CONNECT Workshops to Enhance Physician and Patient Experience: Interviews Reveal the Physician Perspective.

INTRODUCTION: Physicians' relationships with patients are a critical determinant of job satisfaction, and patients who experience compassionate care have better outcomes. The CONNECT workshop at Seattle Children's teaches communication strategies to optimize both patient and physician experience. This article describes participants' experiences during the workshops and the impact on their subsequent behaviors and satisfaction.
METHODS: Thirteen semistructured interviews were conducted with physicians, representing 11 specialties. Researchers used a series of immersion-crystallization cycles through which they iteratively immersed themselves in the data by reviewing all transcripts and coming up with key themes. According to thematic findings, they adjusted the interview guides, adding or deleting probes. After crystallizing an initial list of key themes, they created a codebook, coded using qualitative analysis software and met after coding each transcript to discuss their codes, add, and change codes, and recode when necessary.
RESULTS: Researchers identified 2 thematic responses concerning workshop experience. Physicians valued colleague interaction (Theme A) and appreciated the nonprescriptive curriculum (Theme B). Likewise, 3 themes reflecting workshop impact also emerged. Physicians reported the workshop encouraged presence and self-awareness during patient encounters (Theme C). They learned to address patient-driven concerns (Theme D), and learned empathetic strategies to connect more deeply with patients (Theme E).
CONCLUSION: This study offers perspectives from a diverse group of physicians concerning their experience with the communication workshop, including the opportunity for physicians to focus on self-discovery, authenticity, connect on a deeper level with colleagues, and adopt key strategies to enhance interactions with patients.

INTRODUCTION

The human connection between provider and patient is the foundation of compassionate health care. Patients treated with empathy and compassion have better clinical outcomes,[1,2] while physicians report that their relationships with patients are the most significant determinant of job satisfaction.[3-8] The Institute for Healthcare Improvement identifies “compassionate communication” as a key driver of exceptional patient and family experience.[9]

The Schwartz Center for Compassionate Healthcare defines compassionate care as that which “addresses the emotional and psychosocial aspects of the patient experience and the patient’s innate need for human connection and relationships…recognizing the concerns, distress, and suffering of patients and their families and taking action to relieve them.”[10] Empathy, as defined by Dr. Helen Reiss, is a neural process that “enables us to perceive the emotions of others, resonate with them emotionally and cognitively, to take in the perspective of others, and to distinguish between our own and others emotions”[11] and strongly contributes to the delivery of compassionate care. Communication skills such as listening, eye contact, showing interest in the patient as a person, expressing caring for the patient’s situation, and explaining things in a way the patient can understand are critical aspects of demonstrating empathy and compassion to patients.[12]

Despite the importance of compassionate care, it is often lacking. A 2010 survey of 800 recently hospitalized patients and 510 physicians found that only 53% of patients and 58% of physicians reported that the health care system provides compassionate care.[13] Productivity demands, time constraints, and focus on the electronic medical record, require that physicians become skilled at quickly establishing rapport and trust with patients. Unfortunately, many physicians are unprepared to meet this challenge due to the absence of formal communication training and systemic barriers inherent in many healthcare organizations.[13,14] Physicians can modify practices to better connect with patients when exposed to strategies and techniques, such as self-awareness, small group discussion, modeling, role-playing, and feedback, that enhance communication and empathy, thus leading to greater satisfaction and meaning from their work.[8,15-19]

Recognizing both the importance of compassionate communication and that most of our physicians had not received formal training in this area, the CONNECT workshop at Seattle Children’s Hospital (SCH) was developed to introduce communication strategies that optimize both the patient and physician experience.[3]

The CONNECT Workshop

The CONNECT workshop[3] recognizes the challenges of engaging busy clinicians in any quality improvement endeavor. Thus, it is designed to appeal to a physician’s sense of purpose. Through a process of self-discovery, physicians develop authentic behaviors and language to communicate better with their patients. The workshop is experiential, focusing on strategies demonstrated to be effective in teaching communication skills: small group discussion, feedback, and role-play.[20-23] Participants in this study each attended one 4-hour workshop. Each workshop was co-facilitated by external consultants with expertise in healthcare communication. One consultant is a clinical psychologist, and the other is an emergency medicine physician employed by another health care system in Seattle.

