Anthony Back, M.D.
Professor of Medicine, Division of Medical Oncology
University of Washington, Fred Hutchinson Cancer Research Center
Dr. Baile:
Hello, I'm Dr. Walter Baile and I'm
pleased to bring you I*CARE Roundtable; a discussion with leaders in
the field of communication skills in medicine, sponsored by the M. D.
Anderson program on Interpersonal Communication And Relationship
Enhancement. Today our guest is Dr. Tony Back, Professor of Medicine at
the University of Washington in Seattle. Tony is Director of the Cancer
Communication and Palliative Care programs at the Seattle Cancer Care
Alliance and the Fred Hutchinson Cancer Research Center.
Tony is a medical oncologist by training and practices gastrointestinal oncology. He was a faculty scholar on the "Project on Death in America," and has written extensively in the area of communication skills in oncology. Tony has been the principle investigator for two important educational grants: Oncotalk and Oncotalk Teach. Both NCI funded programs for teaching communication skills first to medical oncology fellows, and now to train medical oncology faculty to actually teach communication skills. Welcome Tony.
Dr. Back:
Thank you.
Dr. Baile:
You know I just wanted to go back to
something you had said, which sort of traces your line of thinking a
bit about organizing these communication skills training for fellows
and faculty, and that was a discussion about changing the culture of
medical oncology, and I wonder if you could tell us a little bit about
what you were thinking and what the idea was?
Dr. Back:
Yeah, absolutely. The culture change aspect, I think, is a consequence
of the way that the nature of oncology practice has changed. It's
become so much more complicated. I think the biomedical aspects of just
the anticancer technology are at a point where they become overwhelming
for both the patients and even the oncologists who are trying to
explain it to them. You know, I do GI oncology so if you take for
instance metastatic colon cancer, 10 years ago there was one drug and
we used to kind of argue about what schedule to have it in. But now
there is a whole array of drugs, there's a whole array of schedules,
there's all these new ways of evaluating what the outcomes are, there
are ways of even predicting who's going to respond to what drug with
these KRAS mutations. And that level of medical complexity has made all
the basic aspects about deciding what treatments are worthwhile, what
treatments are really doable, and how patients feel about treatments.
It makes all those basic issues much more complicated because there's
this whole layer of other stuff, and so the culture change I see is
integrating the biomedical complexity with the approach to the whole
person. That... integration and inclusion of those things together is
the culture change that I think is waiting in the wings. I think it's
starting to happen. I certainly see it in the lay press. You guys might
have seen the New York Times recently, Pauline Chen had a blog about do
doctors have time for empathy, and the response is overwhelming. She
writes this one little thing in there... and gets 200 responses by the
next day. And so I think this is something that really is on the minds
of patients and families.
Dr. Baile:
Do you think that patients today also
really want to be better informed and have information about their
illness, even things that weren't talked about like prognosis.
Dr. Back:
Yeah it's interesting. I think it cuts
both ways. I see there's this group of patients who want lots of
information, they want to know all the details. There's another group
of patients who still, they want to keep a little bit at arm's length.
They want to be able to trust the doctor to help them with the big
decisions. They don't want to be uninformed. I'm not talking about
people who are completely in denial, but they just don't want to look
at all the complicated, sobering, worrisome stuff. I have patients now
who tell me that they limit how much they look at the web and that when
they first got diagnosed they did a lot of reading and they were like,
oh my gosh, and they've stopped. I even have a friend who's an expert
cancer blogger who advises other patients on the web about what to do,
and she actually advises newly diagnosed people to be very abstemious
about their reading, very selective, and she points them to just a
couple of places and says stop there and go talk to your doctor.
Dr. Baile:
So information can be a double edged sword?
Dr. Back:
Absolutely.
Dr. Baile:
... for patients, and in fact some can be totally overwhelmed by what
they read and then it can be very confusing. So one of the new jobs of
the oncologist is really to be able to explain at a level of the
patient, what's going on.
Dr. Back:
Meeting the patient where they are in
terms of the level of detail they need, the level of understanding and
complexity that they need. That's more important than ever, especially
with so much information on the Internet that it's so variable in
quality. Some of it is great but very technical, some of it is great
but for a given patient might be too basic, and some of it is just who
knows where it's coming from?
Dr. Baile:
You've been involved a lot in
palliative care. In fact, it's one of your specialties - end of life
communication. Could you talk about just a few of the issues regarding
the importance of communication at the end of life, some of the
decisions that patients and family members, need to make, and what's
been missing in end of life discussions?
