Communication is a critically important skill for all physicians to master in their clinical practice. The Accreditation Council for Graduate Medical Education (ACGME) requires all physicians to demonstrate competency in “interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and other health professionals.”1 Much has already been written on the topic of teaching communication skills to physicians from a variety of perspectives and approaches. This chapter is not an exhaustive overview of those perspectives. Instead, it draws from a review of the literature and our own experience as seasoned clinical educators to present a “toolbox” of strategies for teaching communication skills, particularly related to teaching physicians new to the field of hospice and palliative medicine (HPM). This toolbox includes the following:
♦ A conceptual model for patient- and family-centered communication that can be used to help learners operationalize communication strategies and to demystify the “magic” in complex communication encounters that trainees often attribute to their attending physicians.
♦ An outline of various approaches to teaching communication skills such as simulated patient experiences, clinical bedside checklists, and so on.
♦ A discussion of the importance of and approaches to providing effective feedback as an integral part of teaching communication skills.
♦ A discussion of the importance of communication skills in common HPM clinical settings, such as family meetings and telemedicine.
Communication as an Essential Skill
Communication is a core skill essential to the daily practice of caring for patients and their families facing serious or advanced illness.2 Consequently, ACGME-accredited HPM fellowships require graduating physicians to exhibit competence in the following communication skills3:
1. Initiate informed relationship-centered dialogues about care
2. Demonstrate empathy
3. Demonstrate ability to recognize and respond to own emotions and those of others
4. Demonstrate the ability to educate patients/families about the medical, social, and psychological issues associated with life-limiting illness
5. Use age-, gender-, and culturally appropriate concepts and language when communicating with families and patients
6. Demonstrate these skills in the following paradigmatic situations with patients or families and document an informative, sensitive note in the medical record (e.g., giving bad news, discussing transitions in care, introducing a palliative care consultation, etc.)
7. Organize and lead or cofacilitate a family meeting
8. Collaborate effectively with others as a member or leader of an interdisciplinary team
9. Develop effective relationships with referring physicians, consultant physicians, and other healthcare providers
10. Maintain comprehensive, timely, and legible medical records
Given the complexity inherent in demonstrating these competencies of HPM training, many physicians in our field assert that communication is HPM’s core “procedure.”
There are many benefits of quality communication. It improves patient and family satisfaction, decreases the psychological morbidity for patients and families, improves quality of life, fosters adherence to therapeutic regimens, avoids malpractice litigation, and supports bereavement adjustment for families.4,5,6,7 Nonetheless, provider communication often fails to meet the needs of patients and families,6,8,9,10,11and the outcomes of poor communication are dire. Adverse mental health sequalae, late hospice referrals, and more aggressive, unwanted life-prolonging care are all potential consequences of ineffective communication.7
Multiple barriers exist in communication with patients and their families. In part, ineffective communication can be related to the characteristics of the physician such as emotional stress, competing time demands, and fear of confronting illness and death.12,13 Moreover, most physicians receive inadequate communication training and thus report discomfort with complex communication tasks.14,15 Multiple studies have revealed that residents feel unprepared to provide end-of-life care and ill equipped to facilitate medical decision-making with patients and families.14,15
Communication education has made great advances over the past decade, with an increase in the implementation of communication curricula across the training spectrum (medical student, resident, fellow). Numerous studies have illustrated the valuable use of feedback, deliberate practice, simulation, communication roadmaps, and so on for honing communication skills particularly related to patients with serious or advanced illness. However, many of the training strategies have focused on discrete communication tasks such as breaking bad news, having a code discussion, and/or facilitating a family meeting. This has required learners to remember and employ separate communication rubrics for distinct situations, often making complex communication tasks feel even more complicated. To make teaching and learning communication less daunting, discrete communication tasks should be integrated into a comprehensive conceptual model for physician–patient–family communication. This schema allows the teacher and learner to move beyond a communication task approach and operationalize the elements and associated skills that foster communication in most contexts.
Patient- and Family-Centered Communication: The Five Elements and Their Associated Tools
This chapter’s conceptual model builds on the concept of shared decision-making through patient- and family-centered communication. Communication in HPM often involves highly charged discussions and decisions related to breaking bad news, transitions in care plans, and advance care planning related to end-of-life care. Shared decision-making is often the crux of these discussions with five basic tenets16 (see Table 43.1). Most simply, shared decision-making requires a patient-centered approach whereby healthcare providers engage in a partnership with patients and families to develop medically appropriate care plans that are consistent with patients’ values and goals.
