Gary Clayman, M.D., Walter Baile, M.D., Janis Apted
The University of Texas M. D. Anderson Cancer Center
Janis Apted:
Good afternoon! I'd like to welcome you to our ninth session of Scientific Excellence. My name is Janis Apted. I'm Director of Faculty Development. We host this series for our postdocs and junior faculty as a kind of mentoring program with our senior faculty talking to our junior faculty about the skills they're gonna need to have successful careers. Our next Scientific Excellence is on May 22. We're going to focus on unleashing creativity, innovative labs and work groups in the M.D. Anderson environment and we have an exciting bunch of speakers lined up for you. So, we hope you are going to be here. Today we have two very distinguish Speakers: Dr. Walter Baile and Dr. Gary Clayman. We're going to be talking about The Human Touch: Skills for Thriving in the Technological Age. And I'm going to do just a little bit of an introduction to why we wanted to talk about the human touch focusing on communication skills and just to outline for you something that's happening in the scientific and medical field that's emphasizing these skills more and more, so, that you are in touch with what's happening. Human touch actually means communication skills in the broadest sense. Now, communication skills is a squishy term, as far as I am concerned just like leadership skills. It embraces a whole bunch of different things and people throw a lot of issues into the communication skills basket.
It's actually being used to embrace interpersonal skills, relationship skills, and emotional intelligence. Traditionally, in science and medical research we focus on two major areas of communication: The ability to write, which is fundamental to your future success, that's papers, composes, grants, book chapters, book reviews; and the ability to speak. That is to get up in front of people and present your data, to appear on a panel, to articulate a coaching argument. But the tide is starting to shift. Communication skills is now starting to include in the scientific literature, if looking closely at the ads and some of the advertising supplements for instance in science magazine, you're gonna see that not only are places of employment and postdoc programs asking for oral and written skills, they're also asking you to be able to do the following or to learn how to do the following, that is influence peers, superiors, and decision makers. Inform, share information and ideas, listen well, debate, dialogue, facilitate, inspire, negotiate, work effectively in teams and multicultural groups, ask for what you need from people in authority over you, deal with difficult supervisors or colleagues, resolve conflicts, lead and motivate work groups, work effectively in large organizations where political savvy and interpersonal sweetness are required.
Promote yourself. Be able to sell your ideas and abilities to prospective bosses, granting agencies and so on. Provide and receive feedback. If you've ever sat in a performance for you, you're gonna know what's that all about. And on the clinical side in addition to these skills, talk to patients about difficult issues, such as death and dying, dealing with families in crisis or communicate with doctors, nurses and other care givers. The January 26 issue of Science had a section on -- focus on careers, which is on new graduate programs in life science, I always read that section very carefully because it shows you the trends in science and medical research and at the head of this article it said, administrators also recognize the top notch scientific ability, while essential, is no longer sufficient to land good jobs in academe or industry. Thus, several graduate programs expose students to courses in scientific writing, presentations, management of scientific teams and other communication skills. One of the Deans cited in this article, and it was Harvard, [inaudible], Ohio State and UCSF that were quoted in here, Dean Orlando Taylor says, "No matter what line of work our graduates will engage in, they'll find themselves in a position to communicate their research or advocate on behalf of their disciplines or communicate to their colleagues." So, they are training them in presentation skills and communication skills.
The Biotech Industry, as well, is emphasizing communication skills and interpersonal skills. Here's one of the Dean of Biotech Industry saying, "Since we rotate and promote a lot of people to team leader positions in specific projects, we look for leadership skills, such as people management, problem solving and listening skills." Roche Molecular, "The diligent postdoc who can't get on with other people is on the way out." The Hartwell Center for Biomed Informatics and biotechnology, "You have to be an effective team player, you have to communicate well particularly with researchers," and so on. You're gonna see these in your slides. Dr. Baile is going to be talking about Communication Skills for clinicians and in a recent conference he hosted here by the ACORE group, which is Advance in Communication Skills in Oncology through Research and Education, they brainstormed a list of poor communication skills of oncologists and you could see right at the top, relationship and partnership development skills and going on interaction with families, counseling, facilitation, listening skills, negotiating skills and so on.
