Walter F Baile M.D.
Professor, Behavioral Science
Director, Interpersonal Communication and Relationship Enhancement
The University of Texas MD Anderson Cancer Center
Dr. Ki: This morning's speaker is extremely well-known to you, Dr. Walter Baile, who is a professor and the director of the program for Interpersonal Communication And Relationship Enhancement, Faculty Development, MD Anderson Cancer Center. He is widely known and published in the area of doctor-patient relationships. And as a part of the I-CARE program, you can see that he designed an educational website where he uses video instruction to enhance competence in cancer communication. So without further adieu, I'd like to invite Walter to come to the podium, to present communicating with cancer patients. Thank you.
Dr. Baile: Thank you, Ki. Good morning, everyone. So today, I'd like to talk a little bit about the idea of communication as a skill. And I think this is a very important concept because often, it's regarded as something you are born with, or that you sort of pickup along the way. And I hope to convince you instead of a way of thinking about it as a specific competency that can be learned, and not only learned, but is associated with important outcomes with regard to patient care, research, and other aspects of oncology. Talk a little bit about some of the road blocks to effective--to being an effective communicator, and then something about how we teach communication skills across the spectrum of oncology professionals. I think we can all agree that there are some very important purposes of communicating with patients, family members, and colleagues.
The first is to develop a rapport with them and have them trust us as we guide patients and families along the different trajectory of cancer care therapies to obtain information from them regarding the illness that concerns their preoccupations, their previous treatments, to provide information regarding a plan of action which patients so widely appreciate, knowing what's in store for them and how we're going to be helping them. And lastly, how to address their emotions and concerns, for example, when they get bad news, and I think this is one of the more challenging aspects of patient care, both from the standpoint of addressing patient emotions and how we teach it. I like to think about communication as being a skill set, and being kind of a hierarchy of skills. The first one sort of being basic skills such as being able to greet the patient appropriately, ask open ended questions when we request information from them, and how to listen without interrupting. And these skills are pretty accessible to most of us, just by reflecting upon what we're doing, because the skills are social skills that often we implement when we have encounters other than those with the patients and families. So if we think about it as related to another set of skills such as playing tennis, that a fundamental skill would be learning how to grip the racket. And it seems kind of silly, but if we don't grip the racket appropriately, then we're not going to hit the ball right. And so, it's important to pay attention to this. A lot of people can learn this by maybe having someone else show them simply without extensive coaching, but it's still an important skill.
Another skill is learning how to volley and how to coordinate a racket with the motion of hitting the ball that's coming at us. And again, you know, some instruction really can help here and help you from hitting popups and hitting the net, but again, sometimes, that there are people who have natural ability who can do this without too much effort. The second set of skills are second order skills which are a little bit more difficult, and they involve explaining complex information without using jargon. And you know, one of the biggest complaints that patients have about the way we talk about things is that we use med speak and words that they often don't understand that we use when we speak to each other collegially regarding medical care. Another skill would be knowing a strategy for giving bad news. What are the steps involved, how do we do it, how do we handle patient emotions, and then responding to a patient who becomes emotional. We all sort of, you know, sometimes fumble when patients make statements like it's the worst news I've ever heard, how am I going to tell my husband, things that evolve from an emotional state that the patients are in, and what we do to help to support the patient at that time. So that would be akin, I think, to learning how to serve, because serving requires some instruction. It requires knowing how to throw the ball in the air, how to hit the ball at a certain angle when at a certain point in the serve so it goes over the net, how to place our feet, and how to incline our body. So this requires some instruction because there are very few people who could become probably good servers without someone telling them what to do. And again, you know, also somewhat like a good backhand. And you can see some of the skills involved in a backhand holding the racket at a certain angle, coordinating it with the position of the ball so it doesn't go out of bounds. This eye contact which the player has with the ball, which is one of the hardest parts I think of almost any sport like baseball or golf, is that keeping your eye on the ball. And so again, this requires not only some instruction, but probably a lot of practice before you become good.
