Poor communication between practitioners and patients is associated with a number of adverse outcomes. These include patient dissatisfaction with care, the propensity to sue for medical malpractice,1 uncertainty and denial, anxiety and depression, and a poor psychological adjustment to cancer.2 In contrast, good practitioner-patient communication is associated with adherence to drug regimens and diets, better pain control, resolution of physical and functional symptoms, control of blood sugar and hypertension, and improved psychological functioning of patients.3–5 Communication is also a vital conduit for providing support, and family communication has been shown to influence both patient and family adaptation to illness.6–8 Finally, poor communication has been shown to increase the likelihood of malpractice litigation. Further, we can extrapolate that poor communication exerts costs that may potentially include economic, social, psychological, emotional, and collateral costs to the patient, the patient’s support network, the clinicians, the cancer care system, and to the larger society itself.9
Unfortunately, few oncologists or nurses have received adequate formal education in communication skills using methods likely to promote change, confidence, and competence.4,5,10–12 Practitioners caring for cancer patients acknowledge that insufficient training in communication and management skills is a major factor contributing to their stress, lack of job satisfaction, and emotional burnout.4,5 Effective communication between doctor and patient is a core clinical skill that should be taught with the same rigor as other basic medical sciences.13 Underlying this belief is a growing body of research and guidelines development acknowledging that practitioners do not have to be born with excellent communication skills, but rather can learn them as they practice the various other aspects of medicine.14
The first task in teaching effective practitioner-cancer patient communication is defining and distributing a comprehensive evidence-based curriculum.15,16 Second, to teach this curriculum, faculty and/or local practitioners who embrace the curriculum and use it in practice must be recruited and trained.17 Third, anchoring the curriculum in evidence-supported behaviors promotes effective interventions and focuses clinical controversies on the spectrum of naturally occurring communication styles that arise in the course of working with patients.18 The fourth element of a successful communication program is longitudinal reinforcement.1 Given a well-developed and broadly endorsed curriculum, the next building block to a successful communication program is creating environments that maximize the opportunity to learn, practice, and internalize the curriculum. Longitudinal learning programs, utilizing a cohesive faculty, result in more meaningful incorporation of curricular elements into learner practice styles.1
Various approaches to training practitioners in improving communication with cancer patients have been instituted.18–20 Two approaches to meeting these goals are Oncotalk21,22 and Oncotalk Teach.17 Oncotalk is a communication skills program built around evidence-based educational techniques. In an intensive 4-day retreat focused on communication at the end of life, medical oncology fellows are exposed to didactic material, which incorporates specific interviewing skills. Oncotalk Teach is a similar program designed to teach academic oncologists how to teach communication skills to oncology fellows and other cancer practitioners. In this chapter we will describe the key strategies for teaching fellows communication skills, focusing on the Oncotalk method.
Oncotalk and similar teaching programs are anchored in theories on doctor-patient relationship and also in educational principles.23–26 First among these is the fact that communication is a skill that can be observed, described, learned, and taught. Second is that the functions of communication go well beyond conveying information and serve other important functions for the patient and family, such as establishing rapport, listening to concerns, dealing with emotions, and reassuring the patient. In this regard, communication may be said to be “therapeutic,” in that patients perceive these communication strategies as being helpful in supporting them through the various crises of cancer, such as diagnosis, recurrence, intractable side effects, failure of treatment, and at the end of life.27
The skills of communication represent a hierarchy of levels of complexity. First-order or second-order skills may comprise tasks such as greeting the patient, asking open-ended questions, and listening to the patient without interrupting. Examples of second-order skills are explaining complex information without using jargon, implementing a strategy such as SPIKES28 for giving bad news, and responding to patient emotions. Third-order skills such as discussing a medical error are even more complex. Finally, teaching communication represents a very high-order skill. This observation is important because the learner-centered method, which predominates communication skills teaching 29 mandates that one meet learners “where they are.” That is, learners may begin with very different sets of skills, and finding their “learning edge” so that they are challenged to learn new skills precludes that we recognize what they already know and what they are challenged to know. Therefore, new skills build upon old ones, just as a pilot who is learning to fly a jet plane can build upon his or her experience in flying a propeller aircraft. Learning communication skills also involves dispelling the myth that communication skills are a natural ability and can be learned through observation alone. Although this may be true for some of the lower order skills (and not true for every learner), the fundamental assumption is that skills must be learned through guided practice.
