three different schools of thought on feedback, one capitalizing on Barbette's point. And that is that if two people are communicating about what one is doing that, an initial step that's easy to forget is the step that we think about when we're talking to patients, but may not think about when we're talking to colleagues and that's to establish the relationship between the two people. As we studied teaching what we recognize that if a teacher doesn't establish a relationship with the learners to where the students that they're teaching care, realize they care, much of the material that's presented gets lost, but it's in the first step of establishing a relationship that makes the feedback one thing that could come across and be more effective.
Now, it's rather interesting that with technology feedback can be even more sterile and relationships can be totally forgotten. For example, we often give feedback to physicians now in organizations as to how they're performing by giving them a comparison of their performance with another group's performance side-by-side and under lyrical fashion.
So people open their emails to see how they're doing in comparison to others, where 93% somebody else's 95. We're 92, somebody else's is 90. So what comes to mind there as the emotion of having won against somebody else or lost against somebody else. So the feedback to an organization of physicians in health care, which should be, how do we raise everybody's performance? Is being given in a way to actually foster the competitive model that has gotten everybody where they are now. Without an introduction to say, what is the relationship and the purpose of the feedback. If I find out that my group isn't doing poor less well on screening for cancer, do I concentrate on what or how well we're screening for cancer? Do I concentrate on the number that I'm given as a percentage on how well my group did?
Because people in medicine have been living on numbers since they were in high school, they concentrate on the number and they feel good or badly based on how well they did on their numbers, not on how well we're doing in cancer screening. So I'm going to refer again back to Pink and Sinek and Cole and others for communication, where the establishment of the relationship and the purpose is often forgotten and totally neglected as the feedback is given in a numerical technological way. Two wonderful scholars, one from Harvard and Stanford, Gardener and Showman wrote about the fact that technology has made it possible to let people know how well or how badly they're doing so fast, that we're now saying technology as the punishing instrument to tell people how badly they're doing.
So one of the physicians who told me look, says, “I don't want to open my email anymore because there's never good news. It's always how badly are you doing in comparison to somebody else.” So I would suggest that the technology and the feedback principle of relationship and purpose are commonly forgotten as we're giving feedback to each other.
Oakes: I have to say, I think that's such an important reminder of what is the purpose of feedback? I think sometimes it's used as a stick in some settings, but there is an opportunity just to use it as an opportunity to water and fertilize someone and develop them. And I think that we might miss that because we don't develop the relationship. These feedback mechanisms you mentioned don't have any relationship to the person.
Adewuya: Excellent, excellent point. I want to address or throw out a question that was asked by an attendee through the Q and A. It says, this question relates to the first article around different communication styles and types. And the question is, if you have any suggestions for how to navigate when there is a need to have a conversation based on regulations where there is a clear hierarchical structure, for instance in a disciplinary setting, and then transitioning back to a person centered approach. And so I think this has to do with the person centered approach versus the positional centered approach. And I don't know who wants to go first, but then you might want to try answering that question?
Weimer-Elder: Sure. I can start if you want me to. One thing that I think about all the time is, was I clear, are the expectations clear? I try to put it on myself because most of the time I find is that the person I might've made an assumption that the expectations are clear and even having been in the military for 26 years, I go back to myself. Was I clear on the expectation? Does the person know the [inaudible] policy? They might not. I'm making an assumption again. So I start with the ask. I find that out first. And from that point I use a technique called an art loop. I asked again, it's about the relationship of you and me and the environment that we're practicing. So our expectations clear once I find that information out that they may not have been, it's my opportunity then to emotionally respond to that.
So acknowledging it with, wow, we have a lot of policies here in the military, and I was hoping today that I could explain some of these policies. So always going back to reflecting back as a leader, when I ask somebody something there are already, scared, I mean, feedback. I like to think the word alone is triggering. So I'm in a tango with another person, a metaphor of a dance is giving feedback is finding out where that point is that we're on the same level. Once I know that, then I can respond to that emotion using a statement of, I really want to make sure that the expectations are clear. So let's review the policy. And then I tell, so most of us are in a tell mode and that's what's different about a relationship centered approach. As you start with humility, asking then partnering with the person through listening and learning together, where are they? And I think expectations, if you look at all the research, the correlations are expectations clear.
Once I know that they are clear, I say, there's three reasons people don't perform. It's skill, will or hill, and you can have leadership conversations based on that. So that would be my starting point. Kelley, what would you like to add?