And then there are third order skills that have to do with more complex kind of interactions, like how do you respond to a family that says, "Doc, just do everything for my loved one. ", or discussing DNR with the patient and family member, or how to talk about a serious medical error that's happened, all the highly charged--kind of emotionally charged conversations, or conducting a family conference for a patient in the ICU. And those are somewhat akin, to having--to being able to do an overhead smash. You know that leaving your feet and jumping in the air and sort of bringing the racket up so it hits the ball down at a certain angle, a lot of coordination, a lot of practice, probably a lot of instruction also. And then we have actually, a fourth order skills which I added upon some reflection, and those are really tough, like talking to a colleague when they left your name off of a paper and, you know, how to have that conversation, and then teaching communication skills. And this is sort of akin to one of Dr. Hong's favorite shots here, you know, hitting the ball between your legs. Just when people think they've got you, you know, you come up with something that is highly skilled. And this probably requires years and years of practice to get it right. So communication is a skill. And you know, one of the things that I want to get across is that we can describe these skills. These skills, you can name them; handshake, smiling, greeting, which lead to rapport, which lead to a--which help the relationship with the patient. So when we teach communication skills, we teach particular competencies. And actually, we put our learners in situations where they interact with patients so they can get a feel for what the skill looks like. And I'll talk about that a little bit later.
So why are these skills important? Well, because they're associated with important outcomes, and I'll, just go through this quickly and then highlight a few of them. One, they are responsible for the--for patient satisfaction and ensure patient retention. We know that patients fire doctors who are rude and who don't meet their expectations for care. They can reduce malpractice litigation as I'll show in a minute. More specifically, Terry Albrecht who was here a few years ago, showed in her research how effective communication can actually increase accrual to clinical trials. This is a really important one, and because, you know, patients sometimes receive chemotherapy toward the end-of-life, when it's ineffective because the clinician really feels awkward in talking to the patient about the end of active chemotherapy. It can reduce burn out because our relationship with the patient is an important factor in allowing us to feel as though we've been effective clinicians, and it can increase physician competence in discussing difficult topics such as transitioning the patient from anticancer therapy to supportive care.
It can enhance teamwork in oncology which is a big issue today because of the importance in communication in handing patients off from one team to another, and it can allow patients to feel supported in times of disease crisis. And I wanted to touch on these—a few of these more specifically, but not at length. The first one is communication in malpractice suits. And this is from an older article by Beckman that was in the archives of internal medicine somewhat back, but it is still very relevant. And what he did is he reviewed 45 malpractice depositions to take a look at what factors provoked the loss suit on the part of the patient. And he found out that in 13 percent of the cases, that it was the failure of the clinical team to understand the perspective of the patient or the family to kind of talk about their concerns about their care, delivering information poorly in 26 percent, devaluing the patient or family's viewpoint, such as by saying, you know, "Oh, it's silly to think that way. " You know, patients are very offended and insulted by that, and deserting the patient. By deserting, I really mean not returning phone calls, not following up with the patient. And as we can see, that was the major cause of malpractice suits.
This is a study from Canada where they looked at medical students who took in fourth year clinical exams and actually had an encounter with the standardized patients to kind of take a look at their communication skills. So there were almost 3500 physicians who took the Medical Council of Canada exam between '93 and '96, and they were followed subsequently for 10 years in 2005. During that period of 10 years, there were 1116 complaints to the medical board during the follow-up period about that group of doctors. 89 percent--and this is really a notable work for communication skills or quality of life problems such as symptom control--and no scoring below the mean for clinical communication skills on the standardized exam were one and a half times more likely to have a complaint against them. So it has some very practical implications in communication. The second piece is that the relationship between communication skills and health care outcomes. And there were two articles recently that touched, I think, very poignantly on this, one by Wright in JAMA in 2008, and the other by Zhang in the archives of internal medicine in 2009. And they looked that end-of-life discussions with patients such as, you know, preferences for DNR, discussions about the end of anticancer treatment, and these were in its relationship to some healthcare outcomes. So there were 603 advanced care patient, 31 percent of them reported that the medical team had had a discussion with them about their resuscitation preferences, DNR, and of active treatment transition to palliative care.