Dr. Back:
You know what - I think that in the past few years, there is this
increasing acknowledgement on all sides; doctors, patients, and
families, that some kind of end of life planning is important because I
think there's this growing realization that without some confronting of
the issues, without some preparation, that you can get to the end of
life and run out of time - run out of time to talk to your family, run
out of time to say the important things, run out of time to make a will
or make preparations, and it leaves everybody in this just horrible
frenzy. I think that is becoming more and more well known. I think the
thing that's not as well known now, is how, as the clinical team, you
can start to prepare people in small ways; small steps, and keep those
kinds of things moving. I've worked with lots of trainees and they'll
talk to patients and say, oh she's in denial and kind of throw up their
hands like that's the end of it, we're not going to do anymore. And yet
the challenge I see is how do you continue to engage with that kind of
person, and not to keep confronting them? There's this study of
oncologists that Chris Dougherty had already talked about how the
oncologists felt like they were "hitting the patient over the head"
because that's the only way they know how to go about it and it turns
out that's wrong. There are other ways, and I think those other ways
about how to engage people in these processes of thinking ahead need to
be more widespread, more taught, more a fixture of the culture instead
of us just saying - us the clinicians just saying - you know so and
so's inappropriate. If I hear that one more time, I'm going to flip.
Dr. Baile:
So let me go back to the point because I think it's a really important
one, and maybe start with the perception that many doctors,
oncologists, generalists, have that idea that communication is
something that either you're good at or you're not good at. And that
well, some folks have communication ability and other folks don't, and
it's something you really can't learn and I wonder whether you could
speak to the point of... is communication really a skill?
Dr. Back:
Sure, sure. So, what all the empirical
studies show is that you can improve, with a certain kind of teaching.
It's not the kind of teaching we all grew up with, it's not the see
one, do one, teach one. It's a much more interactive, faculty
intensive, close attention kind of dialogue and feedback with a
learner. And that kind of skill is definitely learnable. I mean
certainly we all start out in different places with communication
because we've all had different life experiences. But the fact is, we
can all improve and my feeling is that the average level right now,
it's a little too low. The average level ought to be higher.
Dr. Baile:
So tell us about Oncotalk and how
that came about and what you've learned from Oncotalk, and sort of how
this process really went for the learners?
Dr. Back:
So Oncotalk was a project funded by
the National Cancer Institute to give an intensive communication skills
intervention to medical oncology fellows. These were mostly fellows in
their second and third year of fellowship, so they're really finishing
a long process of acquiring biomedical expertise.
Dr. Baile:
And they've had some experience with taking care of the...
Dr. Back:
... had some clinical experience.
They've had some experience watching their mentors etc, etc, and we
brought them to a small group, intensive workshop in Colorado. We work
with them with actors who came in playing patients at different points
in the trajectory of illness every day, and we had every fellow
practice every day with a patient and they learned to give feedback,
they learned to be supportive, they learned where they get stuck, and
we had expert facilitators as you know since you were one of them, who
helped make that process engaging and non judgmental and kind of fun.
And so that was a five year project, we trained about 200 fellows, and
had very interesting results from it. There are a couple of things we
planned and a couple of things we didn't plan. One of the things we
planned was an evaluation looking at what these trained doctors
actually say when they talk to simulated patients. So we tested at the
beginning of the retreat and at the end of the retreat, and we looked
at the kind of things they said like, when the doctor gives the bad
news do they wait for the patient to react before they go on? We
measured that. Did they say the word cancer when they're talking about
the bad news? We measured that. And a whole variety of those kind of
content- based cues, and those who really responded and improved quite
dramatically after...
Dr. Baile:
And those were actual audio recordings?
Dr. Back:
... audio taped recordings, right,
that we had blinded coders read and evaluate both pre and post and that
was done by James Tulsky at Duke who developed the content-based coding
system and the web program that goes along with it. And those changes
are very impressive, P values .001, etc.
Dr. Baile:
And what kind of feedback did you get from the fellows about Oncotalk?
Dr. Back:
Well that was the part that we didn't
expect actually. The fellows were... many of the fellows felt like this
was a side of their practice they had not explored before, and many of
the fellows were quite grateful that they had a chance to sort of think
about this. The parts that I didn't expect, which I was alluding to
earlier, was that for the fellows it created kind of a social network
of people who kind of know each other, they see each other now at other
meetings. I usually have a little night out at a bar at the annual ASCO
meeting where people can kind of get in touch. And there's this
interesting kind of network of people, and it made me think that what
we've done in some sense is create this niche and culture within
oncology of people who are concerned about these issues.