Also, in the clinical literature, we're seeing a lot more research on the effective -- the doctor's communication skills on patient care, the impact it has on patients and how they respond to care. And the issue of breaking bad news, you know, medical students are not trained to do this. They generally learned haphazardly from mentors or watching their senior colleagues do this. But it takes a lot of interpersonal confidence to be able to sit down with a very ill person and talk about death and dying. The Center for Creative Leadership in North Carolina is the top leadership training group in the country. They have benchmarked three top success factors for all professions across the board and you'll see that the third one they have just added is respecting self and others, which is all about interpersonal skills. The top reason that professional careers derail and people shoot themselves in the foot and end up having unsatisfying careers is problems with interpersonal relationships. Now, you're probably familiar with the work of Daniel Goleman, he is the one who emphasizes emotional intelligence. He says, the single most important element in group intelligence is not the average IQ in the academic sense, but rather in terms of emotional intelligence. These are not easy skills to teach.
Faculty development is doing a lot of work in this area, where we were working with Dr. Baile on trying to get more communication skills training out there for physicians and PAs and so on. We will be offering a number of sessions coming up in the near future. We've given you a list on oral presentations. This is something if you want to become a master of oral presentation we really encourage you to attend some of these sessions. One of them is a practice session with Dr. Galec [presumed spelling]. We do have a video tape machine in our office you can borrow. You can work as groups and video tape yourself. The fastest way to improve your presentation skills is to see yourself on video tape. It's a frightening new experience, but it will help you self correct. In addition, I wanted to just point out to you that we have on our evaluation form today if you flip over to the back, it's really important that you fill these out. We have a list of potential communications skills training programs the faculty development can put on for you. Please check your top three. Now, it's my pleasure to introduce our speakers. I'm going to introduce them both and Dr. Clayman will speak first, followed by Dr. Baile.
Dr. Clayman is the Deputy Chairman and Director of research at the M.D. Anderson's Department of Head and Neck Surgery and a professor of Surgery. He's also got academic appointments with Baylor College of Medicine, UT Graduate School of Biomedical Sciences and the UT Dental School. Dr. Clayman started his professional career as a dentist and then acquired his M.D. from Northeastern Ohio Universities followed by an M.S. in Immunobiology at the University of Minnesota. Since 1995, he has been a fellow of the American College of Surgeons. Dr. Clayman came to M.D. Anderson in 1989 as a research fellow. He's a member of numerous local, state, national and international committees and he sits on the editorial and review boards of more than a dozen periodicals. He's also the recipient of 21 awards. Dr. Clayman is currently involved in 9 active grants with 3 pending. He has published over 90 articles and 12 book chapters. I would say he's a master of communication. Dr. Walter Baile is equally and an equally impressive member of our faculty. He is Chief of the Psychiatry section of the Department of Neuro-Oncology and professor of Psychiatry.
Dr. Baile is a graduate of the University of Pavia Medical School in Italy. He did his residency in Psychiatry at Johns Hopkins Hospital and he was a research fellow at the Behavioral Sciences at the National Institute on Aging. He joined M.D. Anderson in 1994. He is the co-founder and Director of our Place of Wellness. He has numerous responsibilities on editorial boards in local, state, national and international committees. And he has widely published in referee journal. Dr. Baile is uniquely qualified to talk about communication skills in physicians as this is a special interest of his. He has done a great deal of work in this area and he is the co-author and producer of a wonderful CD-ROM and video tape series titled A Practical Guide to Communication Skills in Clinical Practice. He recently hosted here in Anderson an international meeting of 28 oncologists, psychiatrists, medical educators and health communications experts to discuss physician communication training programs. If you were in the basic sciences I'd encourage you to listen closely to what Dr. Baile has to say because a lot of the skills he is talking about can be adapted for your work as well, and has to do with interpersonal relations. So, please help me welcome our two distinguished speakers. Dr. Clayman.
Dr. Clayman:
Well, good afternoon! I was a little bit surprised to be invited to give this lecture and I actually just handed a note to Dr. Baile stating that I think that the reason I was selected is I was the foster child for failure in the personal communications. But, we're actually in the most exciting time in science right now and I think everyone in this room that's involved in science on any particular level realizes that funding for science is better than it's ever been before. Your chance for success and impact is so much greater and the need for communication in science is so critical in every level that Janis has spoken about. I pulled this out of Science and you can go back much further, but science is a specific collective human activity. It is about acquiring and understanding of the world that is of practical value. It is different from both commerce and ideology and hence, its practice in society has to be controlled by a separate set of rules and behavioral norms. Exchange of information and opinions among practitioners of science is crucial to its success. Results of scientific research are useless unless they are communicated to other scientists and the public at large.
