Consider the following: One month ago, Mrs. Fallon, a 25-year-old married woman, presented with a breast lump she had palpated. You evaluated and arranged a mammogram (negative) and an ultrasound, which indicated probability of a fibroadenoma (benign lesion). However, the radiologist recommended a biopsy. The results, just received from the pathology department, indicate invasive ductal carcinoma of the breast. The patient is alone in your office, and you have to tell her the news.
Doctor (MD): Good morning, Mrs. Fallon. How are you today?
Patient (PT): Morning. I am great, thanks. You?
MD: Thanks for asking—I am well. So, I see that you’ve had a biopsy, and we are going to discuss the results today.
PT: Right. You told me that it was nothing, though.
MD: Yes, well, I told you I suspected it was nothing. It appears that I was mistaken and you have ductal carcinoma and we should probably schedule the operation pretty soon.
PT: What? I have what? An operation? For what? You said it was nothing and now you are saying I need an operation?
At this point, the facilitator stops the interaction to remind the residents about giving warning and offering time to digest the new information. The interaction begins anew:
MD: Good morning, Mrs. Fallon. How are you today?
PT: Morning. I am great, thanks. You?
MD: Thanks for asking—I am well. How are you feeling since the biopsy?
PT: I feel fine. It wasn’t as bad as I thought it would be …
MD: I am glad to hear that. Are you here by yourself today?
PT: Yeah…. My husband’s at work.
MD: Well, Mrs. Fallon, the results of the biopsy were not what I was hoping to see and I would love to discuss this with you, but perhaps you would like to have your husband here, too, you know, for another “set of ears”?
PT: He can’t leave work but you can tell me whatever it is.
MD: Okay. So, as I mentioned, we did a biopsy because we wanted to be absolutely certain that the lump you discovered in your breast was benign. However, the biopsy revealed that the lump is actually not benign as we all had hoped. Actually, it is called ductal carcinoma which means that it is cancerous. I am so sorry to have to tell you this. I know this isn’t easy to hear but I do want you to know that we have several options for treatment, and you are in very good hands here. While this isn’t life-threatening, it does require treatment to prevent the condition from spreading.
PT: You said it was nothing and the biopsy was “just to be sure.”
MD: That’s right—I wanted to be sure because mammograms and ultrasounds can’t always give us enough information. I am glad we know now, though, so we can treat you appropriately. Although there are no guarantees, the majority of breast cancers can be cured with treatment. Would you like to call your husband? I can speak with both of you now or at another time soon so we can make a plan to move forward. Again, Mrs. Fallon, I am sorry, but I am here for you and we have a very good team and we will explore all our options together to move forward.
PT: Yes, yes…. Please, let’s call my husband now. Thanks.
Had the first scenario been a conversation with an actual patient, the emotional toll could have been devastating. However, these are transcripts from a new medical education/theater arts communication training program called Facilitated Simulation Education and Evaluation (FSEE), which teaches medical professionals how to communicate empathically and effectively.
This program is currently being implemented at Overlook Medical Center, Atlantic Health System, in Summit, New Jersey.
Teaching Empathic Communication Through Theater Arts
Recent changes in how providers are reimbursed for health care services expose many hospitals to risk if patient satisfaction scores are not at acceptable levels. Effective communication skills are integrally tied to patient satisfaction, and teaching hospitals are scrambling to find ways to teach and assess interpersonal communication skills (ICS).1–3 Two of us (A.E. and S.R.) had two mutual acquaintances; one knew each as former medical students, the other as actors. Both acquaintances, who are currently attendings in academic medical centers, are extraordinarily adept at medicine as well as theatrical performance. While in medical school, both were exceptionally competent in communicating empathically with patients. We were inspired by these two individuals to hypothesize that physicians in training could learn empathic communication through theater arts. Therefore, we developed a program to train and evaluate ICS skills using principles of theater arts.
