MD
Anderson Cancer Center
Date: November 10, 2015
Dr. Baile: Hello. I'm Dr. Walter Baile, Professor of Psychiatry and Behavioral Science at MD Anderson Cancer Center and Director of the Program for Interpersonal Communication and Relationship Enhancement, or ICARE, in the Department of Academic and Faculty Development at MD Anderson. Today we're pleased to welcome as our roundtable speaker Dr. Monika Keller. Dr. Keller did her training in internal medicine, hematology and psychosomatic medicine and is also a Board Certified Psychoanalyst. She's currently Vice Head of the clinic for psychosomatic medicine and psychotherapy in Boppard-Koblenz, Germany and research consultant in the Department of General Internal Medicine at the University of Heidelberg. She's been instrumental in the formation of the KOMPASS Program for training and communication skills in Germany. She's on the Executive Board of the European Association of Psychosomatic Medicine and Psycho-Oncology and is an invited expert for the development of national guidelines in training in palliative care and Psycho-Oncology in Germany. Dr. Keller has been funded and published in studies of psychosocial morbidity and distress in cancer patients or communication skills training of oncologists and for a multidisciplinary, multi-centered study of support strategies for children and families where a parent had cancer. So welcome Monika, nice to have you here. Thank you for coming
Monika Keller: Thank you.
Dr. Baile: Thank you for coming across the ocean and being with us. And for those of you who may have missed our talk this morning, there was a beautiful talk given by Monika on coping strategies of patients and families that was really wonderful. And our viewers will be able to actually see that online and learn some things about how to help children cope with cancer. So I'd like to talk a bit about a different topic and one that you've been involved in for a number of years now and that's the KOMPASS Program for Communication Skills Training. And since we're all very interested in the whole topic of communication skills training, perhaps you could tell everyone a little bit about KOMPASS and how it started and where it is now and some of the research that you've been doing on some of the outcomes of communication skills training.
Monika Keller: Yeah, yeah, well I started thinking about doing something like KOMPASS I think 20 years ago when our fiscal leagues started to do national programs and I was really getting envious and it took us until 2008 when we were funded by the German Cancer Aid and we could start a project to provide communication skills, training, to cancer physicians, Oncologists, Palliative care physicians, this was in 2008. And yeah, when we started as a group, so you may know that the KOMPASS group is made from specialists from Psychiatry, from Psychosomatic Medicine, Psychotherapy as well and they were all very experienced in teaching and training before so we wanted to make sure that these are really qualified
Dr. Baile: Trainers.
Monika Keller: Trainers. And we also started with a Train the Trainer Program at [inaudible] who had much experience, about six or seven years already. So we went first to Berlin and had a two days Train the Trainer training before we started ourselves. And then at initially eight places which has been reduced somewhat now to six and later on, yeah to six places, we did a common joint develop program, all using the same methods. And I have to add that this is, the training is on a voluntary basis so we don't have any regulations where physicians or nurses have to do those courses for their accreditation for continuing medical education. So it was, to my opinion, it was one of the most important things to make a training that really attracts clinicians, physicians, that they benefit from it for their clinical practice. So this was the challenge.
Dr. Baile: And your training consists of practice with standardized patients or role play in small groups, is that how it's conducted?
Monika Keller: It's not with standardized patients, no, no. First of all the program is not like many others fixed on a certain topic like sharing bad news or conveying talking to a patient about transitioning to palliative care but it's open from the theme so that's one of the specific characteristics that the, again and the content is not fixed but it's made up by the participants and it's oriented on their needs.
Dr. Baile: So the participants bring their challenging places.
Monika Keller: They bring their cases and challenges in and we use, not standardized patients, but partly patient actors. These are trained in jumping into a role that they didn't know before, just upon a few words. We are talking about Mr. Phillip. He is 70 years old and he has got lung cancer, for instance. And with very little information the actor can jump into the role. And then the role of the patient or the relative in the role play, with a physician having the opportunity, which is really very particular and they appreciate it very much, getting authentic feedback from the patient side. So these actors are really trained to get feedback out from the patient's perspective.
Dr. Baile: So let me see if I have this right, so these actors are able, even with just a minimal amount of information.
Monika Keller: Yeah.
Dr. Baile: To jump into a role and to actually expand the role so that it's authentic. They would make up their social circumstances if needed.
Monika Keller: Yeah definitely.
Dr. Baile: That they have.
Monika Keller: Yeah, yeah, yeah.
Dr. Baile: That's a very important talent and probably that spontaneity in doing that makes it easier so they don't have to remember a script.
Monika Keller: Exactly, exactly.
Dr. Baile: And can't be distracted by a memory. And how's that worked out? Has that really, done the?