Importantly, there was no increased distress found amongst the patients who have had end-of-life discussions. And I think this is important because a certain myth in oncology is that when we talk about death and dying, it destroys patient hope. Nothing could be further from the truth. In fact, patients who had end-of-life discussions can plan for their future. Also, patients who've had end-of-life discussions were less likely to be admitted to the ICU, be placed on a ventilator, and more likely to have hospice and lower healthcare cost at the end-of-life. This healthcare cost issue is really important because the same group looked at the same group of patients, that 603, 31 of whom reported end-of-life discussions, and they found out that the aggregate cost of health care were 1876 bucks for the patients who reported end-of-life discussions, and 2917 for patients who did not, which is 37 percent lower cost for those patients who did not--who had end-of-life discussions. And naturally, less time spent in the ICU, less active treatment when it wasn't indicated, and interestingly, this last factor that patients who did not have a discussion had worse quality of life in their final week.
So these are important outcomes, and it's pretty consistent with what the public's attitudes is toward end-of-life discussions. And this was a gallop poll on spiritual beliefs in the dying process, and we could see that among these 1500 consumers who answered to this poll, that they were preoccupied with being vegetable-like, not having a chance to say goodbye, being in great physical pain, how the loved ones will be--how their loved ones will be cared for, and worried about how death would be the cause of inconvenience and stress for others. So getting these issues out on the table and getting help for the patient and family to deal with end-of-life issues is very much in the--on the radar screen. So--now, here's another important outcome issue, and that is feeling supported in times of crisis. I was really happy to see that the division's cover of the The Year in Review had a very poignant scene of a physician having his hand on the shoulder of the patient, which we all understand is a measure of support comforting the patient. And in fact, interestingly, current--there is interesting data that shows that how human touch increases oxytocin levels, and maybe that's why we do that naturally, because patients feel comforted by it. And you know, when we talk about supportive skills, we're not talking about psychoanalysis. We are talking about some pretty basic techniques such as listening to the patient, understanding what they are most worried about, reassuring them when it's appropriate, encourage them, then acknowledging emotions and praising the patient.
And so, these particular very simple techniques do have an impact on the patient's well-being. The patient feels more respected and regarded, they feel that the doctor is interested when they elicit the concerns, reassures, decreases anxiety, encouragement bolsters optimism, empathic responses, express--or understanding of the patient, and praising the patient acknowledges the effort. These seem like simple things, but they are really a big deal to patients who really look toward doctors who practice them. And I'm going to skip this slide for a minute, but it does talk a little bit about some of the outcomes of care. What I wanted to focus on is this aspect of support that was clearly documented in a study by Zachariah in the British journal of cancer in 2003. And this study was a study of 454 oncology outpatients who were rated by their patients after clinic visits on skills of asking them about their concerns and ability to listen attentively, that is did the doctor say, "Can you tell me what you're most worried about? " And when the patient started to speak, he just kept his mouth shut for whatever the length of time that it took, usually about a minute and 15 seconds. So you see what's going on here. Okay. And what they found is that high scores on empathy and listening were related to patient satisfaction, were related to lower patient distress, and related to increased confidence on the part of the patient that they could take care of themselves during cancer treatment.