Additionally, authors H.B. and J.S. attended all workshops, with H.B. playing the roles of physician champion and third facilitator; J.S. provided logistical and facilitation support. “Presence” and empathy are predominant workshop themes, with the goal of quickly establishing rapport and trust with patients and families. Other aspects of the curriculum are summarized in the CONNECT Model (Fig. 1).

Fig. 1.

The CONNECT model that served as the basis for the communication workshop.

Research Question/Aims and Objectives

CONNECT Program leaders wanted to understand how the workshop might foster a positive physician experience while teaching techniques to create a positive patient experience. Survey data collected at the end of each workshop indicated that physicians generally had positive reactions to the training (Table 1), but the program wanted more detail on physician reflections about which aspects of the workshop are most valuable, and to capture detail and richness about the unique ways that physicians were applying workshop elements to daily practice. With these exploratory goals in mind, the program leaders decided upon a descriptive qualitative approach using Crabtree and Miller’s iterative immersion/crystallization analytical techniques to interpret and organize their data. Researcher E.J.F. conducted a series of interviews with previous workshop participants aiming to understand their experiences during the workshops and to describe the enduring impact of the workshop’s content on their behaviors and job satisfaction.

Table 1.

CONNECT Postworkshop Survey Results

Setting

SCH is a 354-bed academic hospital in Seattle, Washington. The majority of physicians providing care at SCH are faculty of the University of Washington School of Medicine and employed through a physician practice group, Children’s University Medical Group (CUMG). The CONNECT Program is co-sponsored by SCH and CUMG.

METHODS

Sampling and Recruitment Procedure

Physicians were eligible for recruitment after completing 1 of the 13, 4-hour CONNECT workshops offered between March 2015 and January 2016. They were also current employees of SCH/CUMG. Twelve of the 13 workshops were clinical- specialty-specific, meaning that all of the workshop participants were from the same clinical division. One of the workshops included physicians from a variety of clinical specialties. The decision about whether a division would participate in the CONNECT workshop was made by each division’s physician chief, often in collaboration with an administrative leader. The CONNECT team worked with each division’s administrative leadership and support staff to schedule the workshops. Any physician was welcome to attend the workshop, and there were no inclusion criteria. Logistical issues such as the need for clinical coverage and scheduled time off were the reasons that some physicians did not attend a workshop with their division. For large specialty areas, such as Cardiology and Urgent Care, the CONNECT Program offered multiple workshop sessions so that most physicians could attend.

Author H.B. sent an e-mail to all CONNECT graduates introducing the study and letting them know a researcher might contact them. The team used a random number generator to randomly recruit at least 1 physician from each of the 13 workshops. Next, the team sent those randomly selected physicians personalized recruitment e-mails. Four physicians passively declined by never responding to the e-mail, and 3 actively declined. If the researchers received a decline, they repeated the random number generator process within that same workshop cohort until successfully identifying a participant. Studies have shown that researchers can achieve saturation, the point at which they are producing little or no changes to the codebook, within 12 interviews.[24] There was no financial incentive to participate in this study. Seattle Children’s Internal Review Board deemed the study a quality improvement activity focused on educational practice in an educational setting and not human subject research. Therefore, internal review board review was not required. Additionally, the study team was concerned that participants might feel compelled to make positive comments if they believed that the developers of the workshop would know how they had responded. To address this concern, the identity of the physicians participating was known only to the interviewer who is a consultant from outside the organization.

Interviews

Author E.J.F. interviewed 13 physicians between October 2015 and February 2016, conducting 11 interviews in-person and 2 by phone due to scheduling constraints. Interviews ranged from 20 to 45 minutes. The CONNECT team deployed a contracted qualitative research consultant (E.J.F.) to eliminate bias.

