Roundtable with Dr. Sally Thorne

Interpersonal Communication And Relationship Enhancement (I*CARE)
I*Care Roundtable Discussions
Dr. Thorne
Date: December 5, 2013
Time: 28:02

Sally Thorne, RN, PhD, FAAN, FCAHS
Editor-in-Chief, Nursing Inquiry
Professor, School of Nursing
Associate Dean, Faculty of Applied Science
University of British Columbia, Vancouver, BC, Canada

Dr. Baile: Hello I'm Dr. Walter Baile, Director of the MD Anderson program on Interpersonal Communication and Relationship Enhancement or I*CARE. Today we're pleased to have as our guest for this roundtable discussion Dr. Sally Thorne. Dr. Thorne is Professor at the School of Nursing and Associate Dean of the Faculty of Applied Science at the University of British Columbia in Canada. Dr. Thorne has a distinguished career as a researcher on the psychosocial aspects of cancer and chronic illness. She's also made extensive contributions to the methodological, theoretical and philosophical literature of her discipline. Her work has focused recently on methodological issues in qualitative research and on communication challenges in oncology such as shared decision making, discussing clinical trials and addressing the needs of patients with chronic metastatic cancer. Her work has been continuously funded by entities such as the Canadian Breast Cancer Research Initiative and the Canadian institutes for Health Research. As an educator in the school of nursing, Dr. Thorne has been responsible for many teaching innovations in the graduate school of nursing at the University of British Columbia. These include the development of a Master's level course on critical thinking and concept development and a doctoral level course in the philosophy of nursing science. Dr. Thorne's been sought after internationally for her expertise and has been a frequent visiting professor at organizations such as Karolinska Institute in Sweden and the University of Basel in Switzerland She's also received other wide recognition for her work serving a term as a board chair for the British Columbia Cancer Foundation, receiving the Pfizer Award from the Canadian Association of Nurses in Oncology for excellence in nursing research and being appointed Editor in Chief of the journal, Nursing Inquiry. Welcome, Sally.

Dr. Thorne: Thank you so much.

Dr. Baile: So for you it's a bit of a treat being down here because you left behind a little bit of cold air.

Dr. Thorne: Absolutely it was just about freezing level when I left Vancouver and have arrived to beautiful Texas weather.

Dr. Baile: The bad news is it's followed you down and so probably we're going to kind of feel a little bit of frigid air and maybe some rain in the next couple of days but you'll be heading out of here.

Dr. Thorne: Hopefully I'll take some of this warmth back.

Dr. Baile: Okay, well thanks for coming down and you'll be giving a lecture later today on some of the psychosocial aspects of communication with seriously ill patients so I wanted to ask you a little bit, perhaps give us a little preview of some of your research and what you've been focusing on in your investigative work?

Dr. Thorne: Oh, I'd love to. As anybody who works in the communication field knows, communication is incredibly complex and difficult. In fact I think it's so complicated that you should never be able to teach it and you should never be able to do it well. But the good news is from a patient perspective that an amazing number of clinicians are actually able to convey incredibly complex messages under the most, you know, painful and difficult moments of a person's life do it in a way that has a lasting impact. We want to figure out how to make that happen more often and conversely some of the most devastating experiences of a patient's life with a serious illness can be associated with those communication moments. We want to find out how to prevent those ones that keep people awake at night and haunt them and they look back on and it becomes part of the family story. So it turns out to be quite an important part as people like you know all too well, of anybody's experience with a serious illness and anybody who's been through that would recognize the importance of communication.

Dr. Baile: You know the focus has been pretty extensive on what doctors do poorly in communicating and so it's very interesting to speak to someone who has been doing research on what clinicians do well...

Dr. Thorne: Yeah.

Dr. Baile: in communicating because it does really give us some kind of idea or template for what we should be teaching, could talk a little bit about what some of the things that' you've found and what do clinicians do well?