Skeff: Oh my goodness. What a wonderful topic, Barbette, thank you for that. Two or three things that I would like to highlight. One is that the person's question about how to deal with the person centered versus task-oriented leadership style, is I would go back to my suggestion about versatility and try not to get into a situation where you believe that one of those is good and one of those is bad. There are times in leadership where it's a really task oriented leadership question. And that's when Barbette's point about are the expectations of what we want clearer? Now that's based on a person-centered relationship, but if the task-oriented process so that when I found myself making an error and was trying to buy one model and eject the other, because there's times in a leader, when you are task oriented and the clarity of the expectations of what it is, or the reason for your success.
And there are times where as a leader, it's a caring process. Now, as we have defined in our teaching course, which I can now say, I guess I can say this there on campus, that there's a Stanford [Sammy] approved course on teaching that as of two months ago, we now have online, called mastering medical teaching, which I would invite you all to take largely because I think it's very helpful and it's a result of 35 years of work. Our definition of feedback is the process by which a teacher gives the learner information about their performance for the purposes of improving their performance. Now, the most important part of that definition is the last part. The feedback is for the purpose of helping people, for the purpose of helping them become more of what they want to be. And as we think of what our expectations are, we defined our expectation and our goals as goals for the learner, not expectations of the learner.
What do we hope for you? And then how can we give you feedback for the hopes that we have for you? I hope you're hearing a positivity of all this, that the feedback is for you to become as well and as good as you want to be in our profession. So where I shouldn't have to be resistant to what you're doing for me, but if I have to think of what you expect of me, then that can commonly be a messenger, but not on what I'm doing for you rather than for me. So all of this appropriate relationship work is for both people, the feedback giver and the receiver to both get better as we share information. So I didn't anticipate getting the opportunity to mention the course by mastering medical teaching, and it will taking about 12 hours to take that. And I would hope that some of you will do that.
Adewuya: Thank you for sharing that.
Oakes: And teaching is one of our core forms of communication and medicines. We often teach each other and we teach our patients so wonderful skillsets.
Skeff: And I mentioned, Daryl, that one of the things I've found in leadership models is if the leader sees themselves as a teacher, it changes the model because the person who is a teacher is thinking about helping a learner. And if we think of our colleagues, when we have a brief collision between colleagues, if we think of ourselves as a teacher and a learner and how we're helping a colleague learn, it changes our mindset into being more open to what we can do.
Adewuya: Along the same lines of what you mentioned that riff that can develop between physicians and clinicians, the 2010 joint commission noted that the most frequent reason given for the root cause of sentinel events is a communication failure between physicians. However many physicians may feel that they already have good communication skills and so they don't need to work on this skillset. How can we help physicians appreciate the opportunities for growth in their communication skillsets, and Daryl I'll throw this question out to you.
Oakes: With this question, I think it's always humbling and I will just maybe share a story as a clinician, thinking that I'm good at reading my patients or responding to them or that I actually understand what they want at different moments. And I'm an anesthesiologist who does anesthesia seizure for heart surgery, but can be very anxiety provoking. And I had a patient who I was trying to verbally distract by talking about their lives. And he said, “Can we not talk about my personal life?” And I was surprised because a lot of times people have asked me to talk and dialogue and provide this. And I thought, oh, that's so interesting. I didn't stop to ask what would be helpful for this person. And I think we can all have those moments where we recognize that we may have lots of skillsets, but there are blind spots. And so I think it's hard though, for people to recognize the value of that in the moment and curious what you both think as educators in these skillsets, how to help people see where the gaps are.
Weimer-Elder: First and well, Daryl, thank you so much for sharing your personal story, because I think we learn from our challenges or failed. Because that's the first thing is that some patients feel comfortable enough to make a statement back to us. And we're getting feedback as you pointed out earlier all the time non-verbally. So what is that feedback that we could notice through pausing and calling out explicitly what we're noticing? I'm noticing that you're tapping your pencil. Would you like me to focus on something different? So even calling out something non-verbally, you can name the emotion, the patient or the other person will tell you whether or not you named it. So noticing, I think also in addition to the verbal pieces is so important, noticing that feedback that you're getting all the time. Kelley, other things that you'd like to add?
Skeff: Well, thank you, Barbette and Daryl. Well, this is an area very close to my heart. One of the things that got me into the field of medical education was the sadness that I observed when I would hear physicians talking about other physicians in a derogatory fashion. Now, I think it's really important to know as somebody who ran a training program for 20 years, that we teach this unfortunately, we actually teach in such a way that it may well be that one group of physicians feels better when they make a diagnosis that somebody else didn't make. Even as hospitals compete with each other, come to our hospital and we're do a better job than the next hospital. We actually feed a system that makes us adversarial with our colleagues. So it's no surprise that colleagues are talking about sadness and distress coming from relationship with colleagues, because we have fed a competitive model in our teaching process, but a minimal switch of that is for us to take responsibility for the quality of care provided by our colleague.
