Chapter 09: The iCare Program [Interpersonal Communication And Relationship Enhancement]

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Chapter 09: The iCare Program [Interpersonal Communication And Relationship Enhancement]

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In this chapter, Dr. Baile talks about how he developed MD Anderson’s iCare Program [Interpersonal Communication And Relationship Enhancement], serving as the founding director since 2007. He explaining how he left the position of Head of the Section of Psychiatry, a move that came just after he had applied for money from the University Cancer Foundation to make communications videos available via a website. Dr. Baile observes that there was a lot of interest in communication skills at the time and he explains that he adapted his conceptual model of teaching communications via socio- and psycho-dramatic examples. He talks about the different audiences for communication teaching within MD Anderson and the evolution of the program. He explains that, for the last three years, he has been training medical oncology fellows by videotaping them breaking bad news and then giving feedback. He notes that he plans to retire in 2018 and hopes to offer one on one feedback sessions before that time. He explains why some doctors are reluctant to take communications training in contrast with nurses, who are more often willing to do so. Next, Dr. Baile comments on “MD Anderson silos,” noting that a lack of collaboration can result in ineffective programs. He uses the “Language of Caring” initiative as an example. (He was not consulted, though he feels he was uniquely placed to contribute.)

Identifier

BaileW_02_20160823_C09

Publication Date

9-1-2016

City

Houston, Texas

Topics Covered

The University of Texas MD Anderson Cancer Center - Building the Institution; The Researcher; Discovery and Success; Evolution of Career; Professional Practice; The Professional at Work; Leadership; On Leadership; Mentoring; On Mentoring; Education; On Education; Building/Transforming the Institution

Transcript

T.A. Rosolowski, PhD:

Can I take you back to that time? It’s, I guess, 2003, 2004 when you began to focus really intently on the communications issues here at MD Anderson. So tell me about that, because obviously during that period when you were section head you were building all of this. So what was the breaking point when you left that job?

Walter F. Baile, MD:

There was a very important beginning. Bob Bast had a friend from Canada named Rob Buckman, and so one day he called me and said, “I have a colleague here.” So I had become a little bit interested in communication skills. And my colleague Renato Lenzi and I had done some work around this issue with fellows in a very naive way. And then I met Rob. And Rob had written a book on breaking bad news. And so he and I hit it off. And Rob was one of the most creative people that you’ll ever meet and very funny. And he had a comedy show when he was a resident in England.

T.A. Rosolowski, PhD:

Yeah, you mentioned that last time. He worked with John Cleese.

Walter F. Baile, MD:

Right. And so Rob and I got some money from UCF through Bernard Levin, who knew Rob.

T.A. Rosolowski, PhD:

UCF. I’m sorry, what is that?

Walter F. Baile, MD:

University Cancer Foundation, it’s a charity. And we went to Canada and we made the movies that you see on the Web site, which are still relevant. And you see Rob enacting all of that stuff. Rob was brilliant, and his only regret in life is that he wasn’t pretty. Because he did so much camerawork. And he’s a funny-looking guy. So he used to always tell me, “Walter, the camera really likes you, I wish they liked me that much.” But Rob has done stuff for National Geographic. He’s done a lot of movie film kind of thing. He’s probably as funny as Woody Allen, although he never took the comedy route. And so Rob and I did a lot of stuff together. A lot of video, a lot of filming. And so I became comfortable on camera. So we have an ACE lecture series now in which we bring outside speakers in to talk about a communication topic. And we have four speakers a year, and I interview them for our Web site, so they can tell their story about what they’re doing and how they became interested in the topic they came to talk about. And it’s been very productive.

T.A. Rosolowski, PhD:

And Bob Bast, he was the one that introduced you?

Walter F. Baile, MD:

To Rob Buckman.

T.A. Rosolowski, PhD:

To Rob Buckman. So how did the actual position and your involvement with I*CARE come about? When did that get all formalized?

Walter F. Baile, MD:

I’ll tell you what happened. So we made DVDs, because that was the technology back then. We made video, and then we had the video put on DVDs. And so we had all these DVDs which we gave out at meetings and ASCO and all these other places. And then Rob and I were on an ASCO panel around communication skills. And so when I went and looked at this job at Memorial and I came and they offered me a new position and they said, “Well, what would you do?” I said, “Well, I’d create a communication skills training program. And the first thing I would do is take these DVDs and stream them online so that people have more access to them.”