Monika Keller: Yeah I think it's really one of the most important things to take anxiety off the physicians. What many, or most, physicians feel the most is role play. So I was told by many physicians they would have liked to do KOMPASS training but no role play, yeah? So it takes them off the fear because the physicians make the experience there really immediately within a scenario and they say, oh, gosh, I'm really in this situation so that makes it initially very easy and they can try out things they wouldn't do with real patients, saying things maybe they wouldn't dare to and getting authentic feedback from the actor in the patient's position. This is really highly appreciated initially. Later on they get so talented themselves too they don't need it anymore but initially it's really very well.
Dr. Baile: And so over the period of time from when you began the KOMPASS program, how many people have you trained with this method would you say?
Monika Keller: Altogether it's close to 500 physicians who have gone through our training, yeah.
Dr. Baile: That's a very impressive number, a very impressive number.
Monika Keller: So and I have to add that for two years right now we are doing in house training as well which are not two and a half days as the original KOMPASS training, it lasts two and a half days, and increasingly hospitals ask us to come to the hospital so it's cheaper for them.
And the staff can come so physicians, yeah it's only physicians as well. Yeah but like 500, it's a huge number.
Dr. Baile: It's a huge number and when you think about the exponential affect on the patients that they are seeing over the course of their career, that is very impressive. Now do you have refresher courses at all?
Monika Keller: Yeah, yeah.
Dr. Baile: And how does that work?
Monika Keller: Yeah which turns out really, really very, very, highly appreciated and interesting also for us when we meet again four or five months later for half a day and for all those who can manage to come. Those who have to travel long distance, they can't come, but those who are not too far, they come. And they report and share their experiences what they have made, what they learned, what they have lived and experienced during that time in clinical practice. And this is so interesting for us because if you see our final goal is to improve, to really make a practically relevant training for them so if they come back and tell us I couldn't, wouldn't have been able to do such a consultation or such an encounter four months ago and my fear has gone down so much and I find it much easier right now. And I had an encounter with a patient which was so good and finally the patient told me, Doctor, I'm so grateful you were talking to me. So it's really, it's very nice experiences. It's challenges as well and then we work on new challenges during this couple of hours with role play.
Dr. Baile: A lot of anecdotal reinforcements that are apparent.
Monika Keller: Lots and lots, yeah.
Dr. Baile: So you've also now have been doing some research on outcomes, is that correct? Could you say something about that? I know you're going to talk about it a little bit later on today.
Monika Keller: Yeah, yeah, yeah, yeah.
Dr. Baile: Give us a little capsule on what you've been doing.
Monika Keller: So this was the, yeah the plan, to do a kind of evaluation which fits with this multicenter approach. So you can do a randomized controlled study and if you rely on voluntary participants you can do something like this. So we planned on several stages, first to evaluate the participant's satisfaction and estimating the training in itself. But they completed questionnaires right at the beginning of the training and at the beginning of the refresher four months later, on three different issues. The first is the confidence in dealing with challenging communication tasks, which is related to self-efficacy. The second is the must not burn out inventory to see whether communication skills, training, can possibly have a positive impact in ameliorating burnout or preventing burnout. And still another measure we're using is the Jefferson Empathy Scale. And we did this as a controlled study. So we worked hard to get a small number of participants who were prepared or willing to complete the questionnaires twice without taking part in the training. So we have a controlled sample which really turned out to be rather important. Yeah, that's one part and the other part is we did uncontrolled, it's a singular group pre-post study. We did video recordings of interviewers with the standardized patient, scripted interview, that all participants during the study period conducted before the training started and at the refresher four months later. And we analyzed it with those expert classification systems as they are known right now. That's the two parts.
Dr. Baile: That sounds very, very interesting. I wanted to ask you, and we'll hear more about that today, of course, but I wanted to ask you, I'd be very interested in the video recording because not many people have done that. And there's a lot of belief in the fact that nonverbal behavior plays an overwhelmingly but often neglected part of communication with the patient and I'm wondering if you assessed any of that in looking at the video?
Monika Keller: Partly, partly but you are completely right. This is one of the great big obstacles or disadvantages of these expert rating systems which rely on verbal utterances. And we edited on the recommendation of [inaudible] who have done some similar research and to add some global scales of effective atmosphere that the raters also rate when viewing the interviews, the video documented interviews. So it was, there's a little bit of atmosphere, nonverbal within but you're completely right. It's reductionistic, yeah.
Dr. Baile: I wanted to ask you, so your study looked at stress and burnout and its relationship to communication skills training. There has been a little bit of that in the literature up to now, not a whole lot, but I'm not sure that I've ever seen anyone really clearly articulate why they think that improving a clinician's communication skills should result in lower stress and burnout. And I'm wondering what your hypothesis was about that and what your thoughts are about that? Because it's a very, very important topic these days and a lot of our colleagues are somewhat incredulous about the fact that improving the way you talk to patients could result in lower stress and burnout because there are so many other factors.
