Training in Communication Skills
Some believe that effective communication between doctor and patient is a core clinical skill that should be taught as rigorously as other medical sciences are taught. Underlying this belief is a growing body of research and development of guidelines acknowledging that physicians need not be born with excellent communication skills but can learn as they practice various other aspects of medicine.
Clinicians specializing in cancer acknowledge that insufficient training in communication and management skills is a major factor contributing to their stress, lack of job satisfaction, and emotional burnout.[3,4] Unfortunately, few oncologists or nurses have received adequate formal education in communication skills using methods likely to promote change, confidence, and competence.[3,4] On the other hand, good physician-patient communication is associated with the following:[3,4]
- Adherence to drug regimens and diets.
- Pain control.
- Resolution of physical and functional symptoms.
- Control of blood sugar and hypertension.
- Good psychological functioning of patients.
Most (80%) patient-physician communication studies involve primary care physicians (i.e., family medicine physicians, general internists, or pediatricians). However, approximately 20% of studies in one review  used cancer providers, revealing a trend of inadequate training in patient communication for oncologists and other health professionals who deal with cancer patients, particularly with respect to giving bad news and handling strong, emotionally charged interview contexts.[5,6]
One group of authors believes there are four tasks in teaching effective practitioner–cancer patient communication:
- Defining and distributing a comprehensive, evidenced-based curriculum.
- Recruiting faculty and/or local practitioners who embrace this curriculum and employ it in practice.
- Anchoring the curriculum in evidence-supported behaviors to promote effective interventions and focusing clinical controversies on the spectrum of naturally occurring communication styles that arise when working with patients.
- Employing longitudinal reinforcement.
Given a well-developed and broadly accepted curriculum, the next step in establishing a successful communication program is to create surroundings that maximize the opportunity to learn, practice, and internalize the curriculum. Longitudinal learning programs that utilize a cohesive faculty result in more meaningful incorporation of curricular elements into the practice styles of learners.
Various approaches to training physicians to communicate with cancer patients have been instituted to meet these guidelines. One approach is a program titled Oncotalk, 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 that incorporates specific interviewing skills. They then interview standardized patients while they are observed by trained facilitators, who act as coaches to help the oncology fellows recognize and deal with obstacles and challenges in the encounter. The curriculum encompasses basic communication skills such as how to respond to emotional concerns and affect and communication skills along the disease trajectory, including the following:[8,9]
- Giving bad news.
- Conducting a family conference.
- Managing the transition from curative to palliative therapy.
- Responding to requests for futile treatments.
Societies such as the American Society of Clinical Oncology (ASCO) have developed and adopted specialized curricula for communicating with older cancer patients. Several authors have published positive results from randomized trials or other outcomes assessments of communication skills training in oncology.[10,11];[12,13][Level of evidence: I][14,15]
Other approaches that have been used to enhance the communication skills of physicians include the following:
- A skills-based approach that designs structured training activities to teach communication skills.
- Development of an innovative assessment instrument to facilitate curricular mapping of palliative care education.
- Efforts to enhance residents’ knowledge, skills, and attitudes needed for effective palliative care.
- Listening to the patient and responding with care as a model for teaching communication skills and to frame the patient-physician relationship around trust and respect.
- The use of serial standardized patient-based assessments of medical students’ acquisition of core clinical skills.[Level of evidence: II]
In general, nurses spend more time with patients than do their physician counterparts. Nurses play a vital role in supporting the patient through the crisis of cancer. Nurses are frequently left to pick up the pieces after physicians have delivered bad news or explained information about an illness. Questions such as “How bad is it?” or “How long do I have to live?” are often posed to nurses by patients who either are reluctant to bother the doctor or feel uncomfortable about asking for information. Nurses play a vital role on the treatment team, advocating for patients and acting as intermediaries for patient requests or concerns. Thus, teamwork between physicians and nurses is essential. However, role and status differences between nurse and physician can sometimes make communication challenging.
While nurses receive a fair amount of training in communication and interpersonal skills during their undergraduate years, it is widely recognized that for oncology nurses, advanced training in communication skills and subjects such as death and dying are highly desirable. Research suggests that these training programs are useful and well-received.Training Patients in Communication Skills
Although less common than interventions for providers, a number of interventions have been designed to help cancer patients navigate their health care issues and improve communication with their providers. The goals of these interventions have varied across studies and have included outcomes such as the following:
- Increasing patients’ question-asking in the consultation.[22-24]
- Increasing recall of the information discussed in the consultation.[25,26]
- Increasing patient satisfaction.[27,28]
- Improving patients’ psychological adjustment.[26,29,30]
These interventions have met with varying degrees of success, but most are quite labor intensive.References
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- Lee SJ, Back AL, Block SD, et al.: Enhancing physician-patient communication. Hematology Am Soc Hematol Educ Program : 464-83, 2002. [PUBMED Abstract]
- Fallowfield L, Jenkins V: Effective communication skills are the key to good cancer care. Eur J Cancer 35 (11): 1592-7, 1999. [PUBMED Abstract]
- Penson RT, Dignan FL, Canellos GP, et al.: Burnout: caring for the caregivers. Oncologist 5 (5): 425-34, 2000. [PUBMED Abstract]
- Cegala DJ, Broz SL: Provider and patient communication skills training. In: Thompson TL, Dorsey AM, Miller KI, et al., eds.: Handbook of Health Communication. Mahwah, NJ: Lawrence Erlbaum Associates, Inc., 2003, pp 95-119.
