Integrating Storytelling into a Communication Skills Teaching Program for Medical Oncology Fellows.

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.

Effects of patient-centered communication on anxiety, negative affect, and trust in the physician in delivering a cancer diagnosis: A randomized, experimental study.

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.

Survey of patients and physicians on shared decision-making in treatment selection in relapsed/refractory multiple myeloma.

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.

Voice analysis during bad news discussion in oncology: reduced pitch, decreased speaking rate, and nonverbal communication of empathy.

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.

Communicating with patients with idiopathic pulmonary fibrosis: can we do it better?

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.

What patients value when oncologists give news of cancer recurrence: commentary on specific moments in audio-recorded conversations.

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?"

Training oncology practitioners in communication skills.

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.

"When patients and families feel abandoned".

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.

Assessment of palliative care cancer patients' most important concerns.

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.

Wooden's pyramid: building a hierarchy of skills for successful communication.

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.

Communicating with cancer patients: what areas do physician assistants find most challenging?

Physician assistants (PAs) and other midlevel practitioners have been taking on increasing clinical roles in oncology settings. Little is known about the communication needs and skills of oncology PAs. PAs working in oncology (n = 301) completed an online survey that included questions about their perceived skill and difficulty on several key communication tasks. Overall, PAs rated these communication tasks as "somewhat" to "moderately" difficult and their skill level in these areas as "average" to "good." Areas of most perceived difficulty were intervening with angry patients or those in denial and breaking bad news. Highest perceived skills were in communicating with patients from cultures and religions different than your own and telling patient he/she has cancer or disease has progressed, and the lowest perceived skills were in discussing do not resuscitate orders. There are areas in which enhancement of communication skills may be needed, and educational opportunities should be developed for PAs working in oncology.

Breast cancer: unique communication challenges and strategies to address them.

Women with breast cancer have become increasingly more involved on a national and local level in advocating for resources to fight cancer. However, in the context of the relationship with their physicians and other cancer caregivers, much remains to be done in providing them with adequate support. In this paper, we highlight the difficulties in communication related to breast cancer and describe strategies and approaches that may be helpful in improving the communication throughout the cancer trajectory. Specifically, breast cancer patients have high unmet information needs relevant to health information and dissatisfaction with the actual information they receive from their providers. These needs seem even more pronounced when patients are older, of lower socio-economic class and from differing cultural backgrounds which may affect their ability to express their desires for information and desire to be involved in decision-making about their treatment. Other communication challenges can be envisioned as occurring at key points across the cancer trajectory: diagnosis disclosure, treatment failure, transition to palliative care, and end of life discussions. These involve techniques as basic as how to establish trust and rapport and determine a patient's information and decision-making preferences and as complex as giving bad news. These strategies are now viewed as essential skills in that they can affect patient distress and quality of life, satisfaction, and malpractice litigation as well as practitioner stress and burnout.

Overcoming cultural barriers to giving bad news: feasibility of training to promote truth-telling to cancer patients.

BACKGROUND: In many countries, physicians are reluctant to disclose unfavorable medical information to patients with advanced cancer and instead give the bad news to the family. METHODS: The authors modified standard communication workshops to help Italian senior oncologists overcome cultural, social, and attitudinal barriers to disclosure of diagnosis and prognosis. RESULTS: Fifty-seven physicians participated; 88% believed the workshops would improve their medical practice. Many pursued further training and organized communication skills programs of their own. CONCLUSIONS: Communication skills workshops can be modified to meet educational and social norms and help clinicians acquire the interpersonal skills needed for honest communication with patients.

Review of the patient-centered communication landscape in multiple myeloma and other hematologic malignancies.

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.

Efficacy of communication skills training for giving bad news and discussing transitions to palliative care.