So when somebody from another institution has seen a patient and then they come to our institution and we find out that a mistake was made, how often do we call the other place to say, we now have had enough data to realize there was statements made, we want to make sure you know about it and let us know if we make any mistake. The risk management folks in hospitals say that we're not very good about telling each other about our mistakes and helping each other when we make them. One of the suggestions that I'm having now is if we practice with each other, the same principles we talk about with patients, we will actually move into a better leadership role that our commitment to each other, as physician is equivalent to our commitment, to our patient and equivalent to our commitment to our institution.
We don't do that. We sometimes take pride when other physicians make a mistake, take pride. If somebody else made a mistake and we got it. So I think this is fairly deeply seated in our educational system that we have to recognize that we have to learn to commit ourselves to each other. At the same time we commit ourselves to patient. Now I hope you sense my emotion and this virtual model, but this is something we have a lot of work to do on, but it's such an easy switch to realize that we're in this together. And if we don't help each other whenever we're giving feedback, then we're missing the boat.
Oakes: That is such a powerful way to frame it. And thank you for framing that I think we are in an environment that encourages individuality, but we are so much better if we work and support each other.
Adewuya: And I would just add to that, that it's clear that when we support each other, we also create an environment that is positive, that is safe, and that is also inclusive for everyone. And I think communication can play a role in that. And communication can be a key factor around that. I wanted to, I think we have maybe three more minutes. And so I wanted to end with the one final question for each of you. And if you can provide us with, what are your thoughts and your favorite or effective listening and communication strategies? If you had choose maybe two or three, and I know that's hard to do, but what do you recommend for audience around listening and communication strategies? And I'll start with you Barbette and go to Kelley and then Daryl.
Weimer-Elder: I think the one thing that I always laugh about is that I may work with the premise that communication has happened and it hasn't. So my favorite is teach back, which is I ask, I've done a lot of talking in the last few minutes and I just want to make sure that I didn't miss anything and just see what I get back, because I'm amazed at what comes back. And if you really listen, you then have feedback about maybe how you might alter the information that you said, because at the end of the day, what is it that you want the other person to understand? Why is it so important? And so what? And then the now what? So that teach back, don't cut it off. It's the way of assessing whether or not you're communicating with the other person.
Adewuya: Right. Thank you. Dr Skeff?
Skeff: Good. I was just processing what Barbette was saying. I think for me, the secret is in the two words hopes for, if I can keep reminding myself or what are my hopes for you? Whether it be for the patient, for my colleagues, for my institution, that if I keep my hopes for you and mine, then I will then become more committed to mastering the skills to have that happen. It may not be what I say to myself as I pause between patients as Barbette pointed out, people are trying to do what are my hopes for this next patient? And what are my hopes for you? So that's what I would suggest. If repeating hopes for the other person and then we'll return to the philosophy that got us all in this field.
Adewuya: Thank you so much.
Oakes: Ruth, it's hard to live up to these fantastic answers. I do have to say the one tried and true responses to always assume that the person that I'm giving feedback to is doing their best and they're trying their best. And I take the approach that my job is to help them be better and that together we're going to help them be better. And that this is a team effort and that we're here to champion them on. And if I have that energy it's just a very different interaction.
Adewuya: Fantastic. Thank you so much for those thoughts. And I synthesize it and repeat that. I think what I hear is teach back, hope for, and that our role here is for folks to be better. And so our role is just [inaudible] that people are doing their best and that we're just here to make people be better as well. So thank you all for that. And I think we are at time. So we'll wrap up our time by saying thank you so much to both of you for being Dr Weimer-Elder, thank you for your time, Dr Skeff, thank you for your time. And for both of you, for your insights that you've shared with us, I know that we could talk forever on this topic, but in the short amount of time, I think there were so many insights that were shared. So Daryl, I'll turn it over to you.
Oakes: I just want to reiterate, thank you to both of our panelists, Ruth, thank you for moderating a wonderful discussion. This was a very informative and I think just such an important topic that I think we all often talk about that, oh, we communicate all the time, but I think there's so much richness and depth in this area that we can all be better. So thank you. Thank you all.
Adewuya: Excellent. Thank you all. And our next session will be August, 17 and we look forward to seeing you there. Bye.
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Stanford University School of Medicine
Clinical Associate Professor of Anesthesiology, Perioperative and Pain Medicine
Kelley Michael Skeff, MD, PhD
Barbette Weimer-Elder, PhD, RN
Director Physician Partnership Programs
References:
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