We began by asking the two actors-turned-doctors their thoughts on the relevance of training in theater techniques to communication skills in clinical practice:
In psychiatry, we are taught to “follow the affect” to notice what emotions the patient is feeling and to acknowledge those emotions. In drama school, I became a better listener, paying close attention to the physical and vocal behavior of another person, and finding presence or lack of synchrony between what people are saying and what they’re expressing in terms of body language.4
In learning to be an actor, one is given the opportunity to enter into the given circumstances of another person’s life and to go through their life events as if they were happening to oneself. This profound empathy is exceptionally useful for me in how I interact with my patients. Body language [and] physical cues are particularly important. For example, is the patient sitting with shoulders up around their ears feeling angry or feeling afraid?5
We may think of communication fundamentally as a tool to overcome the powerful barriers that stand between caregivers and their patients. Once we appreciate that communication is bigger than both parties in the interaction, we become open to improving, learning, and growing. There is an increasing presence of humanities classes in medical school curricula aimed at teaching health care professionals how to recognize the barriers to effective communication and how to break down these barriers (see Table 1). This is a positive trend; however, translating humanities curricula into skill development is the challenge. In a field where “hands-on” learning is a vital component of acquiring expertise, it follows that communication skills should be “hands-on” as well. An ideal model comes from the field of theater arts. For example, improvisation and role-playing classes are gaining ground in medical education curricula aimed at guiding medical students, residents, and practicing physicians through the murky waters of effective communication techniques.6–11
Learning and acquiring effective communication skills is a process. FSEE focuses on enabling medical students and residents to cultivate these skills by acting and thinking like doctors. As learners interact with actors playing patients (specifically trained in the distinctions of the medical communication interaction) and view them as people with lives beyond their chief complaint, they become better equipped to understand the nuances of communication exchanges. By practicing doctor–patient communication with actors specifically trained in the nuances of these behaviors, they develop and hone these advanced relationship skills as well. Having practitioners participate in improvisation and simulation over a period of time may prove crucial in ensuring that these skills are incorporated comfortably and naturally into their daily interactions.
Premise to Practice: Beyond “Standardized Patients” in FSEE
Teaching empathic communication requires more than providing a list of “dos and don’ts.” Comprehensive training in interpersonal communication may also require relying on experts outside traditional medical school faculty. In 2009, we tested these principles when we piloted FSEE to teach and evaluate ICS of residents at a large community teaching hospital.
According to a recent study by Curtis and colleagues,12 simulation-based training did not actually improve and may even have worsened the effectiveness of end-of-life conversations between doctors and patients. Moreover, the use of standardized patients has been criticized as a less-than-ideal substitute for real patients because they stick to a prescribed script.
However, unlike “standardized patients” who are asked to relay the same information in an identical manner to each learner, FSEE actors train and test the nonstandard, nonuniform, patient-centered, highly nuanced ICS needed in medical practice to achieve accurate diagnosis and appropriate management of emotionally challenging interactions, leading to high-quality outcomes. FSEE actors are in no way “standardized,” which results in interactions which are unpredictable and very genuine.
Selection of FSEE actors
Suitability of an actor to be accepted as an FSEE actor is determined after training. Successful candidates exhibit the ability to portray (essentially embody) a patient with a specific set of complaints or needs including an accurate personal history and background. They must also demonstrate the capacity for effectively articulating the experience on an intellectual as well as an emotional level in order to provide useful feedback to assess, evaluate, and report on the interpersonal strengths and weaknesses of the resident with whom the actor is interacting. Selected actors are assigned scenarios appropriate for their personal attributes (age, gender, ethnicity, physical appearance). They independently research the chief complaint of their patient character by reading blogs written by patients or their family members, watching patients’ YouTube videos, and reading scholarly material.
The interdisciplinary composition of the leadership team is also critical to the success of the program. A physician–educator (S.R.) provides the link to the medical community, an educator of actors with a degree in medical humanities (A.E.) provides the link to the theater arts community, and a medical sociologist (Y.S.) trained in analysis of psychosocial data assists with theory and developing a scoring methodology for evaluation. In addition, FSEE will be most effective when the culture of the institution supports it at all levels and in all departments.
Principles of FSEE training.
FSEE has three components: didactic training, simulation, and debrief. Essential to the success of this innovative program is the parallel didactic training which establishes a common ICS vocabulary for both medical trainees and actors. Meeting separately, both groups’ training begins with an open discussion of personal experiences with the medical community, including feelings and attitudes toward medical care that they or their family members have received. Residents are asked to reflect on their reasons for choosing a career in medicine, how their attitudes toward the profession may have changed, what their “ideal” doctor looks like, and how they see themselves in comparison to that ideal. Both groups engage in a didactic session which provides a process overview, a discussion of the rationale for communication training, and a dissection of barriers to effective communication. Additionally, actors are taught strategies and techniques for eliciting various responses from residents, attention to nonverbal cues, and suggestions for researching their roles as patients. Actors practice by engaging in actual scenarios with a seasoned medical professional versed in FSEE. They then give and receive feedback. Future follow-up training sessions for both groups are for “brushing up” on skills and learning new, or more specific, techniques employing more advanced scenarios.
Understanding empathic communications by engaging with actors.
