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© 2003 American Society for Clinical Oncology
Teaching Communication Skills to Medical Oncology Fellows
From the Veterans Affairs Puget Sound Health Care System; Department of Medicine and Department of Medical History and Ethics, University of Washington; Fred Hutchinson Cancer Research Center, Seattle, WA; Section of Medical Ethics and Palliative Care, Department of Medicine, University of Pittsburgh, Pittsburgh PA; Program on the Medical Encounter and Palliative Care, Veterans Affairs Medical Center; Department of Medicine and Institute on Care at the End of Life, Duke University, Durham, NC; Section of Psychiatry and Department of Neuro-Oncology, University of Texas M.D. Anderson Cancer Center, Houston, TX. Address reprint requests to Anthony Back, MD, VA Puget Sound Health Care System, 1660 S Columbian Way, S-111, Seattle, WA 98108; email: tonyback{at}u.washington.edu. INTRODUCTION Empirical research indicates that communication between oncologists and patients needs to be improved. Physicians tend to focus on technical aspects of treatment without describing possible outcomes and without eliciting patients’ values and goals.1Observational studies of patient-physician encounters show that oncologists commonly miss the full range of patients’ concerns and that they are also inaccurate at detecting patient distress during a clinical encounter.2 Suboptimal communication has clinical consequences. Poor communication compromises a physician’s ability to assess and manage pain and other physical symptoms, as well as psychologic issues including anxiety, depression, and adjustment to illness. The quality of communication also influences patient satisfaction, compliance with medications, and clinical outcomes. In particular, patients who inaccurately understand their prognoses may make decisions based on unrealistic assumptions, especially regarding life-extending therapy. Finally, poor doctor-patient communication is correlated with increased rates of malpractice claims. Patients value good communication because they recognize its centrality to a therapeutic doctor-patient relationship. Patients with terminal illnesses report that a good doctor-patient relationship is of key importance to them, and doctor-patient communication is the area that receives the most positive and negative comments from families of dying patients. These findings have led national cancer organizations to formally recognize the importance of communication. The National Cancer Institute has designated cancer communication as an area of extraordinary scientific opportunity. The American Society of Clinical Oncology included "Breaking Bad News" in its Supportive Care Curriculum. The National Comprehensive Cancer Network developed guidelines on "Breaking Bad News," and the Institute of Medicine, in its report "Improving Palliative Care for Cancer," named communication as a core clinical skill. However, there exists a gap between the recognized importance of communication skills and the education in communication skills currently available for oncologists. Only approximately 5% of practicing oncologists have received formal education in basic communication tasks, such as giving bad news,3 and most fellowship programs do not have a formal curriculum for teaching communication skills. In controlled studies, communication skills educational interventions have demonstrated effectiveness. A recent randomized trial in the United Kingdom demonstrated that senior oncologists who were given a 3-day course improved their ability to respond appropriately to patient cues and to express empathy.4 However, there is little guidance in the oncology medical literature on how to teach communication. In this article, we describe the communication skills program entitled Oncotalk that we have developed for medical oncology fellows with funding from the National Cancer Institute. This program uses educational techniques that are evidence based, and the content is tailored to medical oncology fellows. Components of this program that are available on our Web site (http://depts.washington.edu/oncotalk) could be adapted to other settings. PROGRAM OBJECTIVES AND PEDAGOGIC APPROACH
Objectives
Conceptual Model To design the educational intervention, we used a conceptual model that incorporates learner knowledge, attitudes, and personal experience as factors influencing learner self-efficacy, which can be refined and enhanced by teaching and practice with feedback to influence communication skills. The model indicates that a communication skills intervention will need to address knowledge, attitudes, and personal experience, and must include practice with feedback.
Educational Principles PROGRAM DESIGN AND IMPLEMENTATION
Intervention Setting
Learner Characteristics
Retreat Curriculum
Overview presentation.
