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Shared decision-making (SDM) is a key component of patient-centered healthcare. SDM is particularly pertinent in the relapsed and/or refractory multiple myeloma (RRMM) setting, in which numerous treatment options can present challenges for identifying optimal care. However, few studies have assessed the extent and relevance of SDM and patient-centered communication (PCC) in RRMM. To describe treatment decision-making patterns between physicians and patients in the RRMM setting, we conducted online surveys of patients and physicians in the USA to compare their perspectives on the process of treatment decision-making. We analyzed the surveys descriptively. Two hundred hematologists/oncologists and 200 patients with RRMM receiving second-line (n = 89), third-line (n = 65), and fourth-line (n = 46) therapy participated. Top treatment goals for physicians and patients included extending overall survival (among 76% and 83% of physicians and patients, respectively) and progression-free survival (among 54% and 77% of physicians and patients, respectively), regardless of the number of prior relapses. Thirty percent of physicians believed patients preferred a shared approach to treatment decision-making, while 40% of patients reported most often preferring a shared role in treatment decision-making. One-fourth of patients most often preferred physicians to make the final treatment decision after seriously considering their opinion. Thirty-two percent of physicians and 16% of patients recalled ≥3 treatment options presented at first relapse. Efficacy was a primary treatment goal for patients and physicians. Discrepancies in their perceptions during RRMM treatment decision-making exist, indicating that communication tools are needed to facilitate SDM and PCC.
Shared decision-making (SDM) is an important facet of patient-centered healthcare. Multiple myeloma (MM) is a cancer of the bone marrow that can return (relapse) after treatment. SDM may be especially pertinent for relapsed MM as there is no uniform standard of care and treatment selection can be complex. Few studies have examined the extent and relevance of SDM and patient-centered communication (PCC) in this relapsed and/or refractory (RRMM) setting. We conducted online surveys of 200 patients who had received 13 previous therapies and 200 physicians to compare treatment decision-making patterns in RRMM in the USA. Both physicians and patients felt that extending patient survival was a top treatment goal, regardless of the number of prior relapses. A lower percentage of physicians believed patients preferred a shared approach to treatment decision-making than patients who reported preferring such a shared role. Twice as many physicians than patients recalled ≥3 treatment options presented at first relapse. In conclusion, while improving survival was an important treatment goal for physicians and patients, there are discrepancies in physician and patient perceptions during RRMM treatment decision-making. Thus, communication tools are needed to facilitate SDM and PCC.
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Mieloma Múltiple , Oncólogos , Médicos , Humanos , Mieloma Múltiple/terapia , Toma de Decisiones , Relaciones Médico-Paciente , Participación del PacienteRESUMEN
Communications between clinicians and patients with idiopathic pulmonary fibrosis (IPF) have the potential to be challenging. The variable course and poor prognosis of IPF complicate discussions around life expectancy but should not prevent clinicians from having meaningful conversations about patients' fears and needs, while acknowledging uncertainties. Patients want information about the course of their disease and management options, but the provision of information needs to be individualised to the needs and preferences of the patient. Communication from clinicians should be empathetic and take account of the patient's perceptions and concerns. Models, tools and protocols are available that can help clinicians to improve their interactions with patients. In this article, we consider the difficulties inherent in discussions with patients with IPF and their loved ones, and how clinicians might communicate with patients more effectively, from breaking the news about the diagnosis to providing support throughout the course of the disease.
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OBJECTIVES: To identify factors limiting and facilitating patient-centered communication (PCC) in the United States hematology-oncology setting, with a focus on multiple myeloma (MM), given the limited attention to PCC and rapid pace of change that has taken place in this setting. METHODS: A literature search was performed from 2007 to 2017 to identify published articles and congress abstracts related to clinician-patient communication and treatment decision-making in oncology. Search results were evaluated by year of publication and disease area. A thematic assessment was performed to identify factors limiting and promoting PCC for patients with MM and other hematologic malignancies. RESULTS: Of the 6673 publications initially retrieved, 18 exclusively reported findings in patients with hematologic malignancies and were included in this review. We identified three critical, but modifiable, barriers to PCC in the hematologic malignancy setting, including insufficient information exchange, treatment goal misalignment, and discordant role preferences in treatment decision-making. Factors that enhanced interaction quality included educational programs for clinicians and patients. CONCLUSIONS: Patients with MM and other hematologic malignancies experience a distinct set of challenges that may affect PCC. PRACTICE IMPLICATIONS: Clinicians have the opportunity to improve patient care by proactively addressing the identified barriers and implementing strategies demonstrated to improve PCC.