- Baile WF, Kudelka AP, Beale EA, et al.: Communication skills training in oncology. Description and preliminary outcomes of workshops on breaking bad news and managing patient reactions to illness. Cancer 86 (5): 887-97, 1999. [PUBMED Abstract]
- Beckman HB, Frankel RM: Training practitioners to communicate effectively in cancer care: it is the relationship that counts. Patient Educ Couns 50 (1): 85-9, 2003. [PUBMED Abstract]
- Back AL, Arnold RM, Tulsky JA, et al.: Teaching communication skills to medical oncology fellows. J Clin Oncol 21 (12): 2433-6, 2003. [PUBMED Abstract]
- Back AL, Arnold RM, Baile WF, et al.: Approaching difficult communication tasks in oncology. CA Cancer J Clin 55 (3): 164-77, 2005 May-Jun. [PUBMED Abstract]
- Fallowfield L, Jenkins V, Farewell V, et al.: Enduring impact of communication skills training: results of a 12-month follow-up. Br J Cancer 89 (8): 1445-9, 2003. [PUBMED Abstract]
- Fallowfield L, Jenkins V: Current concepts of communication skills training in oncology. Recent Results Cancer Res 168: 105-12, 2006. [PUBMED Abstract]
- Razavi D, Delvaux N, Marchal S, et al.: Does training increase the use of more emotionally laden words by nurses when talking with cancer patients? A randomised study. Br J Cancer 87 (1): 1-7, 2002. [PUBMED Abstract]
- Delvaux N, Razavi D, Marchal S, et al.: Effects of a 105 hours psychological training program on attitudes, communication skills and occupational stress in oncology: a randomised study. Br J Cancer 90 (1): 106-14, 2004. [PUBMED Abstract]
- Back AL, Arnold RM: Discussing prognosis: "how much do you want to know?" talking to patients who are prepared for explicit information. J Clin Oncol 24 (25): 4209-13, 2006. [PUBMED Abstract]
- Back AL, Arnold RM: Discussing prognosis: "how much do you want to know?" talking to patients who do not want information or who are ambivalent. J Clin Oncol 24 (25): 4214-7, 2006. [PUBMED Abstract]
- Wagner PJ, Lentz L, Heslop SD: Teaching communication skills: a skills-based approach. Acad Med 77 (11): 1164, 2002. [PUBMED Abstract]
- Meekin SA, Klein JE, Fleischman AR, et al.: Development of a palliative education assessment tool for medical student education. Acad Med 75 (10): 986-92, 2000. [PUBMED Abstract]
- Fins JJ, Nilson EG: An approach to educating residents about palliative care and clinical ethics. Acad Med 75 (6): 662-5, 2000. [PUBMED Abstract]
- DiBartola LM: Listening to patients and responding with care: a model for teaching communication skills. Jt Comm J Qual Improv 27 (6): 315-23, 2001. [PUBMED Abstract]
- Prislin MD, Giglio M, Lewis EM, et al.: Assessing the acquisition of core clinical skills through the use of serial standardized patient assessments. Acad Med 75 (5): 480-3, 2000. [PUBMED Abstract]
- Kennedy Sheldon L: Communication in oncology care: the effectiveness of skills training workshops for healthcare providers. Clin J Oncol Nurs 9 (3): 305-12, 2005. [PUBMED Abstract]
- Butow PN, Dunn SM, Tattersall MH, et al.: Patient participation in the cancer consultation: evaluation of a question prompt sheet. Ann Oncol 5 (3): 199-204, 1994. [PUBMED Abstract]
- Clayton J, Butow P, Tattersall M, et al.: Asking questions can help: development and preliminary evaluation of a question prompt list for palliative care patients. Br J Cancer 89 (11): 2069-77, 2003. [PUBMED Abstract]
- Ford S, Fallowfield L, Hall A, et al.: The influence of audiotapes on patient participation in the cancer consultation. Eur J Cancer 31A (13-14): 2264-9, 1995. [PUBMED Abstract]
- Hogbin B, Fallowfield L: Getting it taped: the 'bad news' consultation with cancer patients. Br J Hosp Med 41 (4): 330-3, 1989. [PUBMED Abstract]
- McHugh P, Lewis S, Ford S, et al.: The efficacy of audiotapes in promoting psychological well-being in cancer patients: a randomised, controlled trial. Br J Cancer 71 (2): 388-92, 1995. [PUBMED Abstract]
- Damian D, Tattersall MH: Letters to patients: improving communication in cancer care. Lancet 338 (8772): 923-5, 1991. [PUBMED Abstract]
- Tattersall MH, Butow PN, Griffin AM, et al.: The take-home message: patients prefer consultation audiotapes to summary letters. J Clin Oncol 12 (6): 1305-11, 1994. [PUBMED Abstract]
- Deutsch G: Improving communication with oncology patients: taping the consultation. Clin Oncol (R Coll Radiol) 4 (1): 46-7, 1992. [PUBMED Abstract]
- McHugh P, Lewis S: Psychological treatments in cancer patients. BMJ 304 (6836): 1247-8, 1992. [PUBMED Abstract]