Table 43.1 Comparison of Shared Decision-Making, Patient-Centered Communication, and Core Functions of Communication
Core functions of Effective Communication18
Discussing the nature of the decision to be made
Eliciting and understanding patient perspective (concerns, ideas, expectations, needs, feelings, and functioning)
Fostering the relationship
Exchanging relevant medical information and information about a patient’s values
Understanding the patient within his or her unique psychosocial and cultural context
Checking for understanding of information for both the healthcare provider and the patient
Reaching a shared understanding of patient problems and its treatments
Discussing preferred roles in decision-making
Helping a patient share power by offering him or her meaningful investment in choices related to his or her health
Achieving consensus about the treatment course most consistent with the patient’s values and preferences
Enabling disease and treatment-related behaviors
Responding to emotion
Although the evidence to support any particular communication practice is limited, multiple organizations such as the ACGME, the American College of Critical Care Medicine, and the National Cancer Institute, to name a few, all advocate the importance of patient- and family-centered communication. The National Cancer Institute17 offers clear components of patient-centered communication that assure the core functions of communication18 (see Table 43.1).
The following section integrates these concepts into a model that is grounded in a patient- and family-centered approach and centered on the concept of shared decision-making. It delineates the elements and skills of communication as a model from which to teach communication to physician learners. This model is comprised of the following five elements: assess patient perspective, exchange information, attend to emotion, manage uncertainty, and engage in shared decision-making. Most discussions between HPM physicians and patients/families involve shared decision-making with varying degrees of gravity (e.g., symptom management, resuscitation status, breaking bad news, advance care planning, and/or goals of care, etc.). Regardless of the type of discussion, the five elements of quality communication remain the same and can be employed for all types of discussions. Some discussions will require more of an emphasis on a particular element of the model (e.g., attending to emotion when breaking bad news). Nonetheless, all the skills are necessary to some greater or lesser degree for most HPM discussions. This conceptual model is not meant to be linear. Instead, it provides a cognitive framework, or scaffolding, on which to build and learn communication (Figure 43.1).
When visualizing this conceptual model, the top three circles are clearly part of patient- and family-centered communication and shared decision-making. We have added “managing uncertainty” as a crucial element to the model, related to common discussions in HPM. For many HPM patients and their families, prognostication and its inherent uncertainty are integral to the illness experience and decision-making.19 Although there are no clear best practices for discussing uncertainty, managing uncertainty while promoting prognostic awareness is an essential skill for HPM physicians, whose primary goal is to foster medical decision-making based on patients’ values and realistic goals.16
This model transforms complex communication into a learnable skill by parsing it into essential elements and tools that can be taught and practiced. The elements are the “what” that constitutes quality communication and the tools are the “how” to employ the elements. These are not difficult skills, and many learners will have been introduced to some of them at some point during their training as roadmaps for specific types of discussions (e.g., SPIKES for breaking bad news,20 VALUE for goals of care discussions in the intensive care unit [ICU]21, NURSE for addressing emotion22). When these roadmaps are deconstructed, they contain similar, if not identical, elements. This conceptual model takes these roadmaps and maps them onto the five elements central to patient- and family-centered communication for HPM physicians. The remainder of this section outlines each element, and its associated tools, with examples to guide the clinician educator in utilizing this conceptual model for teaching communication.
Assessing Patient Perspective and Exchanging Information
The goal of “assessing patient perspective” is to elicit how a patient and/or family understands and experiences the illness. It involves a biopsychosocial model of inquiry that assesses a patient’s understanding of his or her illness from both a cognitive and emotional framework (i.e.: What does the patient know about his or her medical condition and what are his or her feelings related to the illness?). In addition, it includes an understanding of how a patient is being impacted by and making meaning out of his or her illness (i.e.: How does the illness affect functioning, relationships, self-perception, etc.?). The tools associated with this element of the conceptual model include Active Listening, Ask-Tell-Ask, and Tell Me More.