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Comunicación , Neoplasias Hematológicas/terapia , Mieloma Múltiple/terapia , Educación del Paciente como Asunto , Atención Dirigida al Paciente , Relaciones Médico-Paciente , Toma de Decisiones Conjunta , Humanos , Estados UnidosRESUMEN
Oncology training focuses primarily on biomedical content rather than psychosocial content, which is not surprising in light of the enormous volume of technical information that oncology fellows assimilate in a short time. Nonetheless, the human connection, and specifically communication skills, remains as important as ever in caring for highly vulnerable patients with cancer. We previously described a year-long communication skills curriculum for oncology fellows that consisted of monthly 1-hour seminars with role play as the predominant teaching method (Epner and Baile, Acad Med. 89:578-84, 2014). Over several years, we adapted the curriculum based on learner feedback and reflection by faculty and teaching assistants and consolidated sessions into quarterly 3-4-hour workshops. We now describe integrating stories into the curriculum as a way of building empathy and warming fellows to the arduous task of dealing with highly emotional content, such as conversations with young patients about transitioning off disease-directed therapy. Learners read and discussed published, medically themed stories; discussed their own patient care stories; and completed brief writing reflections and discussions. They then worked in small groups facilitated by faculty and upper level fellows who functioned as teaching assistants to work on applying specific skills and strategies to scenarios that they chose. Fellows completed anonymous surveys on which they rated the curriculum highly for relevance, value, organization, content, and teaching methods, including storytelling aspects. We conclude that sharing stories can help highly technical learners build reflective ability, mindfulness, and empathy, which are all critical ingredients of the art of medicine.
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Comunicación , Curriculum/normas , Becas/métodos , Oncología Médica/educación , Narración , Neoplasias/psicología , Estudiantes de Medicina/psicología , Empatía , Humanos , Enseñanza , Revelación de la VerdadAsunto(s)
Comunicación , Relaciones Médico-Paciente , Consenso , Humanos , Oncología Médica , Sociedades MédicasRESUMEN
Purpose To provide guidance to oncology clinicians on how to use effective communication to optimize the patient-clinician relationship, patient and clinician well-being, and family well-being. Methods ASCO convened a multidisciplinary panel of medical oncology, psychiatry, nursing, hospice and palliative medicine, communication skills, health disparities, and advocacy experts to produce recommendations. Guideline development involved a systematic review of the literature and a formal consensus process. The systematic review focused on guidelines, systematic reviews and meta-analyses, and randomized controlled trials published from 2006 through October 1, 2016. Results The systematic review included 47 publications. With the exception of clinician training in communication skills, evidence for many of the clinical questions was limited. Draft recommendations underwent two rounds of consensus voting before being finalized. Recommendations In addition to providing guidance regarding core communication skills and tasks that apply across the continuum of cancer care, recommendations address specific topics, such as discussion of goals of care and prognosis, treatment selection, end-of-life care, facilitating family involvement in care, and clinician training in communication skills. Recommendations are accompanied by suggested strategies for implementation. Additional information is available at www.asco.org/supportive-care-guidelines and www.asco.org/guidelineswiki .
