How to improve the communication skills of oncologists

How to improve the communication skills of oncologists Lesley J. Fallowfield CRC Psychosocial Oncology Group, Department of Oncology, Royal Free and University College London Medical School, London, UK

Introduction

unique, short, intensive training courses are described.

Communication is a core clinical skill but one in which few doctors receive formal education. Consultations about cancer contain many difficulties, which may include communicating bad news about diagnosis or recurrence, explaining treatment options and clinical trials, obtaining informed consent and discussing transitions from active therapy to palliative care. Patients and doctors in cancer care experience multiple problems with much of this communication, and as time pressures and demands for increased patient throughput grows in most of Europe, these problems are likely to intensify. Poor communication results in faulty clinical data, worsened clinical and psychosocial outcomes and greater likelihood of litigation [1]. Despite the importance of effective communication, few oncologists have ever been observed when communicating with patients and given constructive feedback. Many myths exist about the teaching of communication skills with some believing that effective skills reflect personality or natural talent and therefore cannot be either taught or improved. Others feel that time and experience alone will lead to the development of adequate communication skills. However studies have shown that experienced doctors reveal similar communication deficiencies as do recent graduates and medical students [2,3]. Studies show that if appropriate methods are employed, then effective skills can be taught [4,5]. Moreover, oncologists are starting to acknowledge that insufficient communication skills training is a major contributing factor to their stress, lack of job satisfaction, and burnout [6]. Consequently to increase professional effectiveness and to improve patient and physician well being, it is important to conduct a systematic examination of the communication difficulties of oncologists and to develop and evaluate training initiatives to help alleviate them. In this paper the communication difficulties reported by senior oncologists in the UK attending

Methods

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Senior doctors from surgical, clinical and medical oncology were invited to participate in a 3 or l | day course designed to improve their communication skills. The course design was an adaptation, for British oncologists, of one originally developed in the US [7]. This model combines elements of adult learning described by Knowles [8], Rogers [9] and Freire [10], with task-oriented and experiential skills group methods. The model has been shown to improve physicians' knowledge about, and attitudes concerning the medical interview, as well as their communication skills [11]. The model is currently used widely in faculty development activities in the US and has been tried successfully in Israel, Canada, and Australia. The study reported here is the first systematic test of the efficacy of the model in a British setting with a senior group of clinicians within oncology. The courses are a sophisticated melding of exercises and activities designed to create, in an integrated fashion, skills development, knowledge acquisition, and personal awareness of how these impact on both the physician and patient. The design circumvents1 physician defensiveness by allowing each participant to define and direct his or her own learning needs and difficulties. This renders the work immediately relevant and attractive to them. Work on specific skills occurs in small groups using roleplay with standardised patients (actors), video review, and group critique which is embedded in a safe and constructive environment. Knowledge is acquired through interactive demonstrations, selected key readings and during small group discussions. Attitudes and personal awareness are dealt with throughout the courses whenever appropriate and time can also be set aside for this for group dis-

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Results A total of 178 clinicians attended one of 30 courses over a 2-year period. Their different specialities included: radiation, medical, surgical and paediatric oncology, haematology and palliative care. Others included chest physicians with large lung cancer practices, diagnostic radiologists employed in the national breast screening program and a dermatologist specialising in malignant melanoma. Only 61 (35%) of the sample had received any formal communication skills teaching as undergraduate medical students. At the post-graduate level, only 33 (19%) of the sample reported having received any training, usually as part of a management skills course. Very few regarded any of the methods used in

their prior communication skills training as effective. Despite having received little training themselves, or any education as to how to teach communication, 133 (75%) participants had "some" or "a lot" of responsibility for teaching about this to students and junior staff.

Cancer clinicians problems with communication In response to the request to list the patient characteristics that they found most difficult to handle during consultations, 166 clinicians generated 406 problems, (mean 2.4, range 0-6). These were divided into 8 thematic areas. The most common problematic characteristics cited by doctors were ethnic/cultural differences 76 (43%), age related problems 68 (38%), emotional reactions 52 (29%) and issues of identification with the patient 44 (25%). These problems accounted for 281 (69%) of the total number of difficulties generated. 592 general communication difficulties were listed, (mean 3.3, range 0-6). These were divided into 9 categories. Most common were giving complex information in lay terms and eliciting informed consent, with 90 (51%) doctors having problems with these topics. Other key problem areas were dealing with relatives, 65 (37%) coping with emotional or personal reactions 71 (40%), "breaking bad news" 60 (34%), and dealing with colleagues 59 (33%). Together, these areas accounted for 429 (73%) of 592 problems cited.