And so, here is the table which explains some of these findings. And you can see, these are the two dependent variables, attentiveness, "Is the doctor paying attention to me? ", and empathy, "Is the doctor asking me about my concerns? " And so, we can see here, the independent variables are satisfaction with personal contact, and it was a high correlation between these two variables and patient satisfaction with the interpersonal aspects of care. Now surprisingly, there was a relationship that was pretty strong between satisfaction of handling the medical aspects of care and these two variables too. So patients who had more attention in the sense of listening and empathy from their doctors, felt that their medical care was better. Also, their distress levels were lower, and their self-rating of their ability to care for themselves was higher. So here you have some very concrete outcomes in terms of patient satisfaction explained by two very simple variables--communication variables. We did a study several years ago in which we essentially repeated this, and which we saw--we--at the--lead author was Patty Parker, who is here today, and we had 351 cancer patients in MD Anderson from several different specialties, and we asked them, "Gee, when you get bad news, what's really important to you that the physician does? "
And we did a factor analysis and showed that there were three factors which were important to a patient. The first was the content, and here, we see factor one here, and the higher the loading, the higher the number, the more important it is to patients. So patients wanted a lot of information. They want to know about treatment options, they want to know all about their cancer, they wanted detailed information about medical tests we know that patient sometimes like to see their MRI's and their chest x-rays at the beginning of treatment, but they also wanted their physician to be honest about the severity of their condition. Factor two, which you see in red up here, really addressed the issue of what patients' value in terms of support. And we talked about some of these supportive behaviors, telling me its okay if I become upset, encouraged me to talk about feelings about the bad news, comforting me if I become emotional, making me feel its okay if I get upset, and the doctor helps me figure out how to tell others about my cancer. Now, these aren't easy all the time because sometimes, we don't know how to do them.
I will recount a little story of a patient who told me that when she was told by her physician that she had recurrent breast cancer and started to cry, he told her, "If you don't stop crying, I'm going to walk out of the room. " So sometimes, people are taken aback by these highly emotional discussions and don't always say the right thing, and we'll talk about that in a minute. And factor three, with things that help facilitate the discussion, full attention. So we saw the importance of paying attention to the patient being told in person--being told the bad news in person, the doctor giving enough time, and maintaining eye contacts. So these are also all skills which patients have valued about giving bad news. Now, do these skills come naturally to people who've chosen oncology for a profession? Not necessarily so. We evaluated 150 medical oncology fellows as they broke bad news in a simulated situation with standardized patients, and we found out that 44 of them--44 percent of them struggled with simple rapport-building skills such as asking open-ended question, or greeting the patient, 45 percent didn't ask the patient, "Well, tell me what you know about your disease before I get started in explaining the treatment to you. " Only 51 percent used the word cancer in breaking bad news, zero percent responded empathically to the patient's expression "I'm scared ", for example, by saying, "I can see this news has really taken you aback. " And only 53 percent summarized the follow up plan. And these were second and third year oncology fellows, which is why we had a course for them which I'll talk about.
And we know that communication skills don't necessarily improve with experience, and that you could see experienced clinicians giving false or premature reassurance to a patient, or changing the topic when the patient gets upset, or avoiding the patient when the disease takes a turn for the worse, leaving out key information especially about prognosis, talking to the family and not the patient when the family says, "Don't tell Uncle Jack. " and reacting with our emotional brain when the patient gets upset. And I'm going to show some examples of that, and you'll see one of our own faculty members, and our adjunct faculty members, Dr. Buckman, trying to explain to a patient, and you can see what might go wrong. So this is Mrs. Thompson who's 55, and she was diagnosed with breast cancer 10 years ago, and some of the details about her history, she was noted positive--ER/PR positive, she had surgery and adjuvant chemotherapy, and then five years of hormone therapy, and she was doing fine until three weeks ago when she had pain in her lower back, and she got a bone scan which showed multiple bone metastases, and you'll see the doctor here giving bad news. So this is--
[ Video ]
It's come back? Are you sure?
Yes, I am sure. I mean, there can be no doubts about that one. But actually, it isn't so bad because [inaudible]--
Wait. It isn't so bad?
Well, it's not really so bad because it's come back after many years, and with a hormone receptor cancer, that means it will respond to hormone therapies--
Yes, but for how long will it respond to this therapy?
Yeah, well, well--good point. I mean, it might respond for several years.
Several years?
Yes, several years.
Several years? That's three years, I'm only 55. What am I suppose to do after that?
Dr. Baile: So that was one little pitfall that sometimes we can get into when we use kind of reassurance in a way without first addressing the patients' emotions. And sometimes, that can really get upsetting.