Dr. Thorne: Well, first I think that from studying patients and all of my research has been from a patient perspective so I'm not suggesting anything that we hear is necessarily a truth but it's a pattern or a theme in what patients say. The good news I think from a patient's point of view is that you don't need to be articulate and charismatic and extroverted in order to be a good communicator. I think often in the public world and in the health care world you sort of assume some people have good communication skills and they're excellent at it and other people are kind of bumbling and awkward and they don't...patients are incredibly forgiving and they can get who an individual is and if you happen to be bumbling and awkward but you're authentic about it you can be an effective communicator. So it isn't about what ever you're innate personality is like, it's about an authenticity and caring. Patients tell us things like they need the feeling that they are known, they really don't want to be a widget within the system, they don't want to be just a number but what it takes to have them feel known is very different. Some might need to have you be business like and professional and that's respecting their dignity and professionalism, others might need you to be folksy and friendly and that's respecting their need for a familiar kind of connection. So what they need to feel known is quite different but figuring out how to help them feel known might be an important part of communication. So these are the kinds of things you hear from a patient point of view that would be different than other kinds of research.

Dr. Baile: Well, that's very interesting because what you're saying is one size doesn't fit all regarding the relationship with the patient so how can we help clinicians understand what their communicative role should be with individual patients, what do we...what do we need to be teaching them?

Dr. Thorne: Well, part of the challenge with traditional research is that it really looks at average populations so you can document what most people might want in a particular kind of communication encounter. But the real challenge often is figuring out who isn't going to fit the dominant norm, who doesn't want the information of that nature at this particular time or needs it titrated differently. This is one of the advantages from a patient perspective research is that you can start to tease out not just what the general thing is that you ought to do but how you can figure out those variations. I think what that says to me is that we have to be doing research and teaching, recognizing that there are some evidence based things we can find out about general populations of patients, 75 percent of patients like this and 25 don't for example. But we have to teach to that we also have to teach those skills of how to connect with individual people. We have to have health care professionals from day one recognizing that that's a fundamental component of being able to engage with people.

Dr. Baile: So you've talked about two concepts that authenticity and connectivity and I wonder, you know, since you have posited that we can't stereotype individuals as to what style that they like in their doctor or their nurse or their other clinician that does authenticity and connectivity cut across all those domains in the sense that if a patient perceives you as genuine and authentic that you can get away with not being folksy if that's what they want?

Dr. Thorne: Yes, I think patients are actually quite forgiving and quite capable of recognizing that particularly in the oncology world they understand that it can't be fun to be an oncologist and having to have difficult conversations with people, that must be difficult to go to work everyday. So they do have some sympathy and empathy they understand that clinicians are under time pressure so they have an awareness of all of that and what they are looking for is that sense that somebody cares enough about them individually. Even from the perspective of what the treatment plan is, there's a real difference for patients to be told that 87 percent of people do well with this, therefore I'm giving it to you doesn't really mean very much but the thought that you've assessed the patterns and assessed the evidence and you understand something about this individual and their disease and their human experience and on that basis you've made the recommendation so an individualized...the feeling that your recommendation is being individualized is very different than you're being fit into a rubric.

Dr. Baile: So one of the things that I thought or I've taught that was an approach to really understanding patients and being able to tailor information and establish this communicative rapport is trying to take a bit of a social history, what we call a psychosocial history at the beginning of the encounter so that the patient begins to feel as if you have an interest in them as a person.

Dr. Thorne: Yes.

Dr. Baile: Did that come out at all in your interviews as an important factor in...because I know that sometimes clinicians can think about that as snooping into the patient's private life or taking a lot of time but is the patient perception a little bit different is there some disconnect there in...