What makes communication skills work? Experts agree that the essential elements that enhance the effectiveness of communication skills training are the following: 29,30
- The training must be realistic. That is, the cases that the learners encounter in interviews must be constructed in a way that they are medically accurate. Otherwise, learners will be distracted by the need to clarify details that to them may not seem to conform to practice. For example, if one wants to challenge the learner to talk to a patient about transition to palliative care, you must be sure that the patient is scripted to have tried most treatments particular to his or her disease. Otherwise, you could end up in a discussion about whether there is another treatment that could help the patient at this point in the course of their illness. Thus, the important point to note is that the facilitators and course organizers who conduct the training must be knowledgeable about the relevant medical details.
- The training must be based on situations that the learner finds relevant. Constructing learning challenges that the learner will rarely encounter will not usually engage or motivate the learner. Attempting to teach geriatricians about talking to the mother of a newborn with a birth defect will seem irrelevant to them.
- Third, the tasks should be challenging enough to engage the learner. For example, most learners will find that dealing with strong emotions will challenge them more than teaching them to make eye contact.
- Teaching should respect the learner’s skill level. Making the communication challenge too easy will bore the learner; making it too difficult will lead to frustration or anxiety.
- Teaching should focus on the goals and needs of the learner. When learners set their own goals for learning they are usually more engaged.
- Learners learn best when they are told and shown what to do and then have a chance to practice it in a safe environment.
The fundamental educational theories that drive the above are “Positive Psychology,” which states that learning should focus on skills and techniques that need to produce a result and deemphasizes “errors” of the past; adult learning theory, which posits that learner activation is necessary for skill development and behavior change; and social learning theory, which states that teaching skills require that learners engage in simulated encounters. It also explains how small group learning through the contributions of others in the group can accelerate the learning process.31
Other educational principles acknowledge the importance of reflective practice in helping learners be aware of their skills and in correcting them.32 In challenging learners to reflect on where they “got stuck” in an interview with a standardized patient they can not only learn the powers of self-observation but can empower them to come up with new solutions to try and instill confidence in their own ability to improve their communication skills.
HOW DOES COMMUNICATION SKILL TEACHING USING SMALL GROUP METHODS WORK IN PRACTICE?
Organizing a communication skill teaching workshop requires a significant amount of work and knowledge. In order to have effective small group learning and give all learners a chance to practice, groups larger than 7 are usually not viable. In contrast, a group is a group only when there are 3 or more learners present. We have found that 5 learners is an ideal number. While 1 learner is interviewing standardized patients, the other learners can act as observers and give feedback. As a facilitator must attend not only to the learner who is interviewing but also to the actor and the observers while keeping an eye on the time, more than 5 learners can present a challenge.
Many workshops on communication skills are organized by academic medical centers to serve their trainees. However, workshops do not necessarily need to be limited to these entities. For example, Memorial Sloan Kettering Cancer Center has a fee-based workshop open to any physician and is run on a yearly basis. Workshops have also been sponsored by private practice groups such as Texas Oncology and by National Organizations such as the NCI as educational projects.18,21 In any case, workshops work best when learners are motivated to learn and are not attending as a remedial mandate. In these cases, it may take special effort to overcome the stigma attached to having been singled out to attend such sessions.
Workshops also work best when there is sufficient time allowed. We have found that workshops of 3 days are ideal as they allow the group process, which facilitates learning to move into action. Few learners have the luxury of taking more time than this, and workshops of 2 days may be too intense in that they do not allow the necessary time for the group process to unfold nor do they allow time for them to reflect on the learning. That is, just when they are getting settled in at the end of day 1 they are beginning to think about having to leave. With mature and very experienced learners, however, it may be possible to compress the workshop because they are often more clear about their communication challenges. It is also possible to conduct very focused workshops: for example, on “Transitioning to Palliative Care,” in which the goals for the learner are very specific and learners have already been exposed to training in basic communication skills.
Didactic presentations form the “roadmap” for learners to follow. They are the “what to do component” of the teaching process. Didactic presentations are basically the curriculum of the communication skills course and guide the learner through the skills practice. They are indeed the skills to be learned, such as breaking bad news, disclosing a medical error, or talking to patients about end-of-life issues. In Oncotalk workshops, each skills practice was preceded by a didactic presentation of 30 minutes in which the skills were presented. For example, in discussing how to break bad news, the SPIKES protocol was taught. In a workshop lasting 3 days, there might be as many as 4 didactic presentations, each followed by a practice session. In a workshop on discussing end-of-life issues with patients, didactic presentations might include basic communication skills such as establishing rapport, then breaking bad news, followed by transition to palliative care, and finally end-of-life discussions. It should be noted that it is important that skills build upon one another and progressively challenge the learner.