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Comunicación , Oncología Médica/normas , Relaciones Profesional-Paciente , Humanos , Ensayos Clínicos Controlados Aleatorios como AsuntoRESUMEN
BACKGROUND: When bad news about a cancer diagnosis is being delivered, patient-centered communication (PCC) has been considered important for patients' adjustment and well-being. However, few studies have explored how interpersonal skills might help cancer patients cope with anxiety and distress during bad-news encounters. METHODS: A prospective, experimental design was used to investigate the impact of the physician communication style during a bad-news encounter. Ninety-eight cancer patients and 92 unaffected subjects of both sexes were randomly assigned to view a video of a clinician delivering a first cancer diagnosis with either an enhanced patient-centered communication (E-PCC) style or a low patient-centered communication (L-PCC) style. Participants rated state anxiety and negative affect before and immediately after the video exposure, whereas trust in the physician was rated after the video exposure only. Main and interaction effects were analyzed with generalized linear models. RESULTS: Viewing the disclosure of a cancer diagnosis resulted in a substantial increase in state anxiety and negative affect among all participants. This emotional response was moderated by the physician's communication style: Participants viewing an oncologist displaying an E-PCC style were significantly less anxious than those watching an oncologist displaying an L-PCC style. They also reported significantly higher trust in the physician. CONCLUSIONS: Under a threatening, anxiety-provoking disclosure of bad news, a short sequence of empathic PCC influences subjects' psychological state, insofar that they report feeling less anxious and more trustful of the oncologist. Video exposure appears to be a valuable method for investigating the impact of a physician's communication style during critical encounters. Cancer 2017;123:3167-75. © 2017 American Cancer Society.
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Afecto , Ansiedad , Comunicación , Neoplasias , Atención Dirigida al Paciente , Relaciones Médico-Paciente , Confianza , Revelación de la Verdad , Adulto , Femenino , Humanos , Modelos Lineales , Masculino , Persona de Mediana Edad , Grabación en Video , Adulto JovenRESUMEN
SUMMARY STATEMENT: Role-play is a method of simulation used commonly to teach communication skills. Role-play methods can be enhanced by techniques that are not widely used in medical teaching, including warm-ups, role-creation, doubling, and role reversal. The purposes of these techniques are to prepare learners to take on the role of others in a role-play; to develop an insight into unspoken attitudes, thoughts, and feelings, which often determine the behavior of others; and to enhance communication skills through the participation of learners in enactments of communication challenges generated by them. In this article, we describe a hypothetical teaching session in which an instructor applies each of these techniques in teaching medical students how to break bad news using a method called SPIKES [Setting, Perception, Invitation, Knowledge, Emotions, Strategy, and Summary]. We illustrate how these techniques track contemporary adult learning theory through a learner-centered, case-based, experiential approach to selecting challenging scenarios in giving bad news, by attending to underlying emotion and by using reflection to anchor new learning.
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Educación de Pregrado en Medicina/métodos , Relaciones Médico-Paciente , Aprendizaje Basado en Problemas/métodos , Desempeño de Papel , Revelación de la Verdad , Adulto , Comunicación , Femenino , Humanos , MasculinoRESUMEN
Difficult conversations about prognosis, end of life, and goals of care arise commonly in medical oncology practice. These conversations are often highly emotional. Medical oncologists need outstanding, patient-centered communication skills to build trust and rapport with their patients and help them make well-informed decisions. Key skills include exploring patients' perspectives, responding to emotion with empathy, and maintaining mindfulness during highly charged conversations. These skills can be taught and learned. Most previously described communication skills training curricula for oncology providers involve multiday retreats, which are costly and can disrupt busy clinical schedules. Many curricula involve a variety of oncology providers, such as physicians and nurses, at various stages of their careers. The authors developed a monthly, one-hour communication skills training seminar series exclusively for physicians in their first year of medical oncology subspecialty training. The curriculum involved a variety of interactive and engaging educational methods, including sociodramatic techniques, role-play, reflective writing, and Balint-type case discussion groups. Medical oncologists in their second and third years of training served as teaching assistants and peer mentors. Learners had the opportunity to practice skills during sessions and with patients between sessions. Learners acquired important skills and found the curriculum to be clinically relevant, judging by anonymous surveys and anonymous responses on reflective writing exercises. Results from the current curriculum are preliminary but lay the foundation for enhanced and expanded communication skills training programs in the future.