Dr. Thorne: Yeah, absolutely, I think that's one of the important meta messages that you've been teaching all along and it's one that sometimes meets a little bit of resistance because people perceive it to take time. There's a little bit of a fear of a flood gate if you ask one open ended question that you'll be not knowing how to get out of that conversation and everybody's got some time pressures. But there are ways of posing a question like saying we're going to be here for 20 minutes and this is the conversation for the first few minutes I just want to have a little bit of conversation so we know who you are. But there's also very brief conversations that can indicate not necessarily a full social history but you're having a biopsy and you're going to be having results what kind of person are you with regard to those results, are you the one that needs to know the information instantly even if it's an inconvenient time by phone or would you rather reschedule the time and you come into the office. That very brief claim at the very beginning signals something and gives a permission for people to communicate to the best of their ability because they may not know. What we think we've learned is that even if patients get it wrong they might say I really should never have had them phone me with the biopsy results on a Friday afternoon over a long weekend when I was all by myself. But I just so appreciate that I had that choice and I recognize that that was done in my interest. It turned out to be a lousy weekend but I don't blame the clinician, it's a very different feeling than having something done to you.

Dr. Baile: So when we teach, "ask before you tell," that seems to be a universally respected strategy that patients appreciate from...

Dr. Thorne: Yeah.

Dr. Baile: the clinician.

Dr. Thorne: It takes very little time but it's a signal from day one that who you are as a person matters in how I'm going to communicate with you.

Dr. Baile: So your research actually instead of doing observational studies has gone to the consumer so to speak of communications, the patients. So that's really important information that allows people to tailor their educational strategies, anything else that's come out of this that surprised you or one thing you had mentioned is how forgiving patients are and how it's that the core sensation of feeling that resonates most with them is that this kind of respect for their opinion, for their view point, anything that surprised you or that you wanted to underscore about some of the findings that your research has...

Dr. Thorne: Well, one of the great things about the patient perspective research is that it does actually validate a lot of things that many researchers and expert clinicians know to be true but don't actually have a way of demonstrating it. A lot of these things are not amenable to measurement, you really can't create an instrument about it and if you did it would have influenced the results in such a way that you can't interpret patient satisfaction scores for example, they're sort of notoriously bad at actually detecting much of a difference. This kind of research validates the kinds of things that good people have been teaching good clinicians to do so there's no major outrageous surprises but there are some things that actually challenge some of the existing wisdom, one of them is in shared decision making. For example, that experience that many clinicians know when someone says if it were your mother what would you do, if this were you. For many increasingly in this world in which shared decision making is seen as respecting patients and probably a bit of risk management as well many people are turning to say why in principle I don't answer that question, I think it would be patriarchal for me to. And yet from the patient point of view this is an area that requires tremendous expertise and you happen to be the only human being I know that actually has an informed opinion I want to hear. It doesn't mean I'll follow it necessarily but if you actually deprive me of your own opinion in that moment that's really said a fundamental trust issue that you care about something else more than you care about me and this information and I know that's a...it's a contested and complex area in the literature but I was very surprised how many patients raised that as fundamental failure of communication. Another one that was such a surprise was in the context of talking about clinical trials, they started to describe the language change in a clinician so a clinician who has been dealing with them in a situation of having a difficult diagnosis and hearing bad news about having cancer and using serious somber language suddenly shifting into saying I've got some happy news for you, fortunately you have the good luck to be eligible for this clinical trial so all of a sudden we're starting the happy language at the time we're trying to recruit somebody into a clinical trial and patients have noticed that shift in language and they wonder is this the clinician talking or is this the scientist and I may not know much about how science works but I wonder if this person is being remunerated or maybe they got promoted because of the science so I'm actually no longer sure I've lost my grounding in confidence as to what is motivating this conversation. So those are the kinds of things that we can detect from the patient perspective that I think are quite helpful in adding to the knowledge that we have from other perspectives.

Dr. Baile: Very interesting so how does...how have you used qualitative research in your investigations and what's that approach entail?