[ Video ]
Come back? Are you sure?
Yes, of course I'm sure. I mean the bone scan shows [inaudible] binding the ribs and the shoulder--
Are you sure we don't need to do another bone scan?
We do not need to do another bone scan. There is absolutely no doubt about--
It came back?
I'm afraid so--
Are you sure?
Yeah, I'm absolutely sure.
Oh, god!
But please try not to get too over emotional about this--
Overly emotional?
Yes, I'm certain--
Don't tell me that I'm overly emotional.
Please. For--please try and help me help you. Please calm down.
Calm down? I don't want to calm down. I don't have to calm down! Okay?
So when patients get upset, it could really be tough. And if we use a strategy that doesn't resonate with the patients to lower their emotions, sometimes, things don't always go right. So there are certain barriers to acquiring these skills which involve training, and only about, I would say 10 to 15 percent of oncology training programs, really have any kind of substantial role training for fellows during their formative years. Sometimes, we don't know what to say and we're uncertain about how to respond to the patient when they get upset, or sometimes we're afraid of upsetting them even more than they are, sometimes our own sense of failure really gets in the way. And you know, most conversations with patients, many of them can get very, very emotional. And even though we've made extraordinary progress in curing cancer, we still have to have in our work a lot of extraordinarily difficult conversations with patients and family members, especially around disease recurrence or the failure of cancer patients or transition to palliative care, which are very tough. And sometimes, it really hurts us.
And here's an ASCO--a survey that was presented at ASCO by Jim Wallace [phonetic] a few years ago of 729 oncologist who actually responded to a survey. It took 50 bucks to give each one to get them to respond, with 47 percent had negative emotions that were sources of stress and distress on breaking bad news. And these are some of the comments. I felt like the bad guy, I feel sad about the impact on the patient and the family, I'm feeling more drained with each one, my sister calls me the prophetess of doom and gloom, and I feel inadequate. And the important thing about this is that the interaction between doctor and patient is not one way. Because when patients get upset it, resonates on our brains too, okay, and we react in ways sometimes that may be unintentional. It's kind of like talking with our limbic lobe, and you saw some examples with that with Dr. Buckman as he tried to reassure this patient. So our own sadness, okay, about loss is something that really, I think, needs to be acknowledged and dealt with. Sometimes, we get mad and frustrated when treatments don't go well with patients, or family members are difficult, or sometimes, that you know, we get really upset, and you know, this is an easily recognizable shot of John McEnroe who was called the bad boy of tennis, and he used to kind of get a little upset when things didn't go his way, and even, there where times when he tried to undo the call, and here he is arguing with the referee about a shot that went out of bounds. So sometimes, we try to undo things when things go bad by telling patients that, "Well, don't worry about it. It's not so bad. " But that doesn't ring well with them. Sometimes we need to be resuscitated when things go really bad in conversations with patients, and we're feeling burned out. So can we train oncologists, and I might say, other clinicians to be more effective communicators?
And this is a little piece from the Accreditation Council for Graduate Medical Education bulletin back in December of 2005, where they talked about simulation as a key tactic in teaching communications skills. And this is what they say. Musicians, actors, lawyers giving closing arguments, clergy preparing sermons would not consider engaging in this activities without some form of rehearsal, either as an explicit trial of the activity in a low stakes setting or at least as a deliberate mental walkthrough of all the steps that will go in to the actual performance. So here, it makes the point that these are tough conversations, that when you're preparing a speech, you rehearse it. So what we've tried to do is to apply some of this wisdom to our own communication skills teaching. I'm going to talk about OncoTalk for a few minutes, which is a--which was a five year NCI funded communication skills training program for medical oncology fellows, and we actually took fellows to Aspen Colorado 20 at a time for five years--and there were 40 a year. So had close to 150 fellows after a year of planning, and we had a residential retreat for them where they were kind of locked--not locked up, but they were away from the hospital setting where it was tempting to kind of sneak off and see a patient.