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Comunicación , Curriculum , Oncología Médica/educación , Relaciones Médico-Paciente , Cuidado Terminal/psicología , Adulto , Actitud del Personal de Salud , Educación de Postgrado en Medicina/métodos , Empatía , Femenino , Humanos , Masculino , Neoplasias/psicología , Neoplasias/terapia , Evaluación de Resultado en la Atención de Salud , Rol del Médico/psicología , Factores de Tiempo , Revelación de la Verdad/ética , Estados UnidosRESUMEN
Empathy is a core feature of patient-centered care. It enables practitioners to better understand the patient and family concerns that are key to patient and family satisfaction, prevention of anxiety and depression, and provider empowerment. Current methods of teaching communication skills do not specifically focus on enhancing the ability to "stand in the patient's shoes" as a way of connecting with the patient and/or family experience and understanding feelings that may be a source of conflict with providers. In this paper, we present a model for deepening empathic understanding based upon action methods (role-reversal and doubling) derived from psychodrama and sociodrama. We describe these techniques and illustrate how they can be used to identify hidden emotions and attitudes and reveal that which the patient and family member may be thinking or feeling but be afraid to say. Finally, we present data showing that these methods were valuable to participants in enhancing their professional experience and skills.
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We introduce the technique of sociodrama, describe its key components, and illustrate how this simulation method was applied in a workshop format to address the challenge of discussing transition to palliative care. We describe how warm-up exercises prepared 15 learners who provide direct clinical care to patients with cancer for a dramatic portrayal of this dilemma. We then show how small-group brainstorming led to the creation of a challenging scenario wherein highly optimistic family members of a 20-year-old young man with terminal acute lymphocytic leukemia responded to information about the lack of further anticancer treatment with anger and blame toward the staff. We illustrate how the facilitators, using sociodramatic techniques of doubling and role reversal, helped learners to understand and articulate the hidden feelings of fear and loss behind the family's emotional reactions. By modeling effective communication skills, the facilitators demonstrated how key communication skills, such as empathic responses to anger and blame and using "wish" statements, could transform the conversation from one of conflict to one of problem solving with the family. We also describe how we set up practice dyads to give the learners an opportunity to try out new skills with each other. An evaluation of the workshop and similar workshops we conducted is presented.
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Cuidadores/psicología , Cuidados Paliativos/organización & administración , Cuidados Paliativos/psicología , Educación del Paciente como Asunto/métodos , Relaciones Profesional-Familia , Psicodrama/métodos , Enseñanza/métodos , Comunicación , Humanos , Desempeño de Papel , Estados UnidosRESUMEN
End-of-life discussions can be stressful and can elicit strong emotions in the provider as well as the patient and family. In palliative care, understanding and effectively addressing emotions is a key skill that can enhance professional competency and patient/family satisfaction with care. We illustrate how in coursework for a Master's degree in palliative medicine we used dramatic "action methods" derived from sociodrama and psychodrama in the portrayal of two challenging cases to train providers in the emotional aspects of caring for patients with advanced cancer. We describe the specific techniques of constructing and enacting case scenarios using warm-ups, role-creation, doubling and role-reversal. In particular, we illustrate how these techniques and others were used to reveal and address the "hidden" emotions, attitudes, and values that were central to the communication dilemma. Finally, we present an evaluation completed by the 26 participants who attended the course.
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Neoplasias/psicología , Cuidados Paliativos/psicología , Psicodrama/métodos , Enfermo Terminal/psicología , Comunicación , Educación de Postgrado en Medicina/métodos , Personal de Salud/educación , Humanos , Italia , Cuidados Paliativos/métodos , Relaciones Profesional-Familia , Relaciones Profesional-Paciente , Estudiantes del Área de la Salud/psicología , Revelación de la Verdad , Recursos HumanosRESUMEN
PURPOSE: This study was designed to determine if differences exist in the speaking rate and pitch of healthcare providers when discussing bad news versus neutral topics, and to assess listeners' ability to perceive voice differences in the absence of speech content. METHODS: Participants were oncology healthcare providers seeing patients with cancer of unknown primary. The encounters were audio recorded; the information communicated by the oncologist to the patient was identified as neutral or bad news. At least 30 seconds of both bad news and neutral utterances were analyzed; provider voice pitch and speaking rate were measured. The same utterances were subjected to low pass filtering that maintained pitch contours and speaking rate, but eliminated acoustic energy associated with consonants making the samples unintelligible, but with unchanged intonation. Twenty-seven listeners (graduate students in a voice disorders class) listened to the samples and rated them on three features: caring, sympathetic, and competent. RESULTS: All but one provider reduced speaking rate, the majority also reduced pitch in the bad news condition. Listeners perceived a significant difference between the nonverbal characteristics of the providers' voice when performing the two tasks and rated speech produced with the reduced rate and lower pitch as more caring and sympathetic. CONCLUSIONS: These results suggest that simultaneous assessment of verbal content and multiparameter prosodic analysis of speech is necessary for a more thorough understanding of the expression and perception of empathy. This information has the potential to contribute to the enhancement of communication training design and of oncologists' communication effectiveness.
