BY: SUSAN GIBSON, M.A., M.B.A.
Ms. Gibson is vice president, mission services and human resources, Saint Alphonsus Regional Medical Center, Boise, Idaho.
Physician-hospital relationships form in many settings within the health care environment, whether in the board room, the CEO's office, the medical staff lounge, the nursing stations, or the bedside. Some bonds may be formalized in strategic plans, policies or contracts, but the heart of physician-hospital relationships develops more informally as caregivers interact in providing patient care. As physicians, nurses, chaplains and ancillary professionals work together, they form impressions, feelings, assumptions and patterns of interaction that may support or hamper their capacity to provide healing patient care.
This is especially true when cases present difficult emotional challenges. In the midst of dealing with clinical aspects, caregivers seldom have the opportunity to talk about the personal impact of cases. The busyness of clinical tasks takes precedence and opportunities for dialogue and growth among caregivers slip away.
In 2005, Saint Alphonsus Regional Medical Center, discovered Schwartz Center Rounds as a forum that allows caregivers of many disciplines to discuss difficult emotional and social issues arising from caring for patients. Schwartz Center Rounds was developed by the Kenneth B. Schwartz Center in Boston. The man for whom the center was named was a 40-year-old attorney, father and husband, who was diagnosed with lung cancer in fall of 1994 and died the following year. Family members, friends and caregivers established the organization in 1996 with the goal of promoting Schwartz's vision.
The mission of the Schwartz Center, according to its website, is "to support and advance health care in which caregivers, patients and their families relate to one another in a way that provides hope to the patient, support to caregivers, and sustenance to the healing process."
Focusing on Emotions
The Schwartz Center Rounds model, piloted at Massachusetts General Hospital in Boston in 1996, is now used by 148 sites in 29 states. The Schwartz Center provides the format, training and ongoing support for local health care organizations. Each site is required to have a local physician leader, a facilitator and designated support staff. A forum typically takes place monthly during breakfast or lunch. Each session is based on a specific patient case with an identified topic for discussion.
The forum begins with a 10- to 15-minute presentation by a panel of multidisciplinary caregivers, who describe their experiences with a socially or emotionally difficult patient situation. The remainder of the hour is devoted to discussion among attendees, who share experiences, thoughts and feelings on the case and the issues it raises. During the forum, a passive "audience" does not exist. What takes place among the occupants of the chairs facing the panel is the heart of Schwartz Center Rounds. It is the interaction between panel members and "audience" that creates the opportunity to explore the human and emotional side of clinical medicine — with a focus on the patient-caregiver relationship.
Applying Rounds at Saint Alphonsus
Schwartz Center Rounds began at Saint Alphonsus during a time when the organization was focused on creating a more patient-centered culture. The bioethics committee initiated the rounds and recognized the importance of caregiver relations in creating a setting for sound ethical care. During the three years of rounds at the hospital, participants have addressed issues in the intensive-care unit, medical-surgical areas, oncology, family maternity center, palliative care, rehabilitation and the neonatal intensive care.
Presenters generally include a physician, a nurse and other personnel, such as respiratory therapists, chaplains, social workers or physical therapists. Thirty to 50 staff members attend each month. Attendees include nurses, chaplains, clinical resource managers, ancillary professionals, residents, nurse-fellows and physicians. A group of staff members regularly attends and others come when a situation they have been involved in is being presented.
The first Schwartz Center Rounds at Saint Alphonsus set the tone for the many that followed. The presentation revolved around a middle-aged male cancer patient who had traveled to multiple states seeking a cure. Now he was close to the end of his life in a hospital 100 miles from his home still struggling to find a treatment that would reverse the disease. The panel members, his oncologist and nurses expressed their frustration and sadness as they spoke about the challenges of caring for this patient and his family who would not let go. The oncologist described how hard it was for him to enter the room, knowing he would be barraged by Internet material. The nurses talked about their hope that the patient would be able to accept his condition and return home for a "good death" in the midst of his family. Audience members expressed sympathy for the physician and nurses on the panel and related similar experiences.