At the end of each didactic presentation, faculty may choose to demonstrate the skills in question through a brief (10 min) role play, in which 1 faculty member plays the doctor and another the patient. By “seeing” what the skill looks like, the learner is better prepared to practice it. We have also found that learners favorably perceive the willingness of the faculty to engage in the same activity (role playing in front of the group) that they are asking the learners to do.
STANDARDIZED PATIENTS (SPs)
Standardized patients are actors who take on the role of patients. Many act in real life and participate in the training of doctors and other health-care professionals because they find particular meaning in it.33 Often they are not paid large sums of money because many medical schools and teaching facilities that train SPs do not have large budgets. Standardized patients usually follow a script created by the organizers of the workshop. Scripts not only tell the actors “what to say” but describe character traits, emotional responses, family and personal background, etc. Indeed, the scripts create a “role” rather than a formula about what exactly to say. In this way, SPs are often free to respond to the learner in their character. For example, an actor who is “scripted” to be factual rather than emotional might bristle when a learner is vague about the details of the next treatment. This is in keeping with the goal to create persona that the learners may actually meet in real life and respond as such when they are stressed with a medical condition.34 Some SPs are trained to give evaluative feedback to learners commenting on what they thought they did well or less well and why. We have found it more useful to have the group give the primary feedback to the learner and supplement that with nonevaluative feedback from the SP. Therefore, in this latter case we might ask the SP to indicate “how they felt” when a learner engaged in a particular behavior. Thus, it might be more useful for a learner to hear that pulling his chair closer made a patient feel that the learner had aligned with him rather than “I thought that was good.”
In this component of a workshop the learners get to practice the skills discussed and demonstrated in the didactic presentation. When working with groups of learners of 5 or more, the goal is to give everyone a chance at trying out a skill. Some attention is needed to set up a skills practice: a quiet space without interruption, a room that is comfortable (learners will be there for 6 to 7 h per day) and with bathroom facilities so that learners do not disturb the group with their comings and goings. We have found that small conference rooms or, better yet, as in Oncotalk and Oncotalk Teach, condominium rooms provided the ideal combination of openness to light, accommodation, and comfortable furniture.
An important learning principle is that the more “self-directed” the learning process is the more likely the learner will be invested in it. For this we ask each learner what brought them to the workshop and what he or she would like to learn. These goals are transcribed on flip charts and posted on the wall for each learner to keep track of. They are periodically reviewed so that they can be modified, or the learner can reflect on where they are at with regard to their original goals. An individual learner’s goals are also reviewed before each encounter.
Before starting the interviews, the facilitator reviews the “ground rules” (Fig. 1). These help guide the group during the initial workshop phase in which the learners are trying to understand what to do. The ground rules describe in general what will happen (each learner will have X number of minutes to conduct the interview) and also what is expected of the group (group members will act as observers and give feedback to the learner). The facilitator also describes their role and also the role of the standardized patient (Fig. 1).
The Action is divided into 3 parts.31 In the beginning, each learner reviews his or her goals. The facilitator may use the learner’s goals to set tasks for the group to watch out for X, Y, or Z during the interview. The facilitator reviews the task with the learner who has agreed to do the interview (eg, breaking bad news) and checks in with the learner as to their understanding of the steps explained and demonstrated in the didactic (Fig. 2). He may then ask the group to watch for specific skills demonstrated during the interview. It is useful if the facilitator asks the group members to record their observations on paper and to be as specific as possible in giving feedback to the learner conducting the interview. We have also found that giving positive feedback first also diminishes the natural tendency that many observers have in looking for “what went wrong” and lowers the anxiety over “being evaluated.” The facilitator also encourages the learner to call a “time out” if he or she gets stuck so that they can get assistance from the group or the facilitator.