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Comunicación , Percepción de la Altura Tonal , Percepción del Habla , Revelación de la Verdad , Adulto , Empatía , Femenino , Humanos , Masculino , Oncología Médica/métodos , Persona de Mediana Edad , Neoplasias Primarias Desconocidas/patología , Neoplasias Primarias Desconocidas/psicología , Comunicación no Verbal , Médicos/psicología , Voz , Adulto JovenRESUMEN
Many practitioners in oncology receive no or little training in how to effectively communicate with patients and families who are dealing with cancer. Moreover medical teachers are not always aware of the pedagogy of teaching communication skills in a way that results in performance improvement in this area. In this paper a method of small group teaching that was used to instruct medical oncology fellows in the essentials of communication using a retreat format that lasted three days is described. The paper covers the theoretical basis for the teaching format as well as the specific components of the workshops. It describes the process of facilitation using a "learner-centered" approach using standardized patients who take on the role of cancer patients along the trajectory of the illness. It discuss the use of small group process to facilitate skills acquisition and other strategies that facilitate learning such as reflective exercises, open role play and parallel process. It concludes with a consideration of the various ways that such workshops can be evaluated.
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Comunicación , Educación Médica Continua/métodos , Oncología Médica/educación , Neoplasias/psicología , Relaciones Médico-Paciente , Educación/métodos , Evaluación Educacional/métodos , Grupos Focales/métodos , Humanos , Neoplasias/terapiaRESUMEN
PURPOSE: Recommendations for communicating bad or serious news are based on limited evidence. This study was designed to understand patient perspectives on what patients value when oncologists communicate news of cancer recurrence. STUDY DESIGN AND METHODS: Participants were 23 patients treated for a gastrointestinal cancer at a tertiary U.S. cancer center within the past 2 years, who had semistructured qualitative interviews in which they listened to audio recordings of an oncology fellow discussing news of cancer recurrence with a standardized patient. Participants paused the audio recording to comment on what they liked or disliked about the oncologist's communication. RESULT: Three themes were identified that refine existing approaches to discussing serious news. The first theme, recognition, described how the oncologist responded to the gravity of the news of cancer recurrence for the patient. Participants saw the need for recognition throughout the encounter and not just after the news was given. The second theme, guiding, describes what participants wanted after hearing the news, which was for the oncologist to draw on her biomedical expertise to frame the news and plan next steps. The third theme, responsiveness, referred to the oncologist's ability to sense the need for recognition or guidance and to move fluidly between them. CONCLUSION: This study suggests that oncologists giving news of cancer recurrence could think of the communication as going back and forth between recognition and guidance and could ask themselves: "Have I demonstrated that I recognize the patient's experience hearing the news?" and "Have I provided guidance to the next steps?"