Dr. Thorne: Well, qualitative research is kind of a counter to other kinds of ways in which we know things because most of what we know empirically, most of science is based on populations and being able to measure things so something that can be rendered into a numeric form and studied in large groups. That kind of evidence is never about the current moment you have in front of you, you're just extrapolating from what's known about populations and what's been measured about populations to interpret what's happening in the clinical encounter that you've got. But we have a confidence in evidence these days because its part of accountability of health care systems, we're more likely to defend and support things for which there's an evidence base. There's a lot in the whole world of communication that will never have an evidence basis There's a lot in compassion and kindness that's so differently perceived, you might say exactly the same thing with the same tone of voice to 20 patients and offend a couple of them and reassure all the rest. So we know there's something that's so incredibly contextually bound and unique and particular to communication and the value of qualitative research is that what it tries to dig down into individual explanations of how things work. So the doctor said what to you, now we don't know what actually got said but we're hearing your report, the doctor said what, what were the words, how did that...why is it that that made you feel so upset, what do you think was going on. So we can really dig down into the subjective experience that people attribute to communication and of course we can look at groups across time and that doesn't prove anything, it's not a competing form of evidence but what it does is kind of shade out the colors of what could be going on that can help us then go back to what we know from a more scientific perspective and a more population perspective to say that's why this works and that also helps me understand what are the conditions under which that particular approach might not work.

Dr. Baile: Is there...so in analyzing data from qualitative research how frequent is it to find trends for example when you ask that question, well what about your reaction to that, what was that like, do you find that you can group people who are in your study and do you need a large sample in order to really find clusters of responses?

Dr. Thorne: To some extent you do and when we first began this program of research actually we had this idea that we would be able to write the definitive standards and guidelines for communication and it didn't take too many years in the field before we realized the error of our ways in that regard. I think what we can do is try and help document what are reasonably considered patterns and commonalities and what the diversities look like. So if you deal with both conversations, what tends to happen in groupings and patterns and how that varies across...what might explain those variations. Because we've done qualitative research in much larger numbers than is normal for qualitative studies, we've done it because it's in the world of oncology and there's so much variation about disease stage and tumor type, you know, sociodemographic characteristics of people. The larger numbers are quite helpful because we can go back through the data base and trace, for example, for every time there was a conversation about a clinical trial or something like that. Then we can sort out what aspect of this is usefully understood from a pattern point of view and what explains those differences. So that the kind of knowledge we can create doesn't tell a clinician what to do but provides a clinician with a little bit more nuanced wisdom about how to interpret what they might see the next time and what the next question might be.

Dr. Baile: Interesting, so you play an important role and have as a faculty member in the school of nursing and so do you have any thoughts about how one might translate some of these communication findings or theory to nursing education?

Dr. Thorne: Well, nursing fundamentally is always about knowledge in the general applied to the particular case. So a piece of the core tradition of nursing education that I've been really advocating we don't lose is that theoretical or philosophical interpretation of what constitutes an individual and their experience in health and illness and how we go about figuring that out. It's not simply a list of what are the questions but what are all the aspects of that complex, adapting system we call the human being. It's not simply what's embodied but their thoughts and dreams and aspirations, their social world, what's meaningful and it's quite important from the beginning of nursing education that we build in that systematic way of being able to watch for cues, ask intelligent questions, get to know someone. So you're trying to, as closely as you can, get to know the person, not just the population of people but that particular person. So you understand case knowledge and patient knowledge, what's general and what's different about you in relation to what I've seen before. So that aspect of nursing education is a bit amorphous and conceptual but it's absolutely fundamental to being able to learn more and more for the rest of your career, general knowledge and being able to do some kind of translation so you know what, when, where, and why with regard to individuals. I do think that although I don't think medical education has typically obsessed about that as much as nursing education has I do think that how do you actually deal with the individual situation is a fundamental part of all of it and requires actually that capacity to know something about yourself and be willing to reflect on who you are and how you engage.

