Dennis H. Novack, M.D., F.A.C.P.
Drexel University School of Medicine
Associate Dean of Medical Education
Director, Clinical Skills Teaching and Assessment
Division of Medical Education
Philadelphia, PA
Walter Baile: Hello I'm Dr. Walter Baile, Director of the MD Anderson program on Interpersonal Communication and Relationship Enhancement. Today we're pleased to have as our roundtable guest Dr. Dennis Novack. Dr. Novack is Professor of Medicine and Associate Dean of Medical Education at Drexel University College of Medicine. Dr. Novack's trained as a general internist and completed a two yeahr fellowship with Dr. George Engel's Medical Psychiatric Liaison Group in Rochester, New York. Since 1978, Dr. Novack has worked extensively in academic medical centers dedicating himself to improving education in physician-patient communication and the psychosocial aspects of care. At Drexel he oversees clinical skills teaching and assessment and directs the first yeahr medical student course on medical interviewing as well as the doctoring curriculum in the medicine residency. Dr. Novack has conducted educational research, developed curricula and is widely published in the area of physician-patient communication. He's been a leader in the American Academy on Communication and Healthcare known as the AACH since its inception in 1979. He was one of the founding Directors of the first several American Association Communication Healthcare annual national faculty development courses in 1983, which have continued until the present. These courses have trained thousands of faculty members who teach physician-patient communication in medical education. Dr. Novack also founded and is currently Editor of "The Medical Encounter," the quarterly newsletter of the Academy for the past 20 yeahrs. He's currently First Editor of Doc.com, a comprehensive online resource on healthcare communication, a joint project of the AACH and Drexel College of Medicine. Dr. Novack has been in the leadership for many yeahrs in an important organization, The American Psychosomatic Society, which is a scholarly society of almost 1000 members that foster scientific research into mind-body interactions in health and disease and he's a past President of that society. As a recognition for his national work in doctor-patient communication in the past yeahr he's received an Alpha Omega Alpha Robert J. Glaser Distinguished Teacher Award from the American Association of Medical Colleges and a Career Achievement Award in Medical Education at the National Meeting of the Society of General Internal Medicine. What we probably also should know about Dr. Novack is he has his own rock and roll band, so Dennis welcome.
Dennis Novack: Thank you.
Walter Baile: Thank you for coming.
Dennis Novack: Thanks for that introduction.
Walter Baile: You still have the band.
Dennis Novack: I still have the band, playing a gig this Friday night.
Walter Baile: Terrific. So, you know I haven't talked to you in a while about Doc.com and I would imagine most of the people watching the interview don't know about it, they may know, but maybe you can sort of describe how it came about and how it's developed and what direction it's going in.
Dennis Novack: The American Academy on Communication in Healthcare, AACH has for yeahrs been putting out materials to train residents and medical students in communication skills. There's a growing national consensus that physicians really need good communication skills and all of the licensing agencies for medicine residency and medical school training require teaching and assessment of competencies. So, you know some yeahrs ago the American College of Physicians came to us, to our organization and asked us if we could put some materials online you know to support their efforts to teach communication to their members and recently they thought well we'll just put some chapters online. And I was on that call discussing it and I said, geez you know if we're putting something online let's show videos, let's make it interactive. Let's use the capacities of the web. And it was kind of you know like the old Mickey Rooney, Judy Garland movies you know, let's put on a show. You remember that? So, we decided we would try to do that, but we needed funding to do that. So, we were fortunate that the Arthur Vining Davis Foundations liked our idea and funded us. And Drexel University College of Medicine, the Dean at that time really got enthused about the idea as well. We put in something like a million dollars to create DocCom. So, it's 42 modules online. We currently have about 30 medical schools, another 70 residency programs or so who subscribe and it's pretty affordable. We've made it affordable so as many people, as many programs as possible would subscribe. And in these 42 modules we invited some of the, you know scholars who are well known in whatever the module was, like for breaking bad news we asked Tim Quill, who's very well known for his work in palliative care and for his writings. So, someone like Tim would come down, came down to Philadelphia. He wrote a module for us, but then we had standardized patients interact with him in scenarios like the first diagnosis of breast cancer or and then actually we followed this woman in two modules, first diagnosis of breast cancer then the conversation about when the cancer had spread and what to do now and then the transition to palliative care and so on. So, you know we put on a little soap opera, but that's the kind of thing that we were able to do with DocCom. There's over 400 videos in that resource. It's a very rich resource and we're proud of it.