Post-course evaluation of participants' attitudes, skills, and behaviours Evaluation consisted of pre and post course measures of: (1) clinician confidence in handling common situations in oncology, (2) psychosocial beliefs and attitudes (3) patient-centredness and (4), self- rated perceived changes in personal practice and (5) participation in the teaching of communication skills. Post course evaluation of teaching methods and materials used were also assessed. (1) Confidence ratings were significantly greater post course for all but one area namely, discussing clinical trials. (2) The Psychosocial Beliefs Scale showed significantly more positive attitudes towards patients and their psychosocial needs after taking the course (Z = —3.76; p = 0.0002. Wilcoxon matched pairs, signed ranks test). (3) The WERD score test showed a statistically significant shift from disease or doctor centred to more patient centred attitudes


cussion as needed. Care is taken to create an environment in which participants feel assured that other group members will respect the confidential nature of any disclosures made. Because confidentiality of the discussion and proceedings is assured, participants are usually surprisingly frank and direct. Pre-course participants completed an 18 item questionnaire, which covered basic demographic details, previous experience of communications skills teaching, and ten visual analogue scales on which clinicians rated their own confidence about common issues within oncology. Clinicians were asked to list the characteristics of patients whom they felt posed the most difficulty when communicating about cancer and the areas of clinical practice that caused them most communication problems. We were interested in trying to produce attitudinal change and patient-centredness as well as to improve communication skills to help promote the likelihood that gains achieved during courses would be transferred to the real clinic situation. To measure attitudinal changes, a 32 item Physician Psychosocial Beliefs Scale was administered pre and 3 months post course. This is an instrument developed to measure effectiveness of behavioural science teaching and changes in physicians' beliefs about psychosocial aspects of patient care [12]. Participants also completed a Words Emotionally Related to Dying (WERD) score test to measure patient-centredness pre course and one year later [13]. Three months post course, all participants were sent questionnaires asking them to list any changes in their personal practice which they felt had occurred as a direct result of attending the course. They were also asked to list any new teaching of communication skills initiated in their own work setting.

How to improve the communication skills of oncologists

Discussion These results confirm that oncologists experience considerable difficulties in their communications with cancer patients but that, with training they can achieve greater confidence and may adopt changes in their personal practices in these important areas of difficulty. Experience and seniority clearly does not equip doctors to deal even with common problems. The difficulties cited by doctors highlight two key areas that are often omitted from medical training, handling relationship skills, and handling personal reactions to powerful emotional problems such as those encountered when breaking bad news or

having disagreements with angry patients and families. Consultations have been described as having three functions: gathering information, developing and maintaining relationships and communicating information and negotiating plans [14]. Most oncologists found the greatest difficulty with the latter two functions, which demonstrates the overwhelming emphasis in training on the first, information gathering, to the exclusion of the others. Nevertheless we noted significant problems in information gathering of which the participants were often not aware. Review of the videotaped role-plays showed that the majority of doctors relied heavily on closed and leading questions, and that they rarely checked in an effective manner, for understanding of information given. Thus, we would not recommend leaving basic history taking and information giving out of comprehensive curricula on communication skills training; all three functions require attention. In group discussions participants recalled that diey had never been helped to manage their emotional reactions and feelings in training. Doctors educated in a system that does not permit them to acknowledge their own feelings or provide them with the knowledge and vocabulary to articulate them, and which teaches them that feelings are unimportant or secondary issues, are most unlikely to relate empathetically toward their patients [15]. This leads many doctors to develop a cold, professional detachment as the only means of coping with their own emotional reactions. This detachment can be protective but it can isolate doctors from colleagues and family, and seriously interferes with personal satisfaction and performance. Doctors unable to manage their own or patients' emotional reactions do not enjoy the satisfying therapeutic relationships that can make medicine so worthwhile [16]. In summary, our courses appear to have a positive effects on doctors, including improved confidence in many common interviewing situations, more patientcentred attitudes, changes in personal practice and in teaching activities and intentions. They also seemed to be highly relevant, acceptable, and useful to these senior clinicians. Extraordinary expectations are made of cancer doctors; they have to be scientifically adept, cognisant of, and able to implement advances in diagnostic and therapeutic techniques, practically competent, efficient business managers, up to date and inspiring teachers of junior staff, effective and empathic communicators able to deal with people from different social and educational backgrounds, different personality styles and with hugely differing needs for information, explanation and support. It is not