Now, I have to tell you that many physicians and one of your jobs as a scientist is to communicate to physicians and to communicate to lay public what's important, what's going on. The second thing is that you have to realize that most people do not understand the importance of these interpersonal communications that happen on a daily basis from the scientific standpoint. Progress has been made in science over dinner at night, over dinner at midnight, after three o'clock in the morning, exhausted days in the laboratory where you just stumble upon something just through interpersonal communications. If at first you don't succeed, sky diving is not for you, that's an idiom that's particularly associated with science, but the next one is even more important and this is sort of Texans guide to life. There are three kinds of folks. One has learned by reading, the few that learned by observation and all the rest of them have to pee on electrical fence by themselves, but the thing is that you don't have to pee on electrical fence, you need to be able to talk to people in order not to make the same mistakes everyone has made before you. This is just a sort of a diagram, but you know, when you're talking to people you have to realize who your audience is and you need to communicate to them based upon who is receiving that information.
If you're talking to a bunch of people around the table that know nothing about science, but you're trying to tell them the importance of the scientific work that you're pursuing, you need to communicate to them so they understand it. If you're talking to a classroom of five-year olds, it's very different than talking to a graduate school curriculum of thirty people in a small classroom and you're gonna communicate in different ways. So, know who you're talking to. So, essential components of communication is number one, truly know who your audience is. You need to be organized, you need to be clearing your presentation and be efficient and I say here tell a story and telling a story is very important. You need to, you know, when you're writing a grant, when you're writing a paper, you need to be able to carry your audience through that work. Be honest and be honest always. If you're always honest you never have to remember what you said before. Communication requires good listening. And so, when you're communicating you need to hear what the people are saying back to you. Be receptive to questions, and listen closely to questions. Take notes when people are asking you questions because they want you to directly address the issues that they are questioning. Communication skills and I write twenty-four-seven, it's 24 hours a day, 7 days a week, 365 days a year.
Communication skills for researchers include these. There are many other things that can be broadly presented in here, but publications, these are the major hallmarks of your success as a researcher, you will be graded upon communication as they are measuring these things. Publications, grants, patents, laboratory or hospital interaction settings, small work, small informal working groups they can happen on a person by person, small group, lab meetings, journal clubs, classrooms. And lastly, public speaking and public speaking is different in different settings, in groups of 10 to 50 people, in groups of 50 to 500 people or in very large settings. Now, here I can basically make eye contact with every single one of you, but when you're in a large, large auditorium where there's a big screen up behind you and they're showing the image of you, which is being televised that's a very different situation than a classroom setting or a more intimate setting where you have 30 or 50 people hopefully more seated closer up to you. One of the major issues in public speaking is to do it well. If you do it well, you're gonna be well received, if you do it poorly, it's not gonna be well received. There are great courses in public speaking that you can find in magazines. There are courses that are given in local curriculums throughout, including this institution, but one of the real major issues is practice.
And practice makes it perfect in the operating room and in the laboratory and certainly in public speaking. Don't shift around, don't lean on the podium, people, you know, is anyone when you talk to someone like this you're uncomfortable with what you're doing, you're shifting around and it gives a perception of shifting that you're uncomfortable with what you're actually speaking about. Carefully review what you're gonna be presenting to the group. And lastly, observe yourself and be very critical. You can be your best critic. Janis mentioned that there's actually audio material and everyone has this little mini cams, you can have one of your family members or friends sit there and present to them. I keep on knocking these things around. Well, you're supposed to use your hands, that's the goods thing by the way, but use your hands, be animated, talk to the audience, but also, as you're talking, have the camera, have it take pictures of you and sit down and be very, very critical to yourself. And it's actually amazing how you'll see things that everyone else doesn't necessarily perceive, but in your perception of it, you can improve your public speaking just by reviewing yourself. There are all sorts of differences in media, in talking to the press, in talking to the radio, and in talking in television.