Walter Baile: So, it's not just video though. It's also self-testing and additional resources if--
Dennis Novack: Yeah.
Walter Baile: Someone wants more information.
Dennis Novack: Yeah, yeah. We put on, first of all there's a lot of videos, kinds of videos, trigger videos, videos that make you think and ask you to react. There are videos of actual patients, a number of them, patients with various disorders. And yes we have the capacity for students to answer questions online, answer multiple choice questions, but also reflective questions. What kind of doctor do I want to be? You know relate, you know how-- what gets in the way of me considering substance abuse as a disease. You know what kind of qualms do I have when I see a patient like this and so on. And they answer those questions online and those question-- their answers can be seen by other students, by faculty and then spur this discussion.
Walter Baile: So, how widely is your-- are these modules used? Is it mostly medical students?
Dennis Novack: Yeah, it's very interesting. We've had something like 35,000 active users only in the last six or seven yeahrs since it's been out. Interestingly we used to have a free trial, a two week free trial and we discovered that a number of those people on the free trial were folks from India and other countries you know who used DocCom to learn about American culture, communicating in American, in American settings. And I think many of those were physicians who wanted to come practice in the United States.
Walter Baile: Interesting.
Dennis Novack: Yeah, because they used it and then actually didn't buy it afterwards, didn't buy a subscription. But, we've had many, mostly students and residents, but we're beginning to get activity from healthcare organizations that are hoping to train their practicing physicians in better communication skills.
Walter Baile: So, you know I've always been interested in the question whether or not looking at a video and maybe having a small tutorial together with the video and doing a self-assessment can actually kind of translate to the clinical setting or even to a setting where one then practices what they saw with a standardized patient. Have you explored that issue to see whether or not, what's your thought about that sort of transfer of training into another, into the practice area?
Dennis Novack: Yeah, well first of all I think just reading a DocCom module or videos online, all sorts of video training you know can be of benefit, but we always meant DocCom to be used as a, in a blended learning situation where the students will read DocCom. They'll answer reflective questions, they'll come in and discuss it then they'll practice with real patients or with standardized patients. And we've done a couple of studies that show that students and especially residents improve their skill levels when assessed by standardized patients later on. So, we haven't done the studies to look at you know how these skills translate into actual clinical care, although other people have done those studies and we know that they do and that there are better outcomes with some of this training that can involve video and so on.
Walter Baile: Yes. And more recently you've also been involved with the development of sort of online teaching using objective patient assessment methods.
Dennis Novack: Yeah.
Walter Baile: Could you say something about that?
Dennis Novack: Yeah, well again you know we're interested in reaching the maximum number of people. I mean I come from a medical school, I'm responsible for clinical skills teaching for over 1000 medical students and that's a real challenge, especially in the clinical yeahrs when they're in 21 different affiliate sites. You know how do you deliver care, teaching about care in a systematic way so we're sure that everybody gets pretty much the same training and assessment. So, that's why we developed an online standardized patient interaction system where students or residents and standardized patients can interact and the standardized patients can give feedback. And actually, I think, it's maybe more powerful in some ways than live interactions with standardized patients because the standardized patients in our system can pull up a checklist and-- you know talk to them about, well gee when you gave me bad news you know you immediately started talking about how great the oncologists are here. But, I couldn't hear anything because I was so shocked. Let me just show you the video of what you did. And then sure enough there's the student going, yes you do have metastatic ovarian cancer, but I just have to tell you da, da, da, da. And then you can also see the standardized patient's face who's looking down and crying you know and not really listening. And then the standardized patient says, "Okay let me show you a video now of how Dr. Quill does that." You know and you see Dr. Quill going, right after he says the same diagnosis, going I know, it's tough isn't it and he's quiet. And lets her cry and then say something and then emote and then after she's calmed down and ready to listen you can say okay, now we can consider what to do next. You know so it's very different and I think it's a very powerful learning experience and that's what we're told by the students.
Walter Baile: So, let me see if I can understand. So, if I wanted to interact I would log into my computer--
Dennis Novack: Yeah.
Walter Baile: And I would interface with a standardized patient who is on the other side of the screen.
Dennis Novack: Yeah, in Philadelphia, at home.
Walter Baile: In-- wow. And so, then the task would come up, maybe a little brief vignette of the case--
Dennis Novack: Yeah.
Walter Baile: And here's what you need to do.
Dennis Novack: Right.