after the course (p = 0.03 matched pairs r-test). Surgeons were less patient centred than oncologists (p = 0.02) pre course, but one year later they had shifted towards a more patient centred approach and were not significantly different from the oncologists (/> = 0.08). (4) Three months after the course, 154 (95%) reported changes in their personal practice as a direct result of attending the course. The most often cited changes included increased awareness of specific communication skills and techniques 59 (36%) and feeling more confident or at ease in situations that previously had caused communication difficulties 54 (33%). More than 22% of respondents also reported greater self-awareness of the communication needs of both patients and colleagues, differences in the way they gave information, and heightened awareness of the need to communicate effectively. Significantly more changes were reported from doctors who had participated in the 3-day course than in the \\ day course, (p < 0.05, Mann-Whitney U test for mean ranks), a dose-response relationship. (5) Confidence in teaching was greater immediately post-course, (p < 0.0001) and at 3 months, 50.9% (82) had already engaged in new teaching initiatives, and an additional 24.8% (40) were setting them up or intended to do so. Participants rated the courses as interesting, useful, enjoyable, informative and highly relevant to their own clinical practice and for teaching junior staff and students. Particularly valued was the use of role-play with actors, the approach of the facilitators, receiving feedback, and the exposure to new teaching. 170 (97%) of the participants said they would definitely recommend the training to colleagues and 5 (3%) said they might and none of the participants said they felt unable to endorse such courses.

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surprising that many doctors experience psychiatric disorders, emotional exhaustion, and low personal accomplishment. A dearth of training in communication skills contributes to their stress and distress and renders them less likely to be maximally helpful to patients. More resources are needed throughout Europe to make such training initiatives available to all oncologists and to provide funding for the evaluation of new training methods.

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1 Fallowfield LJ, Jenkins VA. Effective communication skills are the key to good cancer care. Eur J Cancer 1999; 35(11): 1592-1597. 2 Maguire GP, Fairbairn S, Fletcher C. Consultation skills of young doctors: 1. Benefits of feedback training in interviewing as students persist Br Med J 1986; 292:1573-1578. 3 Maguire GP, Fairbairn S, Fletcher C. Consultation skills of young doctors: 2. Most doctors are bad at giving information. BrMed J 1986; 292: 1576-1578. 4 Baile W, Kudelka AP, Beale EA, et al. Communication skills training in oncology. Cancer 1999; 86(5): 887-897. 5 Fallowfield LJ, Lipkin M, Hall A. Teaching senior oncologists communication skills: results from phase 1 of a comprehensive longitudinal program in the UK. J Clin Oncol 1998; 16: 1961-1968. 6 Ramirez AJ, Graham J, Richards MA, et al. Mental health

of hospital consultants: the effects of stress and satisfaction at work. Lancet 1996; 347: 724-728. Lipkin M, Kaplan C, Clark W, Novack DH. Teaching medical interviewing: the Lipkin model. In: M Lipkin, SM Putnam, A Lazare (eds), The Medical Interview: Clinical Care, Education and Research. Springer-Verlag, New York, 1995, pp 422-435. Knowles MS. The Adult Learner: A Neglected Species. Gulf, Houston, TX, 1978. Rogers CR. Freedom to Learn for the 80s. Merrill, Columbus, OH, 1983. Freire P. Pedagogy of the Oppressed. Continuum, New York, 1986. Gordon GH, Rost K. Evaluating a faculty development course on medical interviewing. In: M Lipkin, SM Putnam, A Lazare (eds), The Medical Interview: Clinical Care, Education and Research. Springer-Verlag, New York, 1995, pp 436-447. Ashworth CD, •Williamson P, Montano D. A scale to measure physician beliefs about psychosocial aspects of patient care. Soc Sci Med 1984; 19(11): 1235-1238. McMichael H, Barnett M. Learning through own experience of strong emotions increases patient centredness of professionals. J Palliat Care 1994; 10: 97. Bird J, Cohen-Cole SA. The three-function model of the medical interview. In: MS Hale (ed) Methods in Teaching Consultation-Liaison Psychiatry. Basel-Karger, 1990, pp 6 5 88. Fallowfield LJ. Can we improve the professional and personal fulfilment of doctors in cancer medicine? Br J Cancer 1995; 71: 1132-1133. Fallowfield LJ. Giving sad and bad news. Lancet 1993; 341: 476-478.

Educational Session

FOLLOW-UP AFTER PRIMARY TREATMENT Chairperson James Geraghty City Hospital Department of Surgery Nottingham, United Kingdom

Sergei Tjulandin Cancer Research Centre Moscow, Russian Federation

Speakers "Curable diseases primarily treated with surgery" James Geraghty City Hospital Department of Surgery Nottingham, United Kingdom

"Curable diseases treated non-surgically" Carsten Bokemeyer Universitdtsklinik Tubingen Abteilung Medizin II Department of Hameatology/Oncology Tubingen, Germany

"Second primary tumours" P.A. Voute Emma Kinderziekenhuis Department ofPaediatric Oncology Amsterdam, Netherlands


Co-Chairperson