The researchers developed exploratory interview questions to understand better providers’ CONNECT training experiences, including their reaction to the training itself and ways in which training may have affected their clinical practices. For this reason, questions were generally open-ended to give participants the opportunity to provide unique insights. The interviewer asked physicians which aspects of the workshop resonated with them; which aspects of their clinical practice adjusted after participating in the training; if they experienced any barriers to implementation, and for any suggested improvements to the training (Fig. 2, Interview Questions).

Fig. 2.

Demographic and study questions that the interviewer asked physician participants.

Analysis

All interviews were digitally recorded and transcribed by an independent transcriptionist, then input into Dedoose 5.0.11 web-based software for analysis.[25] Two of the study authors (E.J.F., J.S.) independently coded the transcripts and met regularly to discuss codes. H.B. reviewed thematic findings and provided guidance twice during thematic analysis. The varied perspectives allowed for a “checks and balances” of preconceived notions and in-depth content expertise.

The analysis team used an immersion-crystallization analytic style, whereby researchers immersed themselves in the transcript data for multiple cycles until all pertinent themes arose. For the first step of this iterative process, both researchers independently read individual interview data, found thematic patterns, and ways to link those findings. Throughout this first step, based on their findings, they adjusted the interview guides by adding or deleting probes. Next, they systematically re-read each transcript and line-by-line tagged text segments, and from those tags developed codes to insert into a preliminary codebook. This codebook evolved as open coding took place. The researchers added or changed codes as they arose through the continual immersion-crystallization analysis process. After each transcript was coded, they met at weekly research meetings, during which the team determined the most pertinent emerging themes that arose across sites. These points of thematic crystallization guided their decisions on how to finalize their codebook.[26]

After crystallizing an initial list of key themes, they re-read the data, created a codebook, and coded using qualitative analysis software. They then met after each transcript to discuss their codes, upon which they added and changed codes, and recoded when necessary.

The research team performed member checking or the process of sharing the data back to the interviewees to both validate and find out what gaps may exist. Data were shared back to a total of 8 CONNECT trained physicians; 5 were interviewees in the study and 3 were noninterviewees who had completed the workshop in the same period as the interviewees.[26-28] All 8 physicians affirmed that the summarized themes reflected their views and experiences and no additional themes emerged to challenge the results.

RESULTS

Table 2 summarizes the characteristics of the 13 interviewees. Participants included 8 female and 5 male physicians, representing a broad range of specialties: 3 hospitalists, 2 urgent care/emergency medicine specialists, and one of each of the following: cardiologist, nephrologist, general surgeon, infectious disease specialist, orthopedic surgeon, endocrinologist, gastroenterologist, and intensivist. All interviews were collected 1 to 6 months from the date that the physicians attended a CONNECT workshop. Interviews generated responses clustering around themes of physician experience during the workshop and changes they had made in their practices following the workshop.

Table 2.

Participant Demographics

Theme A: Workshop Experience: Colleague Interaction and Feedback

Physician participants reflected on the value of colleague interaction and feedback experienced while participating in the workshop, as summarized in Table 3, Theme A. These interactions included the opportunity to share and reflect on personal experiences working with patients, as well as the opportunity to learn from colleagues’ experiences. Physicians valued sharing perspectives and opportunities for optimizing best practices. Physicians shared that once medical training is complete, health care systems seldom build observation and critique into physician workflow (Supplemental Table 3: Theme A, available at http://links.lww.com/PQ9/A49).

Theme B: Workshop Experience: Emphasis on Self-discovery

Several physicians had positive views on what they perceived as the nonprescriptive and flexible workshop curriculum, as summarized in Table 3, B. Many appreciated the workshop’s emphasis on self-discovery through which facilitators encourage physicians to find and practice their style of demonstrating caring and “presence” with patients, rather than focusing on scripted statements. (Supplemental Table 3: Theme B, available at http://links.lww.com/PQ9/A49).

Theme C: Workshop Impact: Presence and Self-awareness

Physicians described how the workshop curriculum encouraged a sense of presence, self-reflection, self-awareness, and mindfulness, as summarized in Table 4, Theme C. Examples include taking the time to reflect on how patients’ families perceive their communication styles, giving families their undivided attention, creating a greater sense of presence with the family, as well as an increased awareness that there is an opportunity for growth (Supplemental Table 4: Theme C, available at http://links.lww.com/PQ9/A50).