Residents take turns engaging in simulation exercises with the FSEE-trained actor (three to five minutes each). Participants give feedback using “I” statements. An actor may say, “I felt that you were not fully engaged and listening to my complaint,” or “I was completely comfortable disclosing what had previously felt like an embarrassing problem.” Residents may say, “I felt frustrated that I couldn’t get through to the patient.” Residents are asked what they might have done differently, or what they feel went particularly well, and why. If they wish, they are given the opportunity to repeat the scenario. Considerable attention is paid to the subtleties of message conveyance in FSEE training. FSEE actors, trained to recognize nuanced behaviors which may misrepresent actual intent, will “push” the resident to stretch their skills. For example, a resident’s furtive glance at his or her watch may trigger the following responses by an actor: “Am I taking up too much time, doctor?” or “I guess I can tell you about my other problem next time.” Such cues build the resident’s awareness of sending an unintended message.
Observed simulation communication education and evaluation.
After small-group sessions, residents advance to one-on-one training, which we have termed Observed Simulation Communication Education and Evaluation (OSCEE) because it is structurally similar to the traditional clinical assessment tool, the OSCE. In this exercise the actor and resident interface in an exam room, with a faculty member present as an observer and evaluator.
To mitigate subjectivity, faculty evaluators are given prior training in the vocabulary and techniques used in FSEE. They view videos of one scenario enacted three different ways, demonstrating various communication skill levels. The interactions are then evaluated using a checklist based on prior work at Virginia Commonwealth University.13 The training highlights multiple behaviors within the following domains: (1) Beginning effectively, (2) Listening actively, (3) Planning collaboratively, and (4) Achieving closure. Anecdotal comments by faculty indicated that some educators mistakenly equated medical knowledge with effective interpersonal skills; the facilitator and physician–leader guide the discussion to help standardize faculty assessment.
Perceptions of FSEE Participants
After two years of FSEE training, residents reported feeling more confident in their ability to communicate clearly and with empathy. In List 1 we provide examples of feedback we have received from residents on course evaluations.
List 1 Samples of Resident Feedback About the Facilitated Simulation Education and Evaluation Program Using Theater Arts to Teach Interpersonal Communication Skills Cited Here...
- All aspects were important—I forgot that the patients were actors.
- Very good learning experience. Need more such workshops—interactive.
- Great opportunity to be a better physician.
- The atmosphere was very laid back so I felt comfortable sharing thoughts/ideas.
- Emphasizes the patient as the center of communication.
- Practicing how to address families was so valuable.
- Draws attention of the physician to the importance of brushing up communication skills—what is important in real, everyday situations.
- Immediate feedback on real-life scenarios.
- Good way to practice delivering bad news.
- Self-critique; thought process for handling different scenarios; interactive.
- Educating us on a very different subject and then having the chance to practice.
- Absolutely essential training for residents.
FSEE actors have provided valuable feedback as well. We have heard from participating actors that the FSEE training taught them how to apply their skills in a new context and how to look for “red flags” indicating ineffective ICS, such as failure to make eye contact. Actors report being able to adjust their approach to each particular encounter to allow residents to gauge reaction, response, and receptivity.
Finally, faculty observers participating in the debrief felt that observing residents in the OSCEE sessions was helpful in identifying learners who appeared to be challenged in the ICS domain. The largest barrier to implementing FSEE, they expressed, was designating protected time for the simulation experiences.
An Opportunity to Advance the Field of ICS Training
Theoretical support for ICS training has roots in the seminal works of George H. Mead (role theory)14 and Erving Goffman (Dramaturgical analysis).15 Although most disease states have an emotional component, patients seldom verbalize their emotions directly and spontaneously, tending to offer clues instead. Suchman et al16 explain that empathic doctor–patient communication is “recognizing when emotions may be present but not directly expressed, inviting exploration of these unexpressed feelings and effectively acknowledging these feelings so that the patient feels understood.” Osler advised, “Listen to your patient, he is telling you the diagnosis.”17 Skills such as active, uninterrupted listening, reading and responding to a patient’s words and body language, and improvising in unexpected situations must be taught, practiced, and evaluated. These theorists provide insight into the development of empathy through the interplay of roles and demonstrate the influence of contextual cues in assigning meaning to interpersonal experience. Using actors to portray patients in order to enhance and improve physician–patient interactions is a natural extension of these ideas.
We believe that through FSEE, interacting with actors as nonstandardized patients, learners will gain competence in ICS from repeated reflective practice in empathic communication. It would be instructive, however, to test this in a future study. We recommend a qualitative study of learners before and after FSEE training by using the OSCEE as an evaluative tool. Additional faculty development using FSEE training strategies would be important for standardization of evaluation. FSEE might also be of great value to hospitalists, who have limited time to interact with new patients,18 or for medical students challenged by the Communication section of the United States Medical Licensing Examination Step 2 Clinical Skills. FSEE holds promise for communication experiences that acknowledge the subjective realities of physician and patient, ultimately resulting in improved outcomes.