Large-group overview presentations were 25-minute sessions focusing on a specific communication task. Each task had specific learning objectives (Table 1 Communication skills practice. After each overview presentation, a 2.5-hour skills practice session was conducted that focused on the skills just presented. These were small group sessions consisting of five fellows and a faculty facilitator. The high faculty-to-learner ratio ensured that all participants had several opportunities to practice directly in simulated situations, received individual feedback from faculty and other learners, and also observed other participants and provided them with feedback. Because most participants were anxious about interviewing in front of others and because their previous experiences with feedback were often negative, the faculty were careful to set ground rules and to establish a tone in which experimentation was encouraged and good performance, even if in a small aspect, was rewarded. The small-group skills practice is based on learner interactions with patient actors, and in each interaction, the learner had a specific communication task to accomplish, with a strategy to use. Group members who were not playing patient or doctor were given a specific observational task (eg, watch for nonverbal behavior). Patient-actors. Throughout the retreat, the small groups worked with four patient-actors, who portrayed characters developed by the investigators. Each actor played a single patient who moved through a trajectory of illness during successive practice sessions. These patient-actors received written character profiles beforehand, as well as training in providing feedback. During each practice session, each small group worked with all four patient-actors; this structured actor rotation moved the small groups into actual practice and minimized time spent intellectualizing about how to communicate. Each patient-actor had 30 minutes with each small group, which allowed for a brief setup (in which the facilitator explained the situation, asked for a volunteer, and discussed goals for the encounter), the interview (typically 4 to 8 minutes), and a short debriefing (which included structured feedback and possibly a replay of part of the interview using a revised approach). The patient-actors provided feedback about their emotional reaction to the interview or, more effectively, to a specific point in the interview (for example, the facilitator might have asked, "How did you feel when the doctor said ‘I wish I had a better treatment for you’?"). Role-play. Other sessions did not involve actors and allowed learners to draw on their own experience with difficult situations. We chose to elicit situations from our learners rather than to use prewritten scripts because the learner was an expert on the details of the situation, was personally invested in finding out how to better handle the situation, and was less likely to view the artificial setting to be a barrier to learning. The first role-play session was performed after the small groups had worked with patient-actors because learners were generally more confident in the value of using a simulated situation for practice and more willing to participate. The learner who volunteered for the situation was allowed to choose her role as patient or doctor, with faculty pointing out that different kinds of learning occur in each role. Videotape review was not used in this course because of time limitations. Reflective exercises. These sessions were designed to increase awareness of physician emotions and beliefs that could influence communication behaviors and promote effective coping strategies that did not require physician withdrawal or avoidance.5 Previous successful communication courses have all included these sessions in some form. For these sessions, two small groups were combined to form a larger group of 10 fellows and two faculty members. At the first retreat, the topics for these exercises included Emotionally Powerful Experiences With Patients, Understanding Personal Reactions to Loss, and Becoming a Healer. Each of our exercises had a structured opening that oriented learners to a specific topic and gave learners specific expectations about what to do (for example, a short period of writing).
Postretreat Mentorship FACULTY ROLE AND EXPERTISE In the overview sessions, the faculty used standard techniques for giving interactive presentations. In the skills practice sessions, however, the faculty played a role that was more coach than expert and relied on small-group facilitation techniques. The faculty goal in these sessions was to create a safe atmosphere in which learners could express concerns, receive and give constructive feedback, and reflect on their performance. Faculty skills in monitoring and intervening in group processes were critically important to maintain focus and to set a tone that encouraged trying out new skills. The interactions between fellows and patient-actors were treated as raw material that provided opportunities to introduce concepts, principles, and research, and elicit deeper discussion. Difficult communication problems were treated as situations to be solved jointly by the entire learning group. Occasionally, faculty paused to explore a learner’s self-awareness insight to promote the skills of being a reflective practitioner. PROGRAM EVALUATION The design of the program evaluation included process measures, such as fellow satisfaction, and outcome measures. The outcome measures included psychometric instruments measuring learner self-assessment of competence, attitudes towards end-of-life care and psychosocial issues, and communication knowledge. A final outcome measure was a