T.A. Rosolowski, PhD:

I need to ask a crass question, which is obviously you’re in this funny position where your department chair wants you out. Or is not supporting you. And yet you’re obviously building coalitions. Was there a political issue about you staying or leaving?

Walter F. Baile, MD:

The issue was this: that it wasn’t as if the chair wanted me out. I found myself in a position where I had a lot of responsibility but no authority. And that’s something I never want to be in. And I had people who for many practical purposes were dysfunctional. So my job was to crack the whip. That’s what you do. You keep people in line and you keep them doing their job in addition to nurturing them. So one of my colleagues who was reporting to me wasn’t doing her dictations. And I said, “You know, you’re not doing your dictation.” “Oh yes I am.” And I came with a log showing that there were 30 dictations not done. “That must be wrong.” So how do you deal with people like that? And after a few years I said, “Why am I spinning my wheels doing this?” So I met David Kissane, who was the chair at Memorial at that time, and he said, “You want to come up and look at the job directing the communication skills program up here?” So my wife and I went up and we looked at the job. And I tell you they put me through the most bizarre recruiting thing. So first of all I gave a lecture, which was OK. And then they said, “We want you to show us how you would conduct a training session with a fellow. Here are two standardized patients.” So I had to train the standardized patients and set up a thing which demonstrated—and use a Memorial Sloan Kettering faculty member to demonstrate how I would coach them in interacting with a patient and family.

T.A. Rosolowski, PhD:

And how long did you have to do this?

Walter F. Baile, MD:

Two hours. Well, no, the day before I met the standardized patients and met with them. And then I had to meet with this guy Andy and say, “Well, here’s what we’re going to do and I’m going to stop you when things aren’t going right. I don’t want you to be too good.” So it was all this thing about demonstrating.

T.A. Rosolowski, PhD:

Mechanics.

Walter F. Baile, MD:

Yeah. But I might have taken the job except for one thing. The salary was OK. But somebody said, “Well, you got to live in Manhattan because it’s really where things are happening.” And I went to look at apartments. And for like $1.3 million you get nothing. Nothing. And I didn’t think about looking a bit more north, like a half-hour train ride away. And so we had a dog at that time. We said, “Well, how can we be happy in a place where the kitchen is a narrow little corridor?” And so I might have taken it except for the fact that I got a call from Steve Tomasovic, who said, “We’d like to offer you a retention package.” And so there were some dynamics behind that that probably aren’t worthwhile talking about. But in any case he said, “What would you do?”

T.A. Rosolowski, PhD:

And of course that just made me much more curious about them all.

Walter F. Baile, MD:

Well, there were people in important places that didn’t want me to leave. Thought that it would be a loss to the institution. So that’s when John Mendelsohn was here. I was very grateful and said, “This is a real opportunity because I’ll have 60% of my time to spend doing education.”

T.A. Rosolowski, PhD:

Right. Now what was going on in the institution at that time that made the time right? That people thought no, we can’t lose this guy, he’s doing something that’s essential.

Walter F. Baile, MD:

Memorial was doing it too. Do you want to let Memorial Sloan Kettering do something we’re not doing?

T.A. Rosolowski, PhD:

Is that you being a cynic?

Walter F. Baile, MD:

No, I think it’s very true. And there was a lot of stuff going on about informing patients and patient’s right to know and how do you talk to patients about end of life care. The palliative care movement was coming up. And how do you introduce palliative care. So there was a lot of interest in communication skills. I think my only regret is I didn’t say, “Well, I need to have two faculty positions to come along with this.” I was just glad to stay here and try to build something.

T.A. Rosolowski, PhD:

So how did you go about building that something?

Walter F. Baile, MD:

I focused on constructing the Web site. And then developed this conceptual model for doing sociodramatic workshops, and started publishing some articles. And the Web site has been very popular and it’s been accessed by many many people. And then they gave me a project director, Cathy Kirkwood. And she helped obtain CME and risk management credits for people who view the videos. So that was really—

T.A. Rosolowski, PhD:

So how long did it take before you felt there was real traction in developing all this?

Walter F. Baile, MD:

Couple years.

T.A. Rosolowski, PhD:

Was that speedy in your mind?