Theme D: Workshop Impact: Identifying Family-driven Concerns

Most physicians interviewed commented that they had learned the importance of incorporating the patient’s and family’s goals into their agenda for the clinical encounter, as summarized in Table 4, Theme D. The workshop reminded them that a key aspect of providing compassionate care is the physician’s ability to understand the patient’s concerns and perspective, then tailor their approach to address those concerns. Physicians expressed surprise that when they practiced this technique, the family often identified a top concern that was different from the problem identified as the reason for the visit (Supplemental Table 4: Theme D, available at http://links.lww.com/PQ9/A50).

Theme E: Workshop Impact: Learned Empathetic Strategies to Connect More Deeply with the Patient

Overall, physicians responded that the workshop gave them a greater sense of what it means to be empathetic and fully engaged with their patients’ concerns, as summarized in Table 4, Theme E. Some physicians spoke about the repetitive nature of patient interactions, and how at times, that pace can detract from how they convey empathy. Although encounters may be routine for providers, a recognition that each experience is unique to patients and families helped providers to feel and convey empathy. The workshop was a welcome refresher to honor the patient experience and perspective, especially before engaging them in a medical conversation. A CONNECT Program video featuring the stories of physicians who are also parents of children treated at the hospital was especially powerful in understanding and feeling empathy for the patient and family perspective (Supplemental Table 4: Theme E, available at http://links.lww.com/PQ9/A50).

DISCUSSION

This study presents the results of physician interviews describing the impact of the CONNECT program at SCH. Main themes highlight how a workshop focused on enhancing interpersonal connections between physicians, patients, and their families can provide a collegial, affirming experience of self-discovery, as well as teaching specific, impactful techniques for communicating with patients.

Participants reported that the workshop provided the opportunity to discuss the practice of medicine with colleagues in a way that they rarely have time for in their busy clinical schedules. This finding builds upon the finding by Beckman et al.[22] that sharing personal experiences of practice with colleagues in a nonjudgmental setting reduces professional isolation and is one of the most meaningful outcomes of their program to teach mindful communication. Our study found that in addition to conversations enhancing connection with colleagues, the opportunity to see other physicians practice the skills and provide feedback without judgment was a valuable learning opportunity for individual physicians. Based on these findings, organizations developing communication workshops for physicians may want to include time for discussion about personal experiences both within small breakout groups and among all participants in the workshop. These discussions may also increase trust between participants and enhance comfort with the role-playing component of the workshop.

CONNECT workshops are designed to be experiential, intending for participants to have moments of self-discovery that would be more engaging than didactic curriculum, thus leading to more ready and sustainable adoption of the concepts and behaviors into physician practice routines. This premise is borne out in that interviewees liked the unscripted nature of the workshop, which encourages participants to find their own authentic words. Each physician interviewed was able to identify at least 1 new strategy that he or she had adopted since the workshop. Three of the most frequent were (1) identifying patient and family concerns; (2) verbally expressing empathy; and (3) adopting a ritual that enables them to be “present” with the patient and family during the encounter. The authors posit that if all providers adopted these habits, patients would experience compassionate care more frequently. They also believe that both explicitly and implicitly connecting the physician and patient experience engages physicians as partners in improving their practices. Since its earliest days, the CONNECT Program has started every interaction with physicians by working to engage them in WHY this work is important before moving onto WHAT the work is and HOW to do it.[3] Physician engagement in these early workshops may indicate that such efforts are an important foundational step in changing physician communication practices and mindsets.

The training video, “Lessons from the Other Side of the Bed: When the Doctor’s Child is Sick,” featuring peer physicians whose own children were patients at the hospital, is an element of the curriculum that particularly appeals to the physicians’ initial motivations to practice medicine. Participants reported that the video helped them better understand the patient and family perspective and reminded them of the importance of focusing on the relational aspects of care, not only for the family but also for themselves. The video’s influence on the physicians in this study indicates that colleagues can be influential even when not physically present in the session and suggests that perspective-taking and empathy can be learned or re-learned as suggested by Riess.[19] The video’s impact also illustrates the power of storytelling, as physicians often cited specific comments from the video as particularly influential. The video has been particularly impactful at Seattle Children’s, where physicians recognize their peers. It may also be helpful to other organizations and is available on YouTube.