Active Listening involves paying attention to nonverbal cues, using reflective questions and statements, and practicing compassionate silence.23 Quality communication often relies on close attention to nonverbal cues from both the patient and physician. Teaching communication to physician-learners requires an explicit discussion of the importance of nonverbal body language such as presenting an open body posture, encouraging patient input with nodding, sitting down or attempting to be at eye level with the patient, and maintaining eye contact. The setup of the room is another important feature to discuss with learners and includes such factors as minimizing distractions (i.e., silencing phones or pagers), finding a private place for a discussion (e.g., closing the door or curtain), sitting close to the patient, and so on.12
Reflective questions and statements show the patient that the physician is listening.12 With this tool, learners reiterate and/or paraphrase what the patient has said to ensure that there is a mutual understanding of the patient’s comments: “It sounds like you are saying that you are in a lot of pain. Do I understand you correctly?” Sometimes there is a buried question behind a patient’s statement. A reflective question or statement that elucidates or interprets the buried question can often help move a conversation forward: “It sounds like you are saying that your pain is getting in the way of your ability to work.”
In practicing compassionate silence, learners first need to practice allowing patients to talk without interruption. Once a learner has practiced this skill, the educator can introduce the application of compassionate silence. The literature underscores the importance of silence and allowing a patient and family to lead the conversation to areas important to them. Some silences can be invitational or expectant of a response from the patient. In contrast, the main objective of compassionate silence is to be present with the patient, without expectation, and is often helpful in times of high emotion. By employing compassionate silence, physicians create a sense of mutual understanding, caring, and compassion. Compassionate silence can be a very difficult skill to master, thus teachers should normalize the challenges of employing this tool for learners.
The Ask-Tell-Ask24 is used to explore patients’ understanding of their disease, provide information to them as needed, and ensure that the information provided by the physician was received. The initial Ask is exploratory about the patient’s and/or family’s understanding of the illness:
“What have the doctors told you so far?”
“To make sure that we’re on the same page, can you tell me what is your understanding of your illness?”
The first Ask should also explore how a patient wants to receive information; that is, who does the patient want involved in the discussion for support, such as a spouse or friend; how much information does he or she want to receive at a particular time; what is the best way to convey information in terms of level of detail versus general impressions?25,26 Overall, the first ask is a strategy for eliciting what the patient already knows to provide the framework on which to build more knowledge and understanding.
As healthcare providers, we often need to deliver information to our patients about treatment options, results of testing, prognostic information, and so on. The “Tell” of “Ask-Tell-Ask” is the provision of information to the patient and/or family. Learners are encouraged to avoid medical jargon and give information in small, digestible chunks; receivers of information often cannot maintain attention for a prolonged period of time. The Tell requires completion of the initial ask, so that the physician can build on the knowledge of the patient without unnecessarily repeating what is already known. A Tell following the first Ask can also help the physician correct misinformation or misunderstanding of a patient’s knowledge.
The second Ask is to ensure that the physician and patient have achieved a common understanding by asking for the patient’s synopsis. In addition, the second Ask can include assessing what questions the patient may still have, after receiving the Tell:
“I want to ensure that my explanation was effective. Will you tell me in your own words what you understand from what I have just said?”
“What questions do you have about what we have just discussed?”
Tell Me More
Tell Me More24 is a tool for helping learners drill deeper into their assessment of patient perspective. It is an invitation for patients to tell the physician more about whatever topic they have identified as important. Learners can use Tell Me More to uncover the hidden stories or questions in a patient’s communication and to try to understand the full illness experience of the patient beyond just the physical changes to their health. It is a tool that can be used to explore a patient’s cognitive and emotional perspective on their illness:
“Tell me more about your understanding of your illness.”
“Tell me more about how you are feeling about your illness.”
“Tell me more about how you are making sense of all of this.”
“Tell me more how your illness is impacting your life.”
Attending to Emotion
HPM discussions frequently focus on emotionally charged events such as giving serious news or considering advance care planning for one’s impending death. An emotional reaction to difficult news is an expected response from patients and their families. Although physicians often purposefully try to remain emotionally neutral to provide accurate information, communication requires physicians to recognize the emotions of their patients and respond to them. Attending to emotion12,27 can strengthen the patient–physician relationship by explicitly acknowledging and normalizing that emotions play a role in decision-making. If emotions are attended to, physicians can help decrease subsequent psychological morbidity in the future for patients and their families. In addition to Tell Me More and Active Listening, another tool associated with attending to emotion is NURSE statements—a helpful mnemonic of empathetic phrases made by the physician for the same purpose. These tools are used to attend to, explore, and support a patient when emotions have been expressed verbally and nonverbally.