Walter F. Baile, MD:

Yeah, that was speedy. And then I got outstanding—what was it? I got inducted into the UT Academy of Health Science Education. And then I got an outstanding teacher award, which was 25,000 bucks together with recognition and that. So that’s nice to put on your CV. So I thought that was making progress.

T.A. Rosolowski, PhD:

Now what progress did you see on the ground? The impact of your teaching these programs.

Walter F. Baile, MD:

Well, we did some evaluations and some follow-up evaluations. So I was able to publish data showing that people said that they actually used the techniques we were teaching them. It’s hard to get a study where you actually video people and see if their behavior has changed. We did a pilot study on that with Patricia Parker and I. Patricia was in Behavioral Science, and I did that. And so we were able to—we haven’t published it yet. But there are some indications people could change behavior. And you watch people evolve in these workshops. And they learn to say things and do things a little bit differently.

T.A. Rosolowski, PhD:

So you have people who go through a series of workshops. How do the workshops work now?

Walter F. Baile, MD:

Workshops are open to any clinician to come. I’ve done a lot of work also educating nurses. And there’s this position of clinical nurse leader in the institution. Well, I run a lot of workshops for them.

T.A. Rosolowski, PhD:

Really? Why particularly for them?

Walter F. Baile, MD:

Because they have a lot of difficult encounters. And so they need to learn how to manage them. I’ve done some workshops for our fellowship nurses, who are advanced practice nurses. I’ve done at least five workshops for new ICU nurses because they have a lot of very high stakes conversations with patients and families. We’ve done workshops on difficult communications in supervision and mentoring, where you have to give people corrective feedback and set expectations for their behavior. So you can apply communication skills to a lot of stuff that goes on around here.

T.A. Rosolowski, PhD:

What percentage of clinicians at the institution do you think have taken these workshops? Because as you’re describing them, I’m thinking wow, you’re self-selecting.

Walter F. Baile, MD:

Small number.

T.A. Rosolowski, PhD:

Small number.

Walter F. Baile, MD:

Compared to the whole faculty. Now I’ve done a lot of other stuff around lectures and other kinds of things. And we’ve been for the last three years videotaping every medical oncology fellow who is new in a simulated breaking bad news situation, giving them feedback right then and there. So Danny Epner and I lead a four-session course on communication skills for the first year medical oncology fellows. And we videotape them and give them feedback about that. Which is a wonderful model. So I’m retiring in 2018. And one thing that I would really like to see us do and set up maybe before I retire is offer people one-on-one coaching where they sign up, they come in, and we have them interact with a standardized patient, and then give them one-on-one feedback about their progress and have them come back and do it again. So that’s the next step I think. Because the groups are great. But doctors don’t always want to be performing in front of colleagues. They’re very self-conscious about that. Although nurses will do just about anything you ask them to do in terms of an enactment. They don’t feel uncomfortable about it at all.

T.A. Rosolowski, PhD:

Interesting.

Walter F. Baile, MD:

Well, most nurses are women. Women wear their feelings on their sleeve. They’re not that afraid of talking about how they feel. It’s in the acculturization of girls to share a lot of intimate things about themselves. And boys fire guns. Girls play together with dolls. That’s a stereotype, but in fact the socialization—I watch my daughter. She’s 25. She has more friends—guy friends too. But they’re all kind of—they’re not afraid of hugging and sharing stuff. And so that’s a big advantage. Because what you want to get people to do is talk about their emotions.

T.A. Rosolowski, PhD:

What are some other reasons why a larger proportion of clinicians don’t come and take the workshops?

Walter F. Baile, MD:

Because people can’t take four hours out of their day.

T.A. Rosolowski, PhD:

Do you think time is the real reason?

Walter F. Baile, MD:

Absolutely. Or people feel they don’t need it. It’s low on their priority list. Because with doctoring comes great power. You’ve got power over life and death. You’ve got power over patients and their families. We talk about choice. Often there’s no choice. What the doctor recommends is what you do. You don’t say, “Well, tell me about the three other options I have.” Most patients don’t do that. So inherent in the practice of medicine is a lot of power. And sometimes people feel, I think doctors feel, that communication isn’t that important, because patients more or less do what they say. And if they get sad or something you send them to the psychiatrist.