Both patients and physicians value the therapeutic relationships they share.[1-9] Compassionate care promotes these connections, driven, in large part, by the physician’s desire to better understand the patient’s perspective. Unfortunately, many demands placed on physicians can interfere with their ability to be truly present with patients. In this study, physicians reported that strategies that enhance their feelings of being truly present were among the most impactful to their practice. “Presence” appears to underlie the related strategies of attending to patient and family needs and expressing empathy, as physicians must be attuned and attentive to patient needs. This observation is in line with the findings by Krasner et al.[29] that when physicians focus on self-awareness and mindfulness, they experience greater empathy for and orientation toward patients, which is in turn associated with patients feeling a greater sense of trust. Likewise, the 3 CONNECT strategies (presence ritual, identifying patient-driven concerns, and expressing empathy) are fundamental to delivering compassionate care. Furthermore, these behaviors can amplify the sense of meaning that physicians derive from their work and are thus a potential remedy for the crisis of burnout in healthcare providers.[30] Physician well-being is a critical factor in patient safety, clinical outcomes, and quality of care.[31-33]

This work highlights multiple opportunities for future research. The study demonstrates that a wide range of physicians at different points in their careers had an overall positive reaction to the workshop and indicated that the 4-hour training resulted in a self-reported change in behavior. Follow-up works to observe the practices of physicians pre- and postworkshop, at multiple points in time (immediately following, 6 months later, a year later, etc.) would strengthen these findings. Future studies might assess the impact of “booster” training sessions on maintaining behavior change over time.

Limitations

This study has the limitations inherent to qualitative research. Although the data from this study suggest an association between the workshop and improved personal connections to patients as well as increased meaning derived from work, the sample was small and limited to a single institution, which limits this studies’ generalizability. Additionally, we recognize that the physicians who agreed to participate in interviews may inherently have increased buy-in regarding the effects of CONNECT potentially introducing bias. Furthermore, 4 of the physician participants were inspired to seek out additional CONNECT resources beyond the initial workshop, which may have further enhanced their understanding and adoption of workshop techniques. Finally, the time interval between workshop and interview varied among subjects, which may have biased the findings.

CONCLUDING SUMMARY

Researchers interviewed physicians who completed the 4-hour CONNECT workshop at Seattle Children’s about their experience in the training and the enduring impact that the concepts and strategies had on their practices postworkshop. Relational themes were most prevalent, both regarding the opportunity for physicians to connect with colleagues during the workshop and adoption of key strategies to enhance compassionate connections with patients and families. Physicians expressed a greater sense of “presence” with patients and more empathy for their patients’ perspectives and needs. Also, the focus on self-discovery and authenticity appealed to physicians and may have been a motivating factor in their incorporation of behavioral strategies. The findings of this study may be generalizable to other healthcare organizations striving to develop or refine provider communication workshops and thereby enhance the experience of care for patients, families, and providers. Lastly, by augmenting physician/patient communication and boosting physician fulfillment and well-being, measurable improvements to clinical outcomes and patient safety may be realized.

ACKNOWLEDGMENTS

The authors thank the 13 physicians who made themselves available to participate in interviews for this research as well as the 3 additional physicians who reviewed our results through the member checking process. The authors are indebted to Robert Sawin, MD, for his sponsorship and support of this work as well as comments on an early version of the article. The authors also gratefully acknowledge the work of Robert Tull, PhD, and Nina Greenblatt, MD, for their collaboration in developing the CONNECT workshop and for their facilitation of the 13 workshops. The authors thank Kelly Schloredt, PhD, and Julia Wignall, MA, for their review and comments on earlier versions of this article.

DISCLOSURE

One of the co-first authors (E.J.F.) contracted with the Seattle Children’s study team to consult on study design, conduct interviews, code results, and co-write the article.

Table 3.

Themes Related to Experiences in the Workshop

Table 4.

Themes Related to Workshop Impact