And we used the technique that--where we gave instruction in terms of telling them the steps involved, for example, in giving bad news. Then we really focused on what skills we thought that they needed to learn, and then we gave them practice in doing it. So we worked with the--we worked with a group of 20, five at a time with one coach, and we had actors which actually portrayed patients from the time of getting a cancer diagnosis to the end-of-life, and actually--so every fellow encountered a different--a patient at each point in time. And actually, it was very interesting because we had a reporter from the New York Times trail along with us in one of these sessions, and it was quite moving because she came into a room where the fellow's job was to give bad news to a patient about no more chemotherapy, and it was very, very moving. And so, it resulted in a little article in the paper. So we teach reflective exercises, that is how do you pay attention to your own communication skills and monitor yourself? And we audio taped the learners before and after the workshop. So every learner met with a standardized patient other than the ones in the room before the workshop in an interview about breaking bad news or transitioning to palliative care, and then after the workshop.
So these were some of the topics we covered, building a relationship with the patient, giving bad news, transitioning to palliative care, talking about code status, how to do a family meeting, and conflicts, and end-of-life care. So this is what would happen. So we had condo rooms, actually, at this place in Aspen which was a very nice facility, and each coach, which were the four faculty with five learners. So the faculty is here, and these are her fellows , and we sat in the room for 15 to 20 minutes, and we went over the didactic interview--the didactic which was kind of breaking bad news, what do you remember of the steps of it, how you're going to do it. And then every learner, every fellow, set their own goals for the interview. What's most difficult for you, what are you going to have a hard time with, what do you want us to pay attention to--and then we wrote those down on the blackboard so that everybody had his own stickup, okay, which showed their goals, and also, we put up the steps, for example, of giving bad news. After that, the faculty moved into the position of being a coach. One of the learners volunteered to do the interview, and the standardized patient came in for the encounter. So the fellow's job was then to break bad news to the patient who had a script, and the fellows were told this is a patient who had breast cancer, was seen by a colleague of yours, had an abnormal liver function test, now comes back and finds out they have advanced disease with metastases to the liver. And the fellow interacted with the standardized patient. And when the fellow got stuck, we let them call a time out, and then the faculty and the group would help with the coaching. So we did that for 150 fellows over a course of five years, and you know, this was called experiential learning. And the theory was that this active learning and discovery by the fellows of what they were good at and what they needed help with was much better than passive learning.
So information, that is how to break bad news, plus practice would lead to the skill acquisition. And here's the important piece; the more that you had ability to acquire skills, the more that you would become confident in your ability to take it home with you. So the small group helped a lot because they gave advice to one another and built group cohesiveness. And here's an interesting point. So the fellows were very often anxious about telling patients that there was no more chemo, intended initially to refer them for a clinical trial when their job was to say there's really not a clinical trial for you. And when they found out that honesty was the best policy with the patient, it was a tremendous, like relief, for them, and encouraged them to be more open and honest with patients. So here's what we tried to teach.
[ Video ]
It's come back. Are you sure?
Why don't you tell me what's going through your mind right now?
Well, I mean this is exactly what happened to my grandmother.
Tell me a bit more about your grandmother.
Well, she died from breast cancer. And when the recurrence started, she was in a tremendous amount of pain, and it went on and on and on.
So the pain and your grandmother's experience must have made this shock much worse for you?
Yes, it's a shock.
I realize that.
So this was a simple skill called Tell Me More. And asking the patient, tell me more about what is going on with you, tell me more about your grandmother, found that the patient had a previous, kind of traumatic experience with the grandmother who suffered from cancer. So we tried to teach this Tell Me More as one of the skills instead of using reassurance or confronting the patient or telling them it's really not as bad as what they think. So can people learn communication skills? So here, you see that the number of individual skills where improvement occurred and the number of subjects, and if you look right here, this is like one standard deviation from the mean which represents about 66 percent of the fellows. So 66 percent of the fellows kind of learned anywhere from four to seven skills, okay, which is a lot to accomplish in three days.