T.A. Rosolowski, PhD:

Is that going to change? Do you think that the new focus on patient experience and value-based care, some of the discussions about what actually makes value, do you think some of those conversations are going to change the institution so that it’s required to have communication––

Walter F. Baile, MD:

Only if they get the right people making these decisions. And I’ll tell you. I’ve not been encouraged. Because we recently had a big strategic plan in which two committees were appointed to deal with the issue of how do we talk to patients about end of life. Neither of those committees came up with an action plan that really addressed that issue.

T.A. Rosolowski, PhD:

Really? Why?

Walter F. Baile, MD:

One, because people are appointed to head up these committees who have no idea of what they should be doing. And secondly, because people have their own agendas and don’t pull in. So let me tell you. I love this institution. It’s been great to me. It’s been wonderful. But people operate in silos. And often they don’t reach across silos to pull in people who can help them. So recently I learned that there is going to be a sessions, lectures, experience on patient experience. The patient experiences. Now I thought that maybe Danny Epner and I could really contribute something to how you get people to talk about that issue without getting them off track. Do you remember Mike Fisch [oral history interview]who was here?

T.A. Rosolowski, PhD:

Yes, I do, I interviewed him.

Walter F. Baile, MD:

So Mike was in charge of Schwartz Rounds once upon a time, which is—you know what Schwartz Rounds—

T.A. Rosolowski, PhD:

Yeah, he told me about it.

Walter F. Baile, MD:

So one time he said, “Here’s what I’m going to do with Schwartz Rounds. I’ve got four patients that I’m going to bring in and have them talk about their care here.” I said, “Well, are you going to meet with them beforehand?” “No, we’re just going to bring them in.” I said, “You know, Mike, you better meet with them beforehand because you need to establish some ground rules. You need to be the orchestra conductor with these four people.” “Ah, no, I’ll deal with it.” So he did it. And one person dominated the whole panel discussion talking about religion. You’ve got to be a skilled facilitator. So frankly speaking, someone who’s bringing a patient in to talk about themselves or a family member that doesn’t have an idea of how to steer the conversation away from oh, and this doctor was terrible to me. You don’t want people saying stuff like that. You want to steer them so well, what was the positive experiences you’ve had here, what helped you most. Who’s going to come to something where the patient criticizes MD Anderson?

T.A. Rosolowski, PhD:

And also when it happens it puts the kibosh on anything like that happening later.

Walter F. Baile, MD:

Again. Yes. So I was a bit taken aback, because what they’re trying to frame patient experience as is safety. Patient safety. And quality of care. Well, the quality of care is how you’re communicated with, as far as I’m concerned, and that aspect of how you’re taken care of. But anyway what I’m really talking about. There’ve been numerous instances where there have been people like me—and not me in particular—who’ve had experience in doing these kind of things that really people feel they can do anything on their own. And so unfortunately—and I can tell you other things. You know this Language of Caring?

T.A. Rosolowski, PhD:

Yes.

Walter F. Baile, MD:

Right. Do you think that I was asked to participate in that? No. And in fact I heard someone say, “Well, I don’t think Baile is going to give us any pushback about this.” Well, I could have told them it was a total waste of time. We spent $500,000 on getting these people in here. The faculty were never educated. The employees, they did a feel-good type of thing.

T.A. Rosolowski, PhD:

What was the rollout for it? I just have heard the phrase. I haven’t actually––

Walter F. Baile, MD:

The rollout is that one of our nurses was at that time director of something or other in Burke’s office. And she came up with this idea and got the money for it. And there was a big hoopla but never asked the people who were teaching this stuff. And that happens a lot. And fortunately that my boss, Jan Yadiny, has developed the Faculty Leadership Academy, where we incorporate communication skills teaching. She has this liaison with the chairs and the division directors so that we intervene a lot with the chairs who are having problems with doctors who are misbehaving. So I do some coaching of people who misbehave.

T.A. Rosolowski, PhD:

What kinds of issues arise? And I do want to say in asking these questions my purpose is not to quote gather dirt. This is a complex institution.

Walter F. Baile, MD:

I wouldn’t imagine that. My feeling is you’re neutral.

T.A. Rosolowski, PhD:

Yeah, absolutely. And it’s just I always like to say that because I think some people, they’re very reluctant to give a critical evaluation. And that’s really what I’m asking for is a critical evaluation.