In the middle of the Action, the learner begins the interview with the standardized patient (Fig. 3). In workshops that we have conducted, we have tried to have 1 standardized patient for each learner. Thus, if there are 5 learners, each would get to interview the same standardized patient throughout each task of developing rapport, giving bad news, disclosing cancer recurrence, transitioning to palliative care, and discussing end-of-life issues. In this part of the Action, the learner is trying out skills (Figs. 3 and 4). Some of these may be familiar to them and others may be challenging. The group is focusing on skills that the learner wants them to give feedback on, and the facilitator is focusing on the learner, the SP, and the group. The important job of the facilitator is to observe the learner’s skills and how he or she is progressing in the interview. A facilitator may decide to call a “time out” if he observes a learner getting “stuck” or if the learner is struggling to display a skill that is the goal of the encounter. For example, if the learner is responding to a patient’s emotions with a “fix it” response, the facilitator may stop the action to address that issue. Feedback to the learner should ideally begin with a reflection such as “How is it going for you?”. Sometimes the learner will be able to identify what he or she is struggling with (I’m not sure what to say when the patient cries) and sometimes not (I think I’m doing ok). In the former case, exploring this further with more questions may give the facilitator a better idea of how he or she can help the learner (Fig. 5). For example, if it is an issue of “finding the right words” he or she can ask the learner whether it is acceptable to get some suggestions from the group. In this way the group becomes a part of the feedback. This also serves to develop trust and confidence of the learners in each other as sources of encouragement and feedback. In the latter response, in which the learner thought he did well, the facilitator may have to go over the goals and method of responding empathically but again obtain some suggestions from the group. By moving back and forth in this manner, the facilitator will soon get an idea of where each member of the group is in their skills and skill development needs. In the format we use for small group training, each learner gets to spend a fixed amount of time with the task/interaction with the SP. I personally have found that the duration of 25 minutes used in Oncotalk and Oncotalk Teach is too short to successfully allow practice and debrief the learner while allowing the group to interact and give feedback. In training Italian oncologists we have gone to a format of 40 minutes per learner. Although this is a long time for any learner to spend on the “hot seat,” it allows the facilitator much more flexibility in any encounter. For example, for some learners, the facilitator may want to spend more time in the briefing if the cognitive road map is not clear to them. With other learners they may need more practice. Thus, time for stopping, debriefing and re-starting the interview with the SP is important. In other situations there may be a lively group discussion that the facilitator wishes to continue. In any case there is some price to be paid for longer sessions. The day is undoubtedly longer, group members may get “restless” or bored waiting for their chance to interview, and fatigue may set into the group members earlier on. Thus, these are all factors that the course designers may need to factor in when they decide on the format of the group.
The end of the Action is called the debriefing. After the SP has left the room, the facilitator interacts with the learner regarding the interview. Starting off with several open-ended “take home” questions such as “How did that go for you?”; “What did you learn?”; “What are your take-home points?”; “What do you need to continue to work on?” will challenge the learner’s self-observational skills. The facilitator can also refer to the learner’s goals in reviewing the interaction… Does the learner believe that they accomplished their goal? Does the goal need to be revised or a new goal added? These reflective pieces make the learning process more self-directed and thus more likely to be effective. It is important for the facilitator to also involve the group in feedback and reflection. They might ask each group member to articulate a take-home point for them. It is important also that the facilitator not forget to thank the learner and group for their effort and acknowledge their progress. The overall goal of acquiring skills should be accompanied by an increase in self-efficacy in performing the skill. Therefore, not only feedback but also encouragement and praise for progress are essential. This might also come at the end of the day when the facilitator conducts a “wrap up” by reflecting with the group what they had learned during the sessions. This might be something such as empathic statements acknowledging that patient emotions are more effective in aligning with the patient than are statements that try to “fix” the situation.
Facilitation of small group work requires a fairly sophisticated skill set.35,36 Facilitators must not only be capable and confident of their own communication skills but must also understand the principles of adult learning.24 These include the importance of self-directed learning, reflective learning, skills practice, and small group facilitation. They must have some notion of group dynamics and the life of the group (Fig. 6) and be able to have knowledge on how to deal with resistant learners, learners who get emotionally upset during an encounter with a patient, and how to stay focused on the needs of the learners during the encounters. They must have some knowledge of the diseases that are a part of the learning process and be actively involved in creating cases and scripts for the SPs. They must be flexible enough so as to not impose their own thinking on the group but instead let the group and the individual learners come to their own conclusions. Of course, this does not preclude the facilitator from making suggestions, observations, and reflections; however, these should be in the service of helping the group, and group members should think about their communication and its impact on others, moving from a model in which communication is a reflexive act to one in which communication is “intentional”).
It is helpful for the facilitators to get feedback on their own skills and to be able to brainstorm about challenges that come up during the course of the workshops. We accomplish this by having a trained observer periodically sit in our sessions and by using a checklist of facilitator skills to provide us with feedback on our facilitation. Debriefing of the sessions is another way to promote facilitator development and support. Facilitation can be challenging and even stressful at times when you have learners who are struggling or resistant. Debriefing the learning sessions in a group with other facilitators can allow one to brainstorm difficulties, celebrate successes, and get feedback on managing challenges.