Walter Baile: And I would interact with that standardized patient who actually seems to me also has kind of the role of instructor--
Dennis Novack: Yes, yes.
Walter Baile: In this scenario. So, how immersive is it for the student? Do they sort of report that they really felt that you know this was a genuine interaction--
Dennis Novack: Yeah.
Walter Baile: And they felt immersed in the scenario?
Dennis Novack: Our standardized patients are really very good. They're very well trained and I think you know the students and residents get really drawn into the challenge of it. And pretty soon they're talking like it's a real interaction; you know I've watched a number of these. Now, I have to say there's some drawbacks too because and I'm still thinking about how to overcome some of this. Our students have to pass these interactions. They have to get a score of 70 or above. And although there's an honor code you know we notice and the standardized patients tell me that they notice that students are going down the checklist because they know the checklist. They've read the module. You know they read the DocCom module on breaking bad news first. They see the checklist and then they're tested on the checklist. So, we see them looking to the right at the checklist, which is clearly scotch taped to the computer screen and they're going down. So, you know there's no way of, you know we can't have the standardized patient go stop that. [Laughter] So, you know so I worry a little bit about that, but I do like the idea that the students are at least saying the words and seeing the effects of it. So, even though they may be technically cheating I think they may be learning from it too.
Walter Baile: Yeah. So, maybe the standardized patient should, when they see the patient, when they see the student cheating she's like, okay now let's do it without the checklist.
Dennis Novack: Maybe they can do that yeah.
Walter Baile: With second run. Okay do that again. So, the students does it looking at the checklist, sees Tim Quill do it and then, maybe. Please turn your checklist over.
Dennis Novack: Yeah, yeah. That would be, it could be a good idea.
Walter Baile: So, that would be very interesting. Now, I think there are actually some scales that students can also fill out to test how immersed they feel in the experience and that might be one idea. We actually did some creation of a virtual reality for genetic counselors in which they interacted with an avatar and then filled out an immersive scale. And there are some folks at University of Florida working on this immersion issue so that might be something—
Dennis Novack: Oh, that's a very interesting idea.
Walter Baile: Interesting to do to see how much they felt present in the interaction.
Yeah, might give you, give some additional data. So, here at MD Anderson you know we get people who have a variety of competencies in communication. But, of course it's a cancer center, so the challenges of communicating bad news is you know one of the things they do every day.
Dennis Novack: Yeah.
Walter Baile: And one of the-- working with the first yeahr fellows that has been very gratifying because they struggle with the issue of transitioning patients to palliative care and talking about end-of- life issues, which is going to become as you know more and more important--
Dennis Novack: Yeah.
Walter Baile: Because with healthcare reform we're not going to be paying for unnecessary treatment or treatment that's ineffective because the illness has progressed too far and perhaps supportive care is the way to go and approach of choice. But, you know there's always the argument that, well we don't have time to do that and I think that's the most universal argument I've seen where you know these are good skills. We like to do them, but we don't have time. And so, I'm wondering how one-- what does the data show or what does the, how to respond to that?
Dennis Novack: Yeah, so there are studies that show that you know providing empathy, for instance, doesn't take a whole lot time.
Walter Baile: Um hmm.
Dennis Novack: And has many rewards later, you know. You know both for the physician and the patient.
Walter Baile: Um hmm.
Dennis Novack: But, the other thing is that you know you're saving time in the end by learning about the patient's concerns and worries, the patient's social supports. You know because if you get to know the patient as a whole person you have a better chance at keeping them well again. If you get to know why they got sick at this particular time and what contributes to their illness, to their symptoms and to their worry about their symptoms. You know patients who are anxious or whose concerns contribute to sadness or depression you know they'll have more symptoms, they'll have more pain. And if you really know them a little better and can reassure them and can address their concerns they feel more at ease, more at peace. They have less anxiety and thus less worry and less symptoms. So, you know it really does payoff to know people and you know another major issue is adherence and it's been shown that patients who feel that their doctors know them as a whole person and whom they trust, those patients have a lot more, a lot higher rates of adherence than patients for whom the opposite is true. You know if they feel their doctors don't really know them and they don't quite trust them why should they take these medications. So, to the extent that you're prescribing medications that work for people you want your patients to be taking them you know and having good communication skills you know I think keeps your patients healthier. And there have been studies that show that if the patients have physicians that have higher ratings of empathy you know who are, who have better communication competencies by a few different measures those patients actually have better health outcomes.
Walter Baile: And they sue less also.