Then, two questions by an attendee took the conversation in an unexpected direction. "What is a good death? Is it the same for everyone?" A remarkable dialogue followed. Evaluations from that first session stressed the uniqueness of hearing a physician talk about his feelings in a difficult patient situation. Some said how grateful they were to express their emotions. Attendees were amazed by the depth of the conversations and eager to return.
Schwartz Center Rounds has provided a particularly beneficial experience for new caregivers. Family practice residents have participated in the rounds both as panelists and audience members. As presenters, they have had the opportunity to express their feelings as they face the emotional side of the patient encounter in an environment where self-disclosure is accepted and valued. Nurse fellows in their first year of practice attend regularly. One sat wide-eyed as a 30-year neurosurgeon spoke of his self-doubts as he struggled with a difficult patient situation.
"I can't believe I am hearing this," the nurse said. "I go home everyday agonizing over whether I did the right thing. I never thought that you, who have been taking care of patients for so many years, would ever feel the way I feel."
Addressing Challenges
Identifying appropriate cases for Schwartz Center Rounds is fairly easy, but the program has its challenges. It's difficult to assemble a panel of busy health professionals to present these cases every month. The process at Saint Alphonsus involves a committee that meets quarterly to evaluate how the rounds are going, an administrative assistant for logistics, a facilitator to prepare the panel and manage interaction, and the physician leader, who plays an important role in identifying cases, and securing physicians and other caregivers to serve on the panel. This person sometimes rescues the rounds by presenting a case when the best laid plans for another presentation fall through.
Participation by direct caregivers has been difficult due to time constraints. Recently, though, officials have implemented some communication strategies resulting in greater participation in rounds by staff members who have cared for the patient whose case is the subject of the day. Food is an essential convenience and motivator in attracting busy clinical staff.
Finally, it is easy for the rounds to slip into a discussion of the medical facts of the case or a problem-solving exercise. The facilitator and physician leader are essential in keeping the focus of the rounds on the human and emotional side of the patient caregiver experience.
Evaluating Results
Earlier this year, the Schwartz Center reported the results of a comprehensive quantitative and qualitative evaluation conducted by an outside research organization assessing the impact of the rounds.1 The study confirmed that Schwartz Center Rounds had a significant positive impact on patient care, caregiver teamwork and institutional culture. These findings are consistent with less formal evaluations of the rounds at Saint Alphonsus each month. Participants give the rounds high scores for relevance to their daily clinical work and helpful in enhancing their ability to work with their colleagues. The following two comments tell the story:
"I've been needing this for 12 years to help cope with difficult situations I've been put in with no training on how to cope. Well overdue and may keep me from burnout."
"The comments made today have made me so sure that I have chosen the right profession! Thank you for the honesty and wisdom. A 'new nurse' learned a lot today."
The mission statement of Trinity Health, of which Saint Alphonsus is a ministry organization, reads in part: "We serve together in the spirit of the Gospel to heal body, mind, and spirit." The words of this mission statement are seldom heard during Schwartz Rounds, but the spirit of the mission and values pervades the sessions. For the past three years, Schwartz Center Rounds has provided a tacit mission formation and renewal experience for clinicians. Participants absorb our values of excellence, compassion, respect, social justice, and care of the poor as they listen to stories of caring from their colleagues. These gatherings have played a small, but significant role in healing and enhancing the relationships among caregivers. During the rounds, staff members witness those moments of healing as clinicians take the time to reveal thoughts and emotions that are otherwise lost in silence.
The climax of one particularly poignant session summarizes the impact of Schwartz Center Rounds. A stone-faced critical care nurse/panelist, who had described her frustration with the hospital and physicians, listened to a physician talk about a challenging patient they had cared for months before. As the physician talked about his experience of care, her face visibly softened. She turned to him and softly said, "Until today, I didn't know. I just didn't know."