Looking at it a little bit differently, we can see that if you list the skills here, and this is acquisition of bad news communication skills, that assessing patient's perception means tell me what you understand about your disease. Before the workshop, 79 people did not do it. After the workshop, 44 did it. The same for how to make an empathic statement when the patient says, "I'm scared. ". So instead of saying, you know, "Everything's going to be alright. " The fellow was taught to say, you know, "I can see where this would really be a scary experience. " Before the workshop, 15 people were not doing it, and after the workshop, 15 were. Establishing rapport, shaking hands, you know, asking the patient something personal about themselves. Before the workshop, 71 struggled with it, after the workshop, 40 were able to do it. The same thing with transition to palliative care. So listening to patient's values, what's most important to you. Before the workshop, 80 were not doing it, after the workshop, 49 out of those 80 were doing it. Responding to the question, "Is there anything more you can do for me? " Before the workshop, 62 percent were not doing it, after, 26 of 62 were. So we have some data that shows that skills can be improved using simulation with standardized patients, and that it's pretty acceptable after people get warmed up and used to it.
And right now, we have an NCI funded R25 in which we're bringing medical oncology faculties from around the country to learn how to teach these skills in the clinic and bedside, and actually, we have palliative care fellows who--palliative care faculty who have volunteered to take on the role of medical oncology fellows. So they come in and they play medical oncology fellows in encounters at the bedside between a patient, a fellow, and the faculty. So the faculty learn to teach these skills, and they audio record it in a simulated encounter, and we're in next to the last year of this, and we'll have some data for you soon. We'll also have a pilot study here at MD Anderson of teaching communication skills to PA's led by Patty Parker in which we're using some similar techniques. Most of these--a lot of video and information about what I talked about today can be found on our I-CARE website, which is mdanderson.org/icare and there's a brochure outside, and you'll see a lot of video about communication skills that are packaged as an educational module. You can also find information at the University of Washington's website, depts.washington.edu/toolbox in which there are points about both teaching and learning communication skills. And I'm going to skip these two because I wanted to get to the end so we have time for some questions. So it's my belief that--and hopefully, I convinced you of the fact that communication is a skill set which can be taught and learned, and it requires sort of a cognitive map which, in a way, tells you how to do it, and then practice, okay, which allows people to take the how to do it and see if they can do it.
And that higher order of skills such as reflecting on one's relationship to the patient, and can also be very, very helpful in the professional growth of the trainee. So in the end, we hope that, you know, when people exit from the workshop, they have won a championship. And here, I think, this is Serena Williams at a tournament in Mexico who has a sombrero and the big trophy with a tennis ball, and hopefully, people's patients will kind of celebrate their communication skills by giving them good feedback about their ability to take care of them as people and as effective oncologists. So thank you very much for your attention, and--
[ Applause ]
Dr. Ki: Thank you, Walter. And you are welcome to come use the microphone.
[ Laughter ]
Dr. Ki: That's great. Okay. We have some time for entertaining some few questions. Yes, ma'am?
Audience: Thank you, [inaudible]. I just had a question. When you work with the group [inaudible], do you have a weekly session afterwards? Something that can evoke emotional reactions, and also promote growth that's available there also for the provider.
Dr. Baile: Yeah. Debriefing--did you mean faculty debrief or fellow's debrief?
Audience: Either one.
Dr. Baile: Yeah. We have--we talk a lot in the session because we allow 30 minutes for each encounter so there's time for the fellow to interact with the patient, and then there's time for us to debrief the session. Then we debrief the session with the group as a whole, and then the faculty meet in the evening to debrief their experiences. So we do a lot of work on that to make sure we get it right.
Audience: A question and a comment Walter. The comment first was--I think it's important to emphasize that this takes time.. To communicate with the patient properly takes time, and that we are time-constrained. So--and I will say in my own experience, if you take the time early on with your patients, you're saving time through the trajectory of their care to do this. And I really encourage the fellows to take time up front because on the back end, you will not be back peddling wasting anyone's time including the nursing staff or the team. The question I had is have you followed up on the 150 people you put through the Oncotalk program to see, okay, now you're out in the world, have you--has this helped you, do you continue to think about what we talked about?