Dennis Novack: And they sue less.
Walter Baile: So, I wanted to ask you about the question of empathy because I know it's a really important one. It's gotten a lot of attention in the medical literature lately. And I'm sure you're familiar with the studies that have shown you know in first and second yeahr medical students you know empathy is pretty high--
Dennis Novack: Yeah.
Walter Baile: And then in third and fourth yeahrs it goes down.
Dennis Novack: Yeah.
Walter Baile: And there's been a lot of speculation about that, whether or not it's due to the nature of medical training and that students get empathy beaten out of them because they're taught that to be efficient and fast and to know facts. And that the training kind of models that we have really don't encourage the continuity of that empathy into advanced yeahrs. And I wonder working with medical students do you have any thoughts about that or if it's changing or how one can overcome that--
Dennis Novack: Yeah.
Walter Baile: If you believe in that data.
Dennis Novack: Yeah. Well, there are a lot of studies. But, the studies tend to be in one medical school or another or one residency program or another. Still the data, there's enough of those studies to suggest there is a trend in decreasing empathy during the later yeahrs of medical training including residency and it is concerning. And I think it's partly due to the fact that a lot of programs don't explicitly focus on keeping this, you know skills of communication and empathy up in the clinical yeahrs, in the residency yeahrs. And there's not a whole lot of faculty development going on so you know busy clinicians who are kind of, some of whom are feeling stressed and burnt out themselves you know are not great role models. I think there's a lot that's going to change though. I mean hospitals are now extremely worried about patient satisfaction and are going to be graded on that and to some extent reimbursement's going to be tied to that. We know that better physician counseling is associated with less recurrence. For instance, if congestive heart failure or you know other diseases that hospitals are currently worried about you know not getting Medicare reimbursement if patients are readmitted within 30 days and so on. So, I think a lot of hospitals systems are now concerned and are really focusing on improving the communication and empathy communication skills of their faculty, of their attending physicians, of their residents and so on. So, there's a groundswell, I think, for that and I've what I've seen is that you can through training of residents and later yeahr medical students keep their skills up. And it's also a matter of attitudes and preventing burn out and preventing medical student abuse, you know preventing resident overwork because we know that when residents are overworked or feel burnt out they're less empathic.
Walter Baile: And get more irritable.
Dennis Novack: And get more irritable.
Walter Baile: Yeah.
Dennis Novack: You know so there's a lot--
Walter Baile: Yeah.
Dennis Novack: Of factors--
Walter Baile: Yeah.
Dennis Novack: That really have to be addressed to make sure we have compassion and care in all levels of training.
Walter Baile: So, speaking-- getting back to the issue of faculty development I know you'll be working with Tim Gilligan on a project for the AACH.
Dennis Novack: Yeah.
Walter Baile: And the, you know Tim will be down here in a few weeks giving a talk on the efforts at the Cleveland Clinic to defuse communication skill teaching throughout the institution precisely for the reasons that you said, to improve healthcare outcomes, to prevent you know recurrent patients who are ill, going home with an adequate preparation and coming back.
Dennis Novack: Yeah.
Walter Baile: And you know they've made an enormous effort to train the faculty not only in being more effective communicators, but actually to become role models and teachers.
Dennis Novack: Yeah, wonderful.
Walter Baile: And do you know I wonder how you recruit or how you train your faculty trainers at Drexel. Is there a program, is there a faculty development training program in communication skills for those who do the teaching or who want to be teachers?
Dennis Novack: No. So, I oversee the doctoring curriculum for the medicine residencies and it's you know I and one other faculty member do that training. But, really we should have that training throughout all of our residencies, anesthesia, surgery and so on. So, there's not an organized faculty development program, which we really should have, although there are faculty development days where many of the faculty will come and focus on an issue. And sometimes we do communication and teaching skills and so on so a three hour workshop you know may have some impact. And we've had a faculty development workshop, an all day workshop on communication skills and cleverly got some of the people who the health staff had some of the most difficulty with you know because they tended to be very demanding or--
Walter Baile: Critical maybe?
Dennis Novack: Or hyper-critical and so on. And some of those folks came and I saw a difference afterwards you know because they had to do role play, you know and they had never done that before. You know role play you know of teaching and how do you give gentle and constructive feedback to health staff without yelling at them, you know. So, I--
Walter Baile: Yeah.
Dennis Novack: Did see a difference--
Walter Baile: Yeah.