Be perceptive of these, again, these are things that can be taught to you. Realize the first amendment of the United States. There is nothing that can be said "off the record." If you say it, it's on the record. So, they can say anything they want to you that this is off the record and won't be communicated with anyone else, but that's not true. The first amendment gives them the right and anything that you communicate is on the record. And you read that all the time in the Wall Street Journal and things that people have said to the press and then it come back to haunt them. All your measures of success and productivity of researchers are based on the foundation of communication. You will be measured by your publications, your grants, your patents, and your national and international recognition. That is a direct relation to your communications skills. You will be invited for international and national presentations based upon how you are perceived by audiences and just don't forget that there people in audiences that you don't anticipate are going to be there. In summary, for communication skills for researchers, know your audience, be organized, clear, efficient. Always be honest and have very good listening skills. Thank you very much.
Dr. Baile:
Thank you. That was an excellent presentation. Gary has really raised the communications skills bar here because I usually lean on the podium and shift around, so I have to be careful not to do that today. I wanted to comment on something that Janis has said that communication skills really involves a very complex set of tasks that have to do with transactions between individuals and it's very important the context of the patient and family and if I can give you an example of clinical practice, how relevant it is with regards to breaking bad news for example. A busy oncologist in the course of a thirty-year career will break bad news over thirty thousand, twenty to thirty thousand times to a patient and yet there are very few training programs in communications skills. So, I'd like to talk a little bit today about the importance of communications skills in the clinical context. To give you some idea of how much this area has risen on the radar screen of different people that -- let's see, that I wanted to mention a few organizations who now have a vested interest in communication skills. The first is the National Cancer Institute, which recently created a branch on patient communication and informatics research led up by Garry Creps who is the former Dean of two communications schools and they recently issued an RFA for Centers of Excellence in patient communication.
The ASCO, the American Society of Clinical Oncology have a number of initiatives in communication including one that is aimed at developing a curriculum for supportive care and there are a number of modules on breaking bad news and communicating with patients at the end of the life. ASCO has also become very active in putting on seminars at the national meeting and last year I had the honor to participate in a seminar that was rated third out of 227 symposia at the annual ASCO meeting, which gives you some measure of the importance of that to clinicians. The National Cancer Center of Network has instituted a task force on physician-patient communication, which has developed guidelines for breaking bad news. The American Society of Internal Medicine has an initiative in creating a task force on communication at the end of life and has published guidelines and finally, American Board of Internal Medicine will begin requiring that clinicians up for recertification for their boards will need to develop proficiency in patient communication. So, I think that this area is really, has risen to in its significant level of interest in the field of medicine.
That as Michael Levy said at the ASCO meeting several years ago, that communication skills are the cornerstone of comprehensive patient care. That is care of the whole patient, not just technical care, which I think we're all very good at, but really comprehensive total patient care. And why is that? First of all, for the patient, communication is a key component of the transaction with the physician and the staff. It serves the important purpose of reducing fear and anxiety through development of trust and confidence. When you think about it, we really sometimes do awful things to patients for the sake of cure and for the sake of care. And in order to accomplish that goal, patients need to trust us. We need to have a, what we call a rapport with them, which means nothing more than the patient has confidence in us. And when we have, when patient has confidence in us, they will really cooperate very strongly in a treatment plan and communications skills is one way of building that confidence and trust with the patient. Communication skills are one way of assisting the patient sorting out complex information. Today, patients are bombarded with information over the internet and often come with reams of data regarding their illness that they want us to help them understand and sort out.
Communication skills can reduce patient uncertainty, which I think is an important psychological phenomenon that place a lot of patients when they are caught up with a new illness and don't have a plan for how to deal with it. And we can help them create a plan and therefore, see into the future. Communication skills help patients have an enhanced sense of control at the time when they really feel out of control. Patients are quite disenfranchised and their lives change when they come into the medical system. They often have to leave their jobs and leave their homes as many patients who come to M.D. Anderson do and are isolated from their friends and their family members very often. So, helping patients regain a sense of control by discussing options, by discussing a plan and by discussing choices with them and returning some of that control is very important. When we allow patients to ventilate their concerns, we often find out that some of them are related to barriers to patient care, such as finances and distance and work schedules and things of that sort.