BACKGROUND: Few studies have assessed the efficacy of communication skills training for postgraduate physician trainees at the level of behaviors. We designed a residential communication skills workshop (Oncotalk) for medical oncology fellows. The intervention design built on existing successful models by teaching specific communication tasks linked to the patient's trajectory of illness. This study evaluated the efficacy of Oncotalk in changing observable communication behaviors. METHODS: Oncotalk was a 4-day residential workshop emphasizing skills practice in small groups. This preintervention and postintervention cohort study involved 115 medical oncology fellows from 62 different institutions during a 3-year study. The primary outcomes were observable participant communication skills measured during standardized patient encounters before and after the workshop in giving bad news and discussing transitions to palliative care. The standardized patient encounters were audiorecorded and assessed by blinded coders using a validated coding system. Before-after comparisons were made using each participant as his or her own control. RESULTS: Compared with preworkshop standardized patient encounters, postworkshop encounters showed that participants acquired a mean of 5.4 bad news skills (P<.001) and a mean of 4.4 transitions skills (P<.001). Most changes in individual skills were substantial; for example, in the bad news encounter, 16% of participants used the word "cancer" when giving bad news before the workshop, and 54% used it after the workshop (P<.001). Also in the bad news encounter, blinded coders were able to identify whether a standardized patient encounter occurred before or after the workshop in 91% of the audiorecordings. CONCLUSION: Oncotalk represents a successful teaching model for improving communication skills for postgraduate medical trainees.

Career satisfaction, practice patterns and burnout among surgical oncologists: report on the quality of life of members of the Society of Surgical Oncology.

BACKGROUND: Studies show that 30-50% of medical oncologists experience burnout, but little is known about burnout among surgical oncologists. We hypothesized that wide variation in burnout and career satisfaction exist among surgical oncologists. PATIENTS AND METHODS: In April 2006, members of the Society of Surgical Oncology (SSO) were sent an anonymous, cross-sectional survey evaluating demographic variables, practice characteristics, career satisfaction, burnout, and quality of life (QOL). Burnout and QOL were measured using validated instruments. RESULTS: Of the 1519 surgical oncologists surveyed, 549 (36%) responded. More than 50% of respondents worked more than 60 hours per week while 24% performed more than 10 surgical cases per week. Among the respondents, 72% were academic surgical oncologists and 26% spent at least 25% of their time to research. Seventy-nine percent stated that they would become a surgical oncologist again given the choice. Overall, 28% of respondents had burnout. Burnout was more common among respondents age 50 years or younger (31% vs 22%; P = .029) and women (37% vs 26%; P = .031). Factors associated with a higher risk of burnout on multivariate analysis were devoting less than 25% of time to research, had lower physical QOL, and were age 50 years or younger. Burnout was associated with lower satisfaction with career choice. CONCLUSIONS: Although surgical oncologists indicated a high level of career satisfaction, nearly a third experienced burnout. Factors associated with burnout in this study may inform efforts by program directors and SSO members to promote personal health and retain the best surgeons in the field of surgical oncology. Additional research is needed to inform evidenced-based interventions at both the individual and organizational level to reduce burnout.

Patient-Clinician Communication: American Society of Clinical Oncology Consensus Guideline.

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 .

Psychological impact of genetic testing for hereditary nonpolyposis colorectal cancer.

PURPOSE: This study examines the impact of hereditary nonpolyposis colorectal cancer (HNPCC) genetic test results on psychological outcomes among cancer-affected and -unaffected participants up to 1 year after results disclosure. PATIENTS AND METHODS: A total of 155 persons completed study measures before HNPCC genetic testing, and at 2 weeks and 6 and 12 months after disclosure of test results. RESULTS: Mean scores on all outcome measures remained stable and within normal limits for cancer-affected participants, regardless of mutation status. Among unaffected carriers of HNPCC-predisposing mutations, mean depression, state anxiety, and cancer worries scores increased from baseline to 2 weeks postdisclosure and decreased from 2 weeks to 6 months postdisclosure. Among unaffected noncarriers, mean depression and anxiety scores did not differ, but cancer worries scores decreased during the same time period. Affected and unaffected carriers had higher mean test-specific distress scores at 2 weeks postdisclosure compared with noncarriers in their respective groups; scores decreased for affected carriers and all unaffected participants from 2 weeks to 12 months postdisclosure. Classification of participants into high- versus low-distress clusters using mean scores on baseline psychological measures predicted significantly higher or lower follow-up scores, respectively, on depression, state anxiety, quality of life, and test-specific distress measures, regardless of mutation status. CONCLUSION: Although HNPCC genetic testing does not result in long-term adverse psychological outcomes, unaffected mutation carriers may experience increased distress during the immediate postdisclosure time period. Furthermore, those with higher levels of baseline mood disturbance, lower quality of life, and lower social support may be at risk for both short- and long-term increased distress.