Dennis Novack: But you know we should have an ongoing organized systematic program, but you know that's in the future.
Walter Baile: Yes. The teaching mission of medical schools has eroded significantly in the last 20 yeahrs as you know pay as you go has come in for the faculty--Dennis Novack: Yeah.
And so many more demands for paperwork and electronic medical records are stealing time away from teaching.
Walter Baile: Right.
Dennis Novack: So, it's really a dilemma, yeah.
Walter Baile: Well, hopefully this new mandate to improve healthcare outcomes will also you know spur some real interest in the fact that you know we can't abandon teaching for the sake of clinical revenue and patient outcomes. In fact, they're so intrinsically linked that if we don't train people to communicate well with patients that you know the outcomes are going to be poor.
Dennis Novack: Yeah.
Walter Baile: So--
Dennis Novack: And a lot of that has to also include interprofessional teaching. You know in my conversations with house staff they, when we have our sessions on problem communications, problems in communication they're always talking about how the nurses you know are angry with them or you know don't do what they suggest because they're wet behind the ears and they know better. You know and then they yell at the nurses and then the nurses you know put little mustaches on their pictures you know and everybody knows you know who they are. And so you know a little inter-professional communication training would be helpful as well.
Walter Baile: Yeah. And certainly if you become targeted as a trouble making resident--
Dennis Novack: Yeah.
Walter Baile: Other people can make life very miserable for you.
Dennis Novack: Very miserable for you, yeah.
Walter Baile: So, that's one big incentive to teach people early on to be serious about communicating effectively and getting along with people.
Dennis Novack: Yeah, absolutely.
Walter Baile: And I think that this whole issue of teamwork will kind of become more and more important and lend itself to the kind of training that you and I do in simulation. You know how to work as a team on the wards I think we're kind of getting more and more toward doing training as teams rather than individuals--
Dennis Novack: Yeah.
Walter Baile: And--
Dennis Novack: Yeah, you have to take the time to have people to get to know each other, people on the teams to get to know each other and appreciate each other’s abilities you know and who they are, to regard each other highly so that when they do work together--
Walter Baile: Yeah.
Dennis Novack: You know they have that.
Walter Baile: So, I guess the dictum is you know do as to each other as you would like to do to patients. In other words, respect curiosity about their role--
Dennis Novack: Yeah.
Walter Baile: Yeah, and their lifestyle, empathy that-- you know it's, it would seem wise that we apply to ourselves and our work with our colleagues the same things that we held to a high standard in interaction with patients and families.
Dennis Novack: Yeah, absolutely. You know there's, one of the new buzzwords in medical education and one of the new trends has to do with professionalism education.
Walter Baile: Right.
Dennis Novack: And it's very interesting because only a few yeahrs ago people weren't talking about you know educating physicians explicitly in professionalism. You know it was assumed that if you didn't learn honesty and integrity and how to get along and so on by kindergarten you weren't going to learn it you know in medical school or residency. But, I think the erosion of the profession of medicine, I mean after all you know we're providers now and our patients are you know clients. You know it's not physicians and patients anymore. And there's a lot of distrust among patients about the medical profession and conflicts of interest and so on, so there's real danger in those kinds of factors eroding our ability to communicate and to have trusting relationships with patients. So, now we're teaching you know professionalism and that's now coming into third and fourth yeahr into residency programs and I think that's a good trend. In one of the core tenets of professionalism is getting along and working in teams.
Walter Baile: And hopefully we'll see some of that kind of training enter into doc.com.
Dennis Novack: Ah yes. We're currently going for a grant to try to expand you know that teaching of professionalism.
Walter Baile: Well, the success I think you've had with teaching basic communication skills hopefully your experience will spill over into developing modules on professionalism.
Dennis Novack: Yeah, yeah. Thank you, yes.
Walter Baile: Well, thank you Dennis.
Dennis Novack: Whoa, time went quickly.
Walter Baile: We've been speaking today with Dr. Dennis Novack, Associate Dean for Education at Drexel University School of Medicine. Dennis will be giving our ACE lecture today, Achieving Communication Excellence on the topic of the therapeutic aspects of the clinician-patient relationship. So, look for that also on our website in addition to my interview with Dennis.
I*Care Roundtable Discussion, April 23, 2013, Dennis Novack, M.D. (33:41)
©2013 The University of Texas MD Anderson Cancer Center
1515 Holcombe Blvd, Houston, TX 77030
800-392-1611 (USA) / 713-792-6161