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Eight years ago, Walter Baile, MD, and his colleagues at the University of Texas MD Anderson Cancer Center developed a CD-ROM called the “Practical Guide to Communication Skills in Cancer Care.” It was the first step in teaching healthcare professionals how to effectively communicate with cancer patients and their families.
“Communication is so important,” says Baile, a professor of behavioral science at MD Anderson. “Because if we’re not informing our patients correctly, if we’re not understanding their concerns, then we’re only doing half a job. You can cure the disease but not necessarily heal the patient.”
More recently, Baile and his colleagues have taken the videos from the CD-ROM, built them into educational modules, and posted them to the Internet, making them easily accessible to all clinicians. The resulting online education tool, called I*CARE, or Interpersonal Communication and Relationship Enhancement, has been up and running since January 2009. In the first six months, the free site, which includes video lectures, patient scenarios, articles, and other resources designed to improve physician-patient communication.
At MD Anderson, Baile and his colleagues are in contact with oncologists on a daily basis, and they conducted several surveys to assess what oncologists felt were their most difficult communication challenges. Several evidence-based patient scenario videos resulted, and the content on these videos is derived from the shared experiences of actual cancer patients and their families. The scripts that were developed represent actual communication encounters that occur between cancer patients and their clinicians.
One of the leading challenges that cancer clinicians face is identifying and responding to strong emotions in patients. Those emotions are, at least in part, a result of what Baile calls cancer’s social stigma. He points to a survey conducted by the American Institute for Cancer Research where 38% of respondents indicated that cancer is the worst thing that could ever happen to someone.
“When people think about cancer, they think about dying, and they think about suffering,” he explains. “The anxiety and the fear that are associated with the disease sort of create an emotional terrain through which the oncology clinician must navigate.”
Baile points out that oncologists deal with patients whose diseases are often incurable, or have low cure rates. As such, their job becomes two-fold: provide the level of treatment that offers hope of being cured and guiding and supporting them through their emotionally tumultuous cancer journey. The online videos, Baile says, are greared not only to help doctors tell the truth, but to respond in a way where the patient feels that no matter how bad the situation is, the clinician is going to stick with them.
“There’s an attachment that cancer patients have with their treatment team, and it’s a very deep attachment,” Baile says. “Clinicians need to know how to take advantage of the relationship to promote the patient’s quality of life. How to provide the kind of education that is honest and yet hopeful. These are high-order skills that we’re talking about.”
Healing process impact
Baile believes that the healing process has a lot to do with a patient’s sense of security, and that sense of security is the cornerstone of trust. In the absence of both elements, patients are left feeling that the clinician is not taking an interest in them as a person. According to Baile, physicians often focus on curing, and while patients want to be cured, they’re really focused on healing and want their physicians to understand them as a person.
Daniel Epner, MD, associate professor of general oncology at the MD Anderson Cancer Center, has participated in the center’s Oncotalk Teach program, an educational research project that teaches clinicians how to impart communication skills in oncology to others. He explains that, “Far too few of us in medicine respond to patients’ emotions with empathic responses.”
Epner currently teaches communication skills to oncology fellows and often refers back to the I*CARE Website and its video vignettes to further illustrate a point of discussion. He’s learned that just as empathy is important in the physician-patient relationship, it’s equally critical when teaching communication skills.
“A fellow training in oncology is under a lot of stress,” Epner says. “They’re trying to learn a lot of technical, biomedical information. As teachers, responding to them with empathy, listening to them, and allowing them to explore and be reflective is very important. Those are the same skills we use with patients in other conversations.”
Those conversations, such as the process of maintaining hope but balancing it with realism, are often difficult, says Epner. “Words are very important and powerful at that stage, but they really are important at every stage.”
Spreading the words
Baile sees the I*CARE Website as a form of distance learning. The modules are approved for CME credit, and the videos can be downloaded and used by clinicians teaching communication skills to medical students. Modules can be assigned for viewing before going on rounds to deliver bad news. The Website also features video interviews with key experts in the field of communication skills, as well as reflective exercises, and recently added a comprehensive bibliography. The actual dialogue used in the videos can be displayed on screen or downloaded and printed.
“We were recently contacted by a clinician at a university in South Korea who is going to use [the transcript] to translate the video into Korean,” Baile says. “Anyone in another country who is interested in using the video can translate it into their own language. They can also take the transcript and edit it down if they want to use the scenario for a role play, such as in teaching medical students.”
In addition, as part of the cancer center’s Achieving Communication Excellence lecture series, which is part of the I*CARE program, three new lectures will be videotaped and uploaded to the Website. The topics of the lectures include spirituality and communication, end-of-life discussions, and updates in communication skills research.
“The Institute of Medicine has emphasized that communication skills are part and parcel of the care of the patient,” Baile says. “So now, the agencies that accredit all of the specialty fellowship programs, like oncology, have developed core competencies that every fellow must learn, and one is communication skills. There’s a push now to incorporate [communication] training into fellowship programs. But we’re still behind the times in doing this.”
An important skill
Biren Saraiya, MD, an assistant professor of medicine at the University of Medicine and Dentistry of New Jersey, is a graduate of MD Anderson’s Oncotalk Teach program, and believes that communication skills, especially for oncologists, are vitally important.
“One of the things I tell all of my trainees is that any encounter could potentially be bad news for a patient, because bad news is very subjective,” Saraiya explains. “Having a methodology for how to communicate with patients is really important. If you have a framework to work off, and follow it all the time, it becomes a great skill set because it makes everything a bit easier.”
Epner agrees, and points out that effective patient communication skills in oncology are more important than ever, in part because of the volume of information at patients’ fingertips. “When there’s so much information and it’s complex, patients need experts they trust to guide them through.”
“So much emphasis in training has been placed on the medical aspect of things, and communication has taken a backseat,” adds Baile. “But for patients, it’s right on the front burner.”
Ed Rabinowitz is a veteran healthcare journalist based in Bangor, PA.