Walter F. Baile, MD:

So people who are disrespectful to their colleagues or people who are working with them. People don’t do this intentionally. Because when you point it out to them they say, “My God, I didn’t realize that.” So part of the job is developing awareness in people about how important it is what you say to people and how you say it. And how people need praise and they need encouragement. The physicians, whether you like it or not, in this institution are leaders on many many fronts. They’re not only chairs and section heads. But they lead teams. And teams need nurturing. And you need to encourage teams in order to get them to work effectively and efficiently.

T.A. Rosolowski, PhD:

Do you find that people forget to do that?

Walter F. Baile, MD:

Of course.

T.A. Rosolowski, PhD:

Why do you think?

Walter F. Baile, MD:

Because we’re all busy and because people haven’t been trained to think team. I’ll give you an example. So one of the clinical areas was having trouble with low Press Ganey scores. These scores that people get for their—patient ratings.

T.A. Rosolowski, PhD:

I’ve not heard that acronym actually.

Walter F. Baile, MD:

Patients are sent questionnaires by this independent agency that patients rate them. And some of the doctors were getting low ratings. And so they asked me to get involved and I followed some of the doctors around in their clinic and I sent them feedback about what they could do better. But I noticed in the morning that these doctors got together with their team. On the team was a midlevel practitioner. One or two midlevel practitioners. A pharmacist. A floor nurse. And I thought my God, this is an opportunity to solicit these people’s expertise and also give them praise for their work. And that’s what you got to be thinking of. How do you get your people to work? In fact a lot of the midlevel practitioners were doing some of the dirty work of telling patients the really bad news. And you’ve got to give people credit for that. And you got to encourage them. And you got to say, “How’s that going?” So physicians are team leaders in many many settings. And believe it or not, the other people look up to them. And they have a lot of power.

T.A. Rosolowski, PhD:

Were there any interesting quote interventions that you had to do in observing that?

Walter F. Baile, MD:

Yeah. I said that when we went on rounds today and this was the first time you saw that patient, on the side table of the patient was a picture of her and her husband with a San Francisco 49ers banner. I said, “One thing I might have done is to ask them about it. Because everyone wants to be treated like a person. And no one wants to be a guinea pig. That’s the two fundamental rules that patients have. And so you need to acknowledge their personhood and let them know that they’re an individual and you’re going to give them the best care possible without harming them.” That’s one of the lessons.

T.A. Rosolowski, PhD:

Was that individual surprised when you pointed that out?

Walter F. Baile, MD:

I don’t know. They said, “Thank you.” Other person, I said—I saw a clinician do the absolutely perfect visit. Interacted with the patient. Little bit of humor. And then he sat down on the couch and said, “OK, now it’s time for you to talk to me about your concerns.” One minute. So I told this whole group. I said, “Instead of asking people do they have any questions, ask them what they’re concerned about. You’ll get a whole lot more information.”

T.A. Rosolowski, PhD:

Wording is everything.

Walter F. Baile, MD:

Yeah. And exploring. People are afraid that they’ll get Pandora’s box opened up. But that generally doesn’t happen. People are concerned about things like am I going to get that rash again or can my two-year-old nephew visit me. That’s the stuff. Practical things. Is it going to be painful to get this chemo. So this consultation aspect has been very fascinating for me.

T.A. Rosolowski, PhD:

When you observed the physicians interacting with their teams did you provide feedback about that as well?

Walter F. Baile, MD:

Yes.

T.A. Rosolowski, PhD:

And what kinds of things did you observe?

Walter F. Baile, MD:

I just said, “You know, I saw you with your team today. And I think there were some opportunities to involve them in the discussion, get their opinions, and when appropriate tell them what a good job they’re doing.” I said, “I think that’ll go a long way to getting people behind you.” People will work hard for someone who they feel appreciates their work. I don’t know if you’ve had unappreciative bosses ever. But it’s a killer.

T.A. Rosolowski, PhD:

Yeah, it can be. It is. Yeah, makes you feel invisible.

Walter F. Baile, MD:

That’s why I left Neuro-Oncology. I had someone who never ever said, “You’re doing a great job. What do you need from me?” The other problem we have in academic medicine is we put people in leadership positions who haven’t got a clue about how to lead. They’re there because they have CV and grants. And then they mess things up. And then we pay for it with disgruntled faculty and someone we have to remove from their position because they’re not a good leader. It’s a crazy crazy system. I think we’re starting to do motivational interviewing now with our new chair selection. But I’ve never been on a chair selection committee.

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Chapter 09: The iCare Program [Interpersonal Communication And Relationship Enhancement]

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