Monika Keller: So there I rely on my own experiences as a hematologist and I remember very well how much I was distressed when I had to convey bad news to patients, how I observed myself in avoiding, in doing anything but not telling the patient this bad news. So I know very well from my own experiences and also from many, many other colleagues I talked within our consultation liaison services, how much physicians are really burdened by that duty of giving bad news so many times by telling patients that treatment failed, by telling patients they have a cancer recurrence, by telling the mother of two children that her cancer has progressed or by telling a young father that chemotherapy has come to an end and he's transitioning to palliative cancer. So it's really such a, it's a burden, it's really a challenge. And there are lots of emotions coming up with that and that's why I think that if communication is not as hard and if I do not need to protect myself from negative feelings while conveying so many bad news, it might be that my satisfaction at work and my satisfaction with the physician patient relationship gets much better and that this might prevent burnout.
Dr. Baile: So can you say more about this idea of protecting oneself from negative feelings? Because you know just having given a talk and noting the study by Jim Wallace that was actually never published, presented in ASCO
Monika Keller: Yeah.
Dr. Baile: In which he polled a large number, 729 oncologists, 45 percent of which admitted to having very negative feelings when they had to talk about the end of active chemotherapy, it's very kind of impressive that this idea that one could unburden a clinician, in a certain sense, through communication skills training. So what do you think really happens to the clinician? Is it self-efficacy? Is it normalization? Sorry to pin you down about this but
Monika Keller: That's a very interesting question and I would myself learn more about it. So I have some hypotheses. I think one thing is self-efficacy and learning how much energy is wasted in defenses of fears, of anxieties, of keeping patients at distance so they don't come too close to me. So giving up defenses that are energy intensive, psychologically energy intensive, and feeling that even talking about serious and sad things does not necessarily cause stress and burns you out. I think, well self-efficacy, it might be one aspect. I have another idea still. What I'm observing increasingly is some very, very strong group cohesion among the physicians within the training. And so it's very much of a mutual learning. And I think when they see others not being worse than them and that they are all interested in the same, they are really fortify themselves mutually. This is an idea.
Dr. Baile: So fortification, I like that.
Monika Keller: Yeah, yeah.
Dr. Baile: Concept but also, you know, having been trained as a psychoanalyst that this idea of an energy cost in avoiding reality or in being self-critical or having a certain amount of distress is very, very interesting. Now I'll tell you a little anecdote that one of our clinicians here came to me and said you know it's so difficult. I deal with lung cancer patients and I have to tell them all the time about how the disease has progressed and it just eats me up. And you know I come home and it's just terrible. And I said to him, you know one thing that might be helpful to you is something that Rob Buckman said in his Six Steps for Giving Bad News, the first step is try to separate the messenger from the message.
Monika Keller: Right.
Dr. Baile: So I told him that and I said you know what, the disease belongs to the patient. It doesn't belong to you.
Monika Keller: Right.
Dr. Baile: And he was taken aback because he had never thought about the fact that he could step into a helpless role if he didn't take on responsibility for the disease, which is going to have its course anyway, with or without our help. And to this day he kind of remembers that. And I wonder whether the same phenomenon of allowing oneself to sort of connect with the patient, do your job but then be there to support the patient, isn't also something that happens in these groups.
Monika Keller: Definitely, definitely, yeah, it's important that you point to this because my theory really is that if you feel responsible or even guarantee nothing, in Germany, at least, we have lots of, a sense of guilt when being the messenger of bad news.
Dr. Baile: Yes.
Monika Keller: And I think this might be due to the fact that in Europe we are closer to medieval times. And you remember in medieval times what happened to the messenger of the bad news.
Dr. Baile: Shot.
Monika Keller: Yeah, shot or
Dr. Baile: Or worse things happened.
[Laughter]
Monika Keller: Everybody knows that, yeah, and I think this is inside of us even more. And if people can really separate, yeah, and not feeling guilty, I think this is the strongest preventive factor acting against empathy with the patient.
Dr. Baile: And also perhaps allowing yourself to think the unthinkable, which is that your patient may not get better despite what you do.
Monika Keller: Right, right.
Dr. Baile: This kind of sense that we're not all heroes all the time.
Monika Keller: It's that sense of helplessness.
Dr. Baile: Yeah.
Monika Keller: That's what we physicians all hate.
Dr. Baile: And the group I think really validates the fact that you know you don't have to be
Monika Keller: Heroes.
Dr. Baile: Heroes.
Monika Keller: Yeah, yeah.
Dr. Baile: Well thank you very much. We're looking forward to really hearing more about this whole project and burnout and stress with Dr. Keller's ACE lecture today which will focus on an assessment of the impact of communication skills training on stress and burnout and so we invite you to go to our website, mdanderson.org/icare. In a short period of time that talk will be up there as will our interview. So thanks today for watching and thank you, Monika, for this very, very interesting discussion.
Monika Keller: Thank you.
Dr. Baile: And we look forward to your talk today.
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