Communication skills have been shown to promote long term patient psychological adjustment. But a study we did back in 1994 showed that physicians with newly diagnosed breast cancer patients who educate the patients is a caring way have patients with better long term psychological adjustment than physicians who hadn't. For the clinician, communication skills also have important advantages. One, there's a lot of data especially from the primary care field that patients are more satisfied when physicians take the time to communicate well, to educate them and demonstrate a caring attitude. That is our obligation to ensure that patients are informed of their treatments and have options and choices. That's a legal and ethical mandate. A recent study from Rocktashel's group at the University of South Florida showed that the way that clinical trials information is communicated to patients and the attitude of the clinician in discussing the clinical trial with the patient can result in increased accrual, compliances and other important outcome for communication when patients understand the treatment plan and it's communicated clearly, they're more likely to follow it. And lastly, there's a lot of data on malpractice litigation that patient who see their doctors as communicating well and having a caring attitude toward them, get sued less.
And lastly, I think, actually it's not last, but making the patient a partner in our decisions and choices about treatment are very, very important because when we tell patients we're going to do something for them or to them, with them without explaining and giving them at least the option to ask questions, we make the decision ours and when things go wrong, the patient, we often feel like the patient had a part in it and I think that at the end of treatment when things get near the end of life, it's can sometimes result in abandoning the patient if we don't feel the patient has had some responsibility also for decision making. And lastly, a number of studies have shown that clinician burn out can be reduced when the doctor has a good relationship with the patient and gets positive feedback from the patient for the skills. Also, increased confidence in discussing difficult topics we often have to get down there with the patient and talk about things, such as end of life issues, resuscitation, bad news about cancer recurrence. And so, increased confidence in this area is a very important aspect of communication skills. Lately, there's been some emphasis on the development of medical models, which meets some of these objectives of patient communication.
I think if you look at the traditional medical model, the goal was only to diagnose disease and the agenda was pretty much the physicians in eliciting signs and symptoms and the attitude of the physician is very directive in telling the patient more or less what's going to happen under the guise of the doctor knows best. And patient autonomy was really limited to the patient agreeing with the treatment plan that was proposed and support for the patient was limited to reassurance. I think that the new model of patient care, which is being taught in medical school and which incorporates some of the principles which I mentioned previously and is called patient centered. The goal was not only to diagnose the disease, but also to understand the better who is the person with the illness and who is this individual, what are the obstacles to care for this person. What are the person's fears and anxieties and concerns. Also, to elicit the patient's agenda, what does the patient understand about the illness, what do they expect from us and what are their concerns that might transform into barriers to care? I think again, patient participation in this model is a cornerstone, so that patients do -- are able to exercise choices when they are available and decision making is shared.
And that support is tailored to the patient, not just reassurance, but perhaps other things that patients need from us, such as encouragement and advice. To give you some idea about some of the training and some of the obstacles that I mentioned that prevent effective communication that we did a survey of 500 clinicians at ASCO several years ago, participated in the seminar on breaking bad news, and found that most clinicians, the blue line on the right is the summary over two days of questionnaires. So, we see that about 30 percent of clinicians broke bad news from 5 to 10 times a month and another 35 from 10 to 20 times a month and a few over 20 times a month. So, it can be a very frequent and challenging communication task for the clinician and yet what we found is that very few clinicians had any form of teaching in this area. Some sat in with other clinicians in order to, sort of get mentorship in this area, but many also have training -- need a training in formal teaching or sitting in with other clinicians. So, it's an area I think, which is going to receive increasing attention because of some of the outcomes that I mentioned. And I'd like to just discuss a few things, a few communication tips that you may find useful in dealing with patients and the families.
The first is getting the setting right. I think that patients, as I mentioned as somewhat disenfranchised, they're anxious when they come into the exam and they don't know what tests -- that results that they're going to get. There's somewhat of a power difference between us and the patient because we have the information and we have the knowledge. And so, greeting the patient respectfully with a handshake or eye contact is very important. I think when we have an opportunity to sit down with the patient, it's very important also. There's been some studies that show that when you sit down, the patient perceive the time that you spend with them as longer if -- is much longer than if you're standing up and not many patients are comfortable in interacting with physicians who, kind of cower over the bedside at them during very brief rounds. Sometimes there are an opportunities to sit down, but I think that when there are it's very -- it's been shown to be very useful. Doing things like making eye contact with the patient, letting the patient know if you're likely to be interrupted are things that convey an attitude of respect and equality with the patient who often feel powerless in the environment that they're in. I think if we find out what the patient knows or beliefs about their illness, we can often find that there misconceptions, so that folks that have been told things that maybe perhaps aren't true or that they've distorted information.