N = NAME. Learners begin by naming a patient’s emotion to themselves as a way of noting what is happening in an encounter. By acknowledging the emotion silently, learners have a better understanding of where to focus the conversation. In some cases, it may be useful to name the emotion to the patient as a way of showing that the physician is attuned to what the patient is experiencing. By naming the emotion, the physician validates that emotion as expected and normal.
A patient has just learned from recent imaging her disease is worse. Her head is bowed down, and she is visibly tearful. A Naming statement would be: “It seems that this is very upsetting to you”
U = UNDERSTAND. This type of statement shows an appreciation by the physician for the patient’s predicament or feelings. It helps build rapport and focuses on what the patient is experiencing. An Understanding statement, at its most simple, is an empathic statement.
A patient expresses the difficulty of managing work responsibilities with his chemotherapy regimen. An Understanding statement would be: “I can’t imagine what it is like to balance your treatments with your work life.”
R = RESPECT. Physicians show respect for their patients with nonverbal cues such as good eye contact, body posture, and so on. At the same time, a verbal statement that explicitly states that emotions are not only allowable but important is a helpful way of respecting a patient’s emotions. Patients and their families often respond positively to validating statements of their coping in the face of a challenging road.
A husband has been at his wife’s bedside in the ICU daily for two weeks. A Respecting statement would be: “I have been so impressed by your ability to sit at the bedside every day to ensure that your wife is receiving the best care possible. I can’t imagine how hard that must be.”
S = SUPPORT. Patients are often fearful of being abandoned at the end of life by their physicians. A statement about a physician’s willingness to help regardless of the outcome can alleviate a patient’s fears of abandonment.29,30 Ultimately, a Support statement is a verbal recognition of the physician-patient partnership, regardless of illness stage.
A patient has shown no improvement after 2 weeks in the ICU. The patient’s husband has agreed to transition the care plan for his wife to intensive comfort measures. A Support statement would be: “You are not alone in this. We will continue to be here for you to help you and your family with the next steps.”
E = EXPLORE. This tool may incorporate other skills such as Tell Me More to explore further the emotion of the patient and allow the patient and/or family to express the emotional areas most challenging to them.
A terminally ill patient with young children has expressed profound sadness and guilt at not being able to parent her children as they grow up. An Explore statement would be: “I can only imagine how upsetting it must be to consider leaving your kids. Can you tell me more about your concerns?”
Many of the aforementioned skills such as Active Listening and Tell Me More can be used as tools to manage uncertainty for patients and their families. There are two additional tools that help learners incorporate assessing and promoting prognostic awareness while supporting their patients’ coping: Hope and Worry and I Wish …
Hope and Worry
When using Hope and Worry, physician statements of nonabandonment help patients and their families cope with the uncertainty of their illness trajectory.31,32 Many patients and their families often hope for outcomes that the healthcare provider feels may be unobtainable. Nonetheless, targeted questions that ask patients to identify hopes, and at the same time explore their concerns, often reveal a patient’s clear understanding of the likely illness trajectory, despite the unrealistic wishes. To assess prognostic awareness, a healthcare provider may simply ask: “Putting together everything that we have talked about, what are you hoping for, and what are you worried about?”
This tool may also be used to promote prognostic awareness32 and foster realistic expectations and goals, when a patient and/or family has difficulty expressing the likely, and oftentimes undesired, outcome. It is a way of reframing hope by encouraging a dual agenda: hoping for the best and preparing for the worst.33 An important aspect of promoting prognostic awareness should include a discussion of possible trajectories: the best, the worst, and the most common, including not only mortality but also changes in function.34 Example statements include: “Are there other hopes that you have? We have discussed what you are hoping for. May we talk about what if our hopes aren’t realized?” “I am hoping with you that the treatment works, and I am worried that it may not. If it doesn’t work as we would like, I will still continue to work with you to ensure that you are well taken care of.”
I Wish …
This tool is a means to promote prognostic awareness while cultivating a partnership and alignment with the patient and/or family. I Wish28,35 statements are an expression of empathy and an implied acknowledgment that the likely outcome is undesirable and emotionally difficult. I Wish statements also acknowledge implicitly that the healthcare provider is limited in his or her control of the outcome. This tool has the ability to temporarily suspend the physician from the medical expert role, so that the healthcare provider and patient can sit together in their sadness at the likely unwanted outcome. For example, “I wish I had more answers for you as to