comparison of preretreat and postretreat encounters with standardized patients that were audio-recorded and will be analyzed for behavior change. The standardized patients used for evaluation were different from those used for teaching in the small groups and were trained to behave reproducibly. The University of Washington (Seattle, WA) institutional review board approved all evaluation procedures. LEARNER SATISFACTION Learners who attended this program represented a self-selected group of medical oncology fellows who were interested in acquiring communication skills. Learners in the first two retreats have been very enthusiastic; they rated the statement "I would recommend this training to other fellows" at 4.95 of a possible score of 5 on a Likert scale. One fellow wrote that it was "one of the most positive experiences I’ve had in my medical oncology training. A dynamic forum for addressing issues rarely given voice to in fellowship programs." Another wrote, "I thought I did a good job communicating with my patients but felt I could always learn more. I could never have imagined how much I learned from this program." Finally, "I came away more confident and capable of delivering bad news in focused, empathic, and productive ways." Although these comments represent anecdotal data, they illustrate the intense engagement with communication skills by fellows who had little previous training and who attended the program based on interest rather than past positive experience. DISCUSSION The design of this educational intervention was tailored to the needs of oncology fellows and based on rigorously evaluated programs in the medical literature demonstrating the effectiveness of communication skills training. The program design represents a hybrid of curriculum-based and learner-centered approaches. The retreat is designed around a set of communication tasks, which enables us to design overview sessions, patient-actor encounters, and written learning modules that all support the curriculum goals. Yet within each session, faculty facilitators encourage learners to focus on the aspects of each task that represent their learning edge. The structured curriculum allows us to develop simulated clinical situations that depend on patient-actors rather than role-play. Role-play without actors has been the mainstay of many other communication interventions but requires a high degree of learner willingness and depends on the learners’ abilities to act. Using actors portraying patients at defined points in an illness trajectory enables fellows to begin learning from their usual role as physicians and introduces them to the value of simulated situations for practicing communication skills. The actors are able to introduce a convincing degree of emotion and can debrief fellows in a way that reinforces skills and success. Thus, the learning situation promotes skills, attitudes, and self-efficacy. In summary, we have described a communication skills program designed for oncology fellows that draws from previously reported research, incorporates the clinical realities of practice in cancer centers, and attends to the needs of oncology fellows at their particular point in professional development. This program will be continuing with two retreats per year through 2005. In describing the program and the underlying principles that shaped its design, we hope to stimulate other approaches that will address the needs of oncology clinicians who could benefit from communication skills training. Improving the art of oncology, in communication or in anticancer treatments, should be based on innovation, research, and rigorous evaluation.
ACKNOWLEDGMENTS We thank the fellows who participated in the first retreat. Susan Block, MD, and Timothy Quill, MD, provided insightful guidance while this project was being developed. Drs Back, Arnold, and Tulsky are Faculty Scholars of the Project on Death in America. Jeannie Walla, John Goss, Brian O’Neil, and Lynn Aliya contributed their talents as patient-actors. The American Academy for Physician and Patient (St Louis, MO), the Institute for the Study of Health and Illness at Commonweal (Bolinas, CA), and the Contemplative Care Program at Upaya (Santa Fe, NM) were sources of expertise and inspiration. NOTES This project is supported by grant no. R25 CA92055 from the National Cancer Institute, Baltimore, MD. R.M.A. received additional support from the LAS Trust, Pittsburgh, PA, and A.L.B. and J.A.T. received additional support from the Veterans Health Administration, Washington, DC. Additional information, references, exercises, and applications are available at http://depts.washington.edu/oncotalk. REFERENCES
1. Tulsky JA, Fischer GS, Rose MR, et al: Opening the black box: How do physicians communicate about advance directives? Ann Intern Med 129:441–449, 1998 2. Maguire P, Faulkner A, Booth K, et al: Helping cancer patients disclose their concerns. Eur J Cancer 32A:78–81, 1996 3. Baile WF: Practice guidelines for patient/physician communication: Breaking bad news, version 1.01. Rockledge, PA, National Comprehensive Cancer Network, 2000 4. Fallowfield L, Jenkins V, Farewell V, et al: Efficacy of a Cancer Research UK communication skills training model for oncologists: A randomised controlled trial. Lancet 359:650–656, 2002[CrossRef][Medline]
5. Meier DE, Back AL, Morrison RS: The inner life of physicians and care of the seriously ill. JAMA 286:3007–3014, 2001 Submitted September 16, 2002; accepted April 3, 2003. This article has been cited by other articles:
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Copyright © 2003 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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