Dr. Baile: Wow, that's a big task.

Dr. Thorne: Oh, yeah.

Dr. Baile: So you and I both come from sort of psychiatric backgrounds in a way so you know we think a lot about what's going on inside the other person and in many cases been trained to kind of think about what's going on with us as we communicate with people. My experience is that those particular approaches to humanism, to the individual are quite applicable to teaching nurses and for example taking a psychosocial history as we talked about before and how that data can be helpful in formulating atreatment plan. In your experience, are nurses being taught some of those skills like how to take a psychosocial history when you're kind of at the bedside and what to do with the information and how to conceive of...use it to sort of ask the questions about how was the patient coping?

Dr. Thorne: Absolutely, I think that the language of how we teach it shifts and it doesn't tend to use classic psychological or psychiatric language any more but we talk about things like relational practice and what the ingredients of that would be and recognizing that it has a very strong ethical component, it has a very strong interactional component and that intersection of all of the aspects of the human being coming together that take their shape in any particular conversation. I think that the key to it really is being able to in the basic education to be able to create that sense of intellectual curiosity about how amazingly fascinating human beings are, including ourselves and that can come with a good teacher. I think really that's the key to having people who can make that come alive because when you have established an intellectual curiosity and you find people genuinely interesting the clinician mind keeps learning through out a whole career.

Dr. Baile: Very, very interesting that fostering curiosity and mentorship which really requires a faculty that's been consistently on board with reinforcing that not only curiosity about the patient and the family but curiosity about one's own reaction to them might be sort of useful information to have when you have to deal with difficult conversations.

Dr. Thorne: Absolutely and I think traditionally I mean many places have sent students off to psychology 101,

assuming that that would cover the base of that and you know frankly if you can recall what you might have learned, object constancy and all that kind of stuff is pretty boring, pretty technical, pretty theoretical doesn't really relate so it's really re-conceptualizing that as one of the most fascinating and interesting aspects that when you find that fascination will motivate you and carry you through your career.

Dr. Baile: And in fostering those we are always swimming uphill against all the technological and technical things that nurses and other clinicians need to put in their brain and I've been fascinated about the shift that people need to make when they're doing technical work to doing interpersonal work and how to go back and forth between those two domains in a smooth way, that is a big challenge.

Dr. Thorne: Yes. Yes, and I think that's practice craft knowledge. We're learning a little bit more about how that would be. We know how it would work when an Olympic figure skater or something like that starting from learning the technical figures and movingly artistry and it is that kind of complex skill. The act of doing something technical to a human being that you're engaging with simultaneously, but part of it you can have students intelligently watch those that are mentoring them and expose them to expert practice, saying how do you see that, what is it you're seeing that would allow you to see that as expert practiceand I think when students realize that they can only see so much at the beginning. Iif I don't understand figure skating, I just see somebody skating around. The more I understand figure skating, the more I start to see the nuances of what's going on. So if they understand that the practice of clinical work is that kind of complex skill and they become interested in, what it looks like, and start to see more and more at each layer, then all you need to do from that point, once you've got that foundation is expose them to great mentors.

Dr. Baile: Very, very interesting, anything else that you wanted to mention that I haven't covered?

Dr. Thorne: Oh, I think we could talk all day, I've loved this opportunity to chat with you about something obviously we're both passionate about.

Dr. Baile: Yes. Well, thank you so much for coming down and for spending time and for this interview, I think it will be very enlightening to our audiences.

Dr. Thorne: Well, it's a great honor to be here, thanks so much for having me.

Dr. Baile: You're very welcome. We hope you've enjoyed this conversation with Dr. Sally Thorne, you can learn more about her work by watching the video on this website of her lecture, Improving Communication in Cancer Care, The Patient's Perspective. That's the I*CARE website www dot MD Anderson dot org forward slash ICARE, thank you.

» Roundtable with Dr. Sally Thorne (28:02)