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Comunicación , Neoplasias Gastrointestinales/psicología , Oncología Médica/ética , Recurrencia Local de Neoplasia/psicología , Satisfacción del Paciente , Relaciones Médico-Paciente , Adulto , Anciano , Femenino , Neoplasias Gastrointestinales/terapia , Humanos , Entrevistas como Asunto , Masculino , Persona de Mediana Edad , Revelación de la VerdadRESUMEN
AIMS: Patients in the palliative care setting have a number of concerns not necessarily connected to their medical problems, such as spiritual and relationship issues. When these problems are not properly assessed and addressed, they may become a significant source of distress for patients and families. The aims of the present study were to assess the concerns of patients attending a palliative care clinic, to examine physicians' ratings of patient concerns, to access the concordance between patients' and physicians' ratings, and to assess the association between patients' concerns and their level of distress. METHODS: We evaluated 137 patients attending a symptom control and palliative care clinic. Patients completed the Concerns Checklist, Hospital Anxiety and Depression Scale, and Cancer Behavior Inventory at the beginning of their visit. The Concerns Checklist was completed by the patient's clinic physician immediately after the visit and was used to estimate how accurate the physician was in identifying patients' concerns. We examined the correlation between the total number of patient concerns and their levels of anxiety, mood disturbance, and self-efficacy. RESULTS: Patients were most concerned about loss of function, the future, and caring for themselves. Concordance between physician and patient rating of concerns was poor (all kappas, 0.26 or lower). Higher levels of patient concerns were associated with greater anxiety (r = 0.52) and depressive symptoms (r = 0.40) and lower self-efficacy (r = -0.37). CONCLUSIONS: There was generally poor concordance between patients reporting of their concerns and physicians reporting of the patients' concerns. In addition, patients' with more concerns also had higher levels of anxiety and depressive symptoms. Thus, it is important to find strategies to more accurately identify patients' concerns, so that they can be adequately addressed.
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Actitud Frente a la Salud , Neoplasias/psicología , Cuidados Paliativos/métodos , Adulto , Anciano , Anciano de 80 o más Años , Ansiedad/epidemiología , Ansiedad/etiología , Actitud del Personal de Salud , Depresión/epidemiología , Depresión/etiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Trastornos del Humor/epidemiología , Trastornos del Humor/etiología , Neoplasias/patología , Neoplasias/terapia , Autoeficacia , Adulto JovenRESUMEN
PURPOSE: Patients with serious illness derive a sense of security by forming strong, healing relationships with their providers. These bonds are particularly strong in life-threatening illnesses, such as cancer, which carry the stigma of death and suffering. These strong relationships create expectations in patients that are not necessarily shared by their clinicians. Providers often focus on treating disease and emphasize technically excellent, "evidence-based" practice while failing to fully appreciate the power of the patient-provider relationship. In contrast, vulnerable patients expect much more than technical competence, including open and clear communication, security, continuity, and access. Patients are often left feeling abandoned when their providers do not meet their expectations, even when their care is technically sound. METHODS/RESULTS: In this paper, we describe scenarios that can lead to feelings of abandonment and discuss strategies to avoid and respond to them. CONCLUSIONS: These strategies can help us maintain healing relationships with our patients by maintaining their trust, confidence, and satisfaction. Cultivating relational aspects of medical practice requires an interchange and takes time. Experienced doctors know this and continue to do so because being present and staying with the patient during difficult times is a pillar of moral and ethical training and a fundamental attribute of a good physician.
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Familia/psicología , Neoplasias/psicología , Relaciones Médico-Paciente , Comunicación , Continuidad de la Atención al Paciente , Accesibilidad a los Servicios de Salud , Humanos , Satisfacción del Paciente , Negativa al Tratamiento , ConfianzaRESUMEN
BACKGROUND: John Wooden, the legendary college basketball coach, created the "Pyramid of Success", which he constructed from 14 timeless character traits and interpersonal skills that are critical to competitive greatness. Wooden's pyramid is a powerful symbol that he and others have used for several decades as an educational tool to promote leadership and teamwork. AIM: This article proposes the "Pyramid of Relational Excellence (PRE)", patterned after Wooden's pyramid, as a mnemonic-based educational symbol for communication skills training. METHOD: Literature review, personal reflection. RESULTS: The PRE is constructed of four tiers with a total of 12 building blocks, with each successive tier built upon the one beneath it. The building blocks represent fundamental elements that are known to be critical to successful communication. CONCLUSIONS: The PRE is process oriented rather than task oriented and focuses exclusively on the face-to-face encounter. It therefore complements established communications curricula, such as the UK communication wheel and others, which are more comprehensive and task oriented. The PRE is constructed of timeless, fundamental principles. It is therefore particularly well suited for training medical students and residents.