NOTE
- Goodman Research Group, Inc., Schwartz Center Rounds Evaluation Report (Boston: GRG, February 2008), www.grginc.com/projects.html.
Schwartz Center Rounds at CHA Member Hospitals
Here's a list of some CHA member hospitals that participate in Schwartz Center Rounds:
Saint Francis Hospital & Medical Center, Hartford, Conn.
Saint Mary's Health Care, Grand Rapids, Mich.
St. Joseph Hospital & Health Care, Kokomo, Ind.
Saint Thomas Hospital, Nashville, Tenn.
Scripps Mercy Hospital, San Diego and Chula Vista, Calif.
A Physician's Perspective on Schwartz Center Rounds
BY KEVIN CLIFFORD, MD
Dr. Clifford is a family practice physician, medical director of palliative care, and physician leader for Schwartz Center Rounds at Saint Alphonsus Regional Medical Center, Boise, Idaho.
Those familiar with the work of Rachel Remen, MD, recognize the power of storytelling in medicine, how it is integral to preserving a sense of meaning in our work. Storytelling allows us to relate to others, to put down our armor (or, in some cases, our weapons) and to recover from the trauma and pain we witness in our daily practice of medicine.
Doctors, however, aren't so good at telling stories.
We are trained to give case presentations, where the content and sequencing of the story are pre-defined. A good case presentation is objective, complete and succinct, but excludes the subjective details that reflect the richness of the encounter. The ideal case presentation is anonymous. What is strikingly absent is the impact of the experience on the physician.
This training is so pervasive that we start to become uncomfortable, almost guilty, when we speak of our experiences. We don't talk about that which has moved us or wounded us, and our moments of passion and beauty can wither behind the same armor that allows our wounds to fester.
As so, Dr. Remen teaches us to tell our stories to our peers, to be honest regarding our experience and so reclaim a sense of meaning in medicine. When we do this we realize we are not alone, that our isolation is of our making. Like Dr. Remen's Finding Meaning in Medicine programs, Schwartz Center Rounds gives us a forum to tell our stories with all the messy, non-scientific yet real subjective components.
Once a month for the last three years, I have identified a doctor who had been part of a medical drama. These dramas often include conflict, frustration, fear or inadequacy. They may involve death and grief, but they also may include inspiration, devotion, compassion and love. The common theme is the emotional intensity surrounding the care of a specific patient.
Most doctors, despite what I tell them, think that I am just asking them to give a case presentation as part of a panel discussion. Sometimes they bring a chart to the rounds, or a typed presentation complete with laboratory values and vital signs. Even though we've discussed the purpose and format of the rounds, they find comfort in the armor of objectivity.
I introduce the panel, and emphasize the purpose of the rounds is to help us find healing and connection by discussing our common experience, and remind the panelists and the attendants to reflect on how these experiences touched them. I encourage the doctor to put away the chart and just tell the story.
And when we do this, when we just start to talk about how hard it was to have our patient of 10 years die at a young age, how frightened we were having to see a newly quadriplegic man for the first time, how uplifting it was to care for the patient who let us remember why we wanted so desperately to be doctors so many years ago. We suddenly realize the room is silent, and that we have just told 40 relative strangers what we could barely acknowledge ourselves. We see understanding in the faces.
For the past three years, I have watched the faces of my colleagues as they realize that they are not alone, that their feelings are shared, that it is OK to be human, or even, that maybe they still are human. I don't always remember the stories from our sessions. But, I remember my colleagues, how they leave the room a little less hurried, and during the next weeks, they seem a little less abrupt. They seem to spend a little more time sitting with their patients, a little more time listening to the nurses.
Starting This Program at Your Hospital
Learn more about Schwartz Center Rounds by visiting www.theschwartzcenter.org.