Other Strategies That Promote Learning
Recreation: Providing “time off” for learners can provide a break from the intensity of the learning process. In a 3-day workshop, giving one afternoon off and not finishing later than 5 PM will provide time for recharging batteries and for reflecting on the learning process.
Reflective exercises27: Helping learners be reflective and aware of their communication is an essential part of the workshops we conduct. Several reflective exercises in which the small groups come together to reflect on a question such as “Think about a time when you recognized that you were a healer in an interaction with a patient and family” and then writing responses to this question and sharing it with the group can serve to support the idea that communication is often a meta-cognitive skill, in which awareness of the impact of our communication with others and the impact of their communication on us can guide us toward the intentionality needed to guide us toward being effective communicators.
Parallel process: This is a process that occurs when the facilitator, in coaching the learner, demonstrates the same skills that the learner will find essential in the interaction with their patients: careful listening, empathy, using praise for the effort taken and exploring concerns and difficulties. They demonstrate how these skills can be used in the interaction with the patient. That is, the facilitator-learner interaction mimics that of the learner patient.
Open Role Play
Open role play gives learners the opportunity to bring their own most challenging cases for consideration. In this format, a learner may choose to “show the group” what a difficult communication looks like (eg, dealing with the mother of a child who refuses to have information disclosed to a 10 y old). The learner, assisted by the facilitator, “steps into the role” of their patient. This is accomplished when the facilitator interviews the learner in the role of the patient by asking questions such as “How old are you? How old is your child? Tell me about the rest of the family.” The facilitator also “sets the scene” by asking the role-playing learner to “set the scene” of the encounter (clinic visit, etc.) and to describe as the patient what they need from their doctor and what they are concerned about. By immersing the learner in the role of their patient, the group can see the communication challenges and surmise the underlying feelings of the patient. A second phase of the encounter begins when one of the group members volunteers to conduct the interview. The learner “in the shoes” of their patient can then experience the encounter as if they were their patient and empathically understand what they need from their doctor. A third phase then begins when the learner in the role of their patient then switches into the role of himself to try out the most effective communication strategy, having understood what that is in the role of their patient. Using this strategy requires that the facilitator be confident in the use of role-reversal and in setting up the situation by interviewing the learner in the role of their patient.
The efficacy of the workshop can be assessed in a number of ways.38,39 Feedback from learners regarding aspects of the workshop such as skills of the facilitator, realism of the SPs, the group experience, the milieu, etc. can provide important quantitative information. Qualitative information that describes the experience of the group members and their take-home points can also be collected.40 More quantifiable information can be obtained on knowledge gained by quizzing the participants on the key teaching points of the didactic sessions. Finally, standardization of interview scoring can allow the investigators to expose learners to interviews before and after the session to compare improvement in interviewing with SPs who were not part of the workshop.41 That is, encounters around giving bad news, for example, are recorded before and after the workshop and then scored and compared with scores after the workshop.42
Excluding small group learning, other approaches that have been used to enhance the communication skills of practitioners include the following1: “Bedside” teaching, either on the wards or in the clinic, can provide opportunities for the teacher to create “teachable moments” around patient care contacts. In this paradigm, a 3-stage approach can be used with the learner, with the first stage being a “briefing” before seeing the patient during which time goals of the encounter are discussed (eg, “We’re going to see Mr X. What are your communication goals for the encounter?”; this is followed by a “middle phase,” where the teacher observes and if necessary intervenes in the encounter; and finally a third stage, wherein the teacher debriefs the learner with reflective questions such as “How did that go for you? What was the most difficult part about it?”.31,43,44 The use of video tapes of interviews with discussion, presentation of cases with discussion, modeling, and demonstrations using role play are also techniques that are commonly used45–48; however, they are less effective than practice. Recently, we have been using an approach based upon sociodrama that uses group construction of difficult conversations that are transformed into a dramatic portrayal in which group participants are encouraged to have a part.49 Other authors have also proposed skill-based approaches,50 role play,51 and the use of virtual reality methods.52 For excellent reviews on issues related to improving communication with cancer patients, the reader is also directed to the Millennium Review of 2000 by Maguire,53 an article by Baile and Aaron,54 and to an article in Pediatrics concerning end-of-life education in the pediatric setting.55
The author would like to thank Drs Anthony Back, Bob Arnold, James Tulsky and Kelly Edwards for the professionalism, skills and dedication to learning and learners which they brought to these workshops.
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