Dr. Baile: You know, I tried to be humble about this because I really didn't want to say that how much of an impact this has had on these people who went to this course, because we hear all the time from them. We have a meeting every year at ASCO, in which we invite all of the fellows to come and they kind of see people that they were in the same group with then meet new people. But actually, we've had some fellows say that this transformed the whole experience as an oncologist because they had a different dimension of skills other than technical skills which enhanced their relationship with their patient in a way that was quite remarkable. I just had a fellow from four years ago e-mail me the other day asking for help in managing a patient who didn't really want to give up aggressive anticancer treatment when the time had come. And so, we exchanged kind of e-mails about that, but we hear it all the time. And I would agree with you that it's the--the point of the training is that it does take more time, but it's like the Mister Goodwrench syndrome, pay me now or pay me later. If you take time up front, you'll save time later on. And actually, there was a study that showed that if you--that using exploratory responses with patients, that is saying, "Can you tell me why you're upset? Can you tell me more about it? " took 22 seconds more of your time because the patient usually does not go into an hour-long monologue about their concerns, which is the scary part of sort of getting into that area of asking patients what they're worried about.
Dr. Ki: Okay. [Inaudible] the way Dr. Walter and I do with the patients?
Audience: Yes.
Dr. Baile: At the first time.
Audience: Yes.
Dr. Baile: Okay. How do you feel about it? I felt [inaudible].
Audience: Yeah.
Dr. Baile: Okay. You provoke the patient. And the first time he tried--he responded to the patient's emotion by trying to reassure the patient, which didn't work because she came back and said, "What do you mean I have five years? I'm only so and so. " So this reassurance, even though we think we're doing something effective, doesn't always work.
Audience: But the patient asked, "Do I have to have another bone scan? "
Dr. Baile: Right.
Audience: And he said certainly no.
Dr. Baile: Right. Right.
Audience: I don't think that is the way I would have done it.
Dr. Baile: You know, this was only to demonstrate how you could get yourself into a trouble by not being more careful about how you explain information. So it was aimed at showing us what is not such a good skill practice.
Dr. Ki: Okay. Okay. Mike?
Audience: So Walter to expound on the sports analogy, just to notice that, you know, professional golfers or baseball players and teams, they get--have coaches, you know. It's very hard to keep your skills and not notice little kinks that you develop in your swing. So I think that what you're talking about can be useful to faculty, even experienced faculty who develop issues. And I'll give you example. I loved your little boxes in your green circle when you're describing the simulated patient experience. I did an ASCO workshop which was a much shorter workshop as a faculty member, and I was involved, and they asked what my goal was before seeing the simulated patient, and my goal that I stated--I didn't have a goal, but I came up with one--and I said I wanted to notice my own emotions. So then I did the simulated patient interview, and in the debriefing, you're asking about debriefing. They said, "Okay. Well, doctor, did--you know, what did you notice about your own emotions? " Nothing. They said, "Oh my, bad. I'll do it next time. " I forgot. And I could not notice it in the visit. But when I was in the box outside of the green, when I was watching the other people do the same exact simulated patient, I could completely notice the emotions. I had to get sort of out of the role. But you know, that was like noticing a kink in the swing. That was pretty useful.
Dr. Baile: So when the coach asks the fellow, "What was going on with you when you told the patient everything is going to be okay? " It takes them a while to arrive at the fact that, well, I was feeling helpless. It's not something immediately available. But let me address the issue of clinical coaching that in medicine, we don't have very developed models for supervising and mentoring clinically, trainees. In nursing, it's developed in a lot of other fields, but we don't have a model. This month's issue of Academic Medicine has a beautiful paper on a model for clinical mentoring which I would recommend to everybody because it exactly lays out some of the strategies you can use when you're working with trainees.
Dr. Ki: Okay. Thank you very much.
[ Applause ]
Communicating with Cancer Patients & Families video
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