Dr. Baile:
Interesting, I remember that James
Tulsky, one of the co-investigators who did the analysis of the
audiotapes, had mentioned exponential affect on patients of training
200 fellows and the downstream affect that... over the course of the 30
year career of the trainees that perhaps one could see a million and a
half patients, and so the impact of training could be substantial.
Dr. Back:
Yes.
Dr. Baile:
That's really important.
Dr. Back:
It's huge actually.
Dr. Baile:
Now Oncotalk was a five year program, and now you've launched into something a little bit different?
Dr. Back:
Yes.
Dr. Baile:
And that is to extend Oncotalk in a way, to teach oncologists how to teach communications skills and...
Dr. Back:
Yes.
Dr. Baile:
.I wonder if you could talk a bit about it.
Dr. Back:
It gets back to the thing you mentioned earlier about how do people
learn, and the usual gig in medical education is see one, do one, teach
one. In communication, it turns out that just doesn't work. It's like
Bob Arnold says, one of the other investigators, would you expect to
improve your golf game by watching Tiger Woods on TV? I don't think so.
So really the issue is you need practice, and if you look at the
expertise literature about how professionals acquire expertise, it
takes many hours of practice but it takes a certain kind of practice;
not mindless practice where you just repeat the same thing over and
over, it's practice with feedback. And that's what we're trying to
create. So that's in a way, what we learned in doing Oncotalk, was the
importance of that kind of teaching because we had videotaped and
audiotaped ourselves as teachers as part of that project, and analyzed
them in great detail. And so now we've taken that methodology and
transformed it into something that oncology faculty can do in clinic,
in real time when they're precepting fellows, and that's what we're
trying to teach them. So the new program is called Oncotalk Teach, it's
for oncology faculty who work at cancer centers that involve oncology
trainees, and we're trying to equip them with a new set of teaching
skills about how to improve fellow communication. And so it raises a
bunch of interesting issues in the faculty's relationship with the
fellows, and how they see fellows' professional development, and how
talking about communication can actually be part of that even if the
fellow is really headed towards a career in basic research.
Dr. Baile:
And some of the contacts that the
faculty will have with fellows are very brief, so this is really making
the most of your five to ten minutes with the fellow and how to do
teaching on the run a little bit?
Dr. Back:
That's right because the teaching
environment is so complicated now in the academic centers, people have
so little time, they're pressed for lots of other things, and we've
received a certain amount of skepticism from faculty who haven't
participated, that I'm never going to have time for this. Well the
reality is they're spending a considerable amount of time with fellows
already, and the important thing is how they can they make that small
amount of time really count, make it a learning moment for the fellow
instead of just another blah blah blah case? That's the issue...
Dr. Baile:
And so far you've done two cohorts?
Dr. Back:
Yeah. We're halfway into our second cohort.
Dr. Baile:
How are things going?
Dr. Back:
You know, it's been really
interesting. The faculty have been very engaged in this, and we've had
some really interesting, thoughtful, deep conversations about what it
means to be a person who ushers other people and mentors them into the
process of becoming an oncologist... the kind of oncologist we'd want
them to be, the kind of oncologist who can talk about the biomedical
stuff, the kind of oncologists who can at the same time talk about
healing, the kind of oncologist who pays attention to the whole person.
Dr. Baile:
And there's an evaluation piece to this project also?
Dr. Back:
Yes, and parallel to Oncotalk we are
looking at the acquisition of teaching skills and we're using James'
content-based coding again, because what's interesting and striking is
that if you look at the medical educational literature, there's just so
little empirical research about how to actually improve communication
skills. I think of this as a complex psychomotor of clinical skill.
There's so little data about how to do that. I thought this was really
important.
Dr. Baile:
And so this is an ongoing project and
has 3 more years to the project, so people who want to find out more
about it, medical oncologists, could... where could they go?
Dr. Back:
Yeah, the website is www.Oncotalk.info and they can find everything there or they could give us a call.
Dr. Baile:
Great. Well thank you much for sharing your wisdom and these very exciting programs with us.
Dr. Back:
Thank you.
Dr. Baile:
And we'll just wait to see the outcomes and I'm sure this will be a great benefit to the faculty.
Thank you Tony. By the way, to hear more about communication skills and cancer, be sure to go to the I*CARE website homepage and click on ACE, that's A-C-E, lecture series to watch Tony's lecture on what to say when the chemo did not work. It's really a fabulous talk.
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