So, before giving information to patients, it's useful to find out what they already know and what they believe, such as by using a phrase, "Tell me what you understand about what's going on with you." Or so, what is the patient expect of us. Okay. Do patients expect cure? The patients expect that we're going to help them survive until they see their grandson graduate from college in a few months. I think that very often we assume that all patients are here for cure. And speaking with my colleagues, their experiences when they ask patients about that, that, they have a very different answers that some of them are very sober and realistic about what we can do for them. And their expectations may be much less than what we have of ourselves for the patient. A phrase says what are your hope we can do for you, maybe very revealing. Also, finding out how much information the patient wants, tailors information to the patient and studies have shown that some patients are minimalists. They want very little information, sometimes they want just to be told what you're going to do. That's particularly true as disease advances, but most patients today, I think want a lot of information. And we need to give it to them in a way that they can comprehend it.
So, are you the type of person who likes to know a lot of details or just like to have basic information. I think also, how a patient can reach us, and get in contact with is very important. Patients are often confused about whom to talk to in clinic and sometimes we are not as available often as patient would like. There's been a recent effort to explore how much the internet could be useful and e-mail could be useful in patients reaching us, but if you have a clinic nurse for example, that person should be introduced to the patient at the time of the initial visit and some education to be done as to how the patient can reach the physician during the course of the patient care. I think the phrase, there's nothing more we can do for you may be true. Okay. And the sense it's not true because there's always something you can do, but that particular phrase sounds like abandonment to patients. And so, I don't think it's a useful part of the vocabulary of medical care because of the way patients hear it. It sort of means the end, I'm not gonna take care of you any longer.
I think having a plan for giving bad news and especially reacting to patient's emotions is very important because of the frequency with which bad news is done and the fact that I think that sometimes bad news gets a little bit fudged because of the inability or inexperience of clinicians in knowing how to react when patients get affect -- get upset. Lastly, a little bit goes a long way and I'll have something to say about that in a second, but I just wanted to show you a slide about addressing patient's emotions that there three techniques which are used commonly in psychiatry, which to support the patient which I think can be easily adapted in a busy clinical practice. One is making empathic statements when patients get upset, such as acknowledging the upsetness. I can see how upsetting this is to do to you. When you do that, patients feel you're tuned in to them and understand. The second technique is using exploratory questions. Can you tell me what you're thinking right now, when a patient is silent or you don't understand something that they said. And in this way, a patient feels you're interested in them as a human being.
And lastly, validating statements that patients say, patients may feel awkward about having taken certain steps. "Oh, I shouldn't have come in to the emergency room. It was just a trivial thing." When it was really not a trivial thing. And I think if you validate those particular statements by phrases, such as comments, you did the right thing or it's common for patients to feel this way. The patient will feel normal and these particular three communication techniques are ways of providing psychological support to the patient. The patient feels you're tuned in, you're interested and that what they said isn't so goofy after all. And lastly, I wanted to say a little bit goes a long way. I think kindness with patients helps enormously to make them feel accepted and I think kindness to colleagues creates an atmosphere as Dr. Clayman said for collaboration, but I think most importantly, kindness to ourselves is very important. In this very difficult task that we have of finding a cure for cancer and treating cancer patients, we need to make sure that we are -- we renew ourselves and that we congratulate ourselves for our accomplishments and really don't be too hard on ourselves when things don't know which go the right way. Thank you very much.
Janis Apted:
Thank you Dr. Clayman and Dr. Baile. We have time now for questions and answers and I'm going to ask Dr. Baile and Dr. Clayman to come to the front table. This is your chance to ask some of your senior colleagues' things you always wanted to know about communications skills or interpersonal skills or presentations. Anyone? Well, I've have a question actually I'd like to put to our two presenters, which has to do with the issue of professional burn-out. And Dr. Baile was just mentioning about kindness, but I have an instinctive feeling that the professionals who do not have really good interpersonal skills or are not comfortable talking about difficult issues with colleagues or asking for help from colleagues probably get a lot more stress and professional burn-out than the others. Do you have any comments about that?
Dr. Clayman:
I think it's a real issue and I think it's a real issue on several different levels. You can certainly burn out just from your emotional ties with your patients. If you take a personal loss of every patient of yours that succumbs to their disease, you cannot survive being an oncologist. You just can't do it. And so, you have to remain connected, attached to your patients, but also, have some cloak of protection for yourself because otherwise, each of those losses becomes a loss of a family member. You just can't do that, but Dr. Baile actually brought up another issue that I think also pertains to burn out and that is the issue of availability and excessive availability. You know, you have your email address at least one here, you have your cell phones and your beepers and the hospital operator has your home and you're basically always attached and that accessibility, you know gets to the point of, you know answering those, you know six to twelve e-mails from patients everyday now where the patient latch on to your e-mail address and you set as a constant way of getting a hold of you. And these are just new grounds that we actually have to start seeing, how are we going to deal with those models because you can't be that accessible.
Dr. Baile:
I think Gary's point of navigating a professional boundaries where you can care about patients, but not feel totally responsible for the outcome of their treatment is incredible important and I think that losses, a feature of cancer, I mean patients lose a lot when they get cancer. They lose economic stability. They lose ties to people, but we also lose patience and how to, I think keep oneself renewed through -- we're fortunate to be in academic center like this because there are, I think ways of tempering burn out with colleagues, with research, with teaching that are very, very healthy, but there's the occasional patient whom we all get attached to, whom when they die, you know we feel we have to grieve and I think that when those losses hit us like that, you know, it's perfectly appropriate to for example go to a funeral and to get some closure on that relationship. So, I will agree with you there. It's an important issue.
Janis Apted:
Any other questions from the audience?
Dr. Baile:
Let me bring up an issue that I'd like to get some feedback about that, the communication skills that I've talked about and touted involved, some have said that well, we could do this if you taught us, but it takes up too much time. And here we only have 15 minutes in interacting with the patient in clinic and I'd like to ask some of my colleagues if they have any, kind of sense about that because there's some controversy in the literature. My impression, it doesn't take a whole lot more time and in fact the time that you put in upfront to establish a relationship with the patient and show concern may save you time down the road when things aren't going so well. Anyone have any thoughts about that?
Dr. Clayman:
Sure. I believe that you establish relationships with patients immediately upon your first interaction with them and that becomes a building process. There are also different relationships between patients and their different care providers based on the care that they're providing. The relationship between a surgeon and a patient is a very intimate relationship. And many of the patients become very, very attached to their surgeons because of the process of undergoing surgery, it's an invasive procedure. On the other hand, I also believe that, you know some of this is HIPAA and National Regulations that are coming down upon us that create relative value. You know, there's relative value for time spent with the patient, but it's not just the patient. You become not only have a relationship that's communicative and caring to the patient, but also to their family members and significant others.
And it's those people that also take your time and it's not just based on face time. It's time on the telephone at night, it's time on e-mails, it's time that is non-qualitative by any of those measures and there's all these relative values. There's a relative value for doing a tonsillectomy, for example of procedure.Now, that relative value is for the technical expertise of doing a tonsillectomy, but it also includes that 90-day period after you do that tonsillectomy. Well, if you do a tonsillectomy for cancer, or you do a tonsillectomy on a five-year old because they have big tonsils, that's a totally different issue. Now unfortunately, HIPAA considers those both the same relative value, but the caring in the relationship and the time spent is not the same. These are on our issues, but they are certainly national health care issues.
Janis Apted:
Uh-hum. I'd like to make a point that I was going to make a presentation, but for those of you who are -- do not speak English as your native language. Please be aware that you're communication skills in English count for a lot and if you're having any problems requiring fluency in English or good writing skills in English there's some wonderful ESL programs that are being offered here at Anderson by the University of Houston. You might also think about getting small group of colleagues together and hiring a tutor or whatever. I was astonished to read by one of the CEO's in a biotech firm, that scientist who lack good communication skills who have English as a second language are often in the second tier of scientist. They do not get those leadership jobs in research and we certainly don't want any of you feeling like you're not getting ahead in your career because of lack of communication skills, so beware of that. Please make sure that fill out those evaluation forms. Let us know what kind of courses you want us to give. As I said these are difficult things to teach, they take time, you're going to need to practice the skills and acquire them over long period of time for your entire career and I would like to thank very politely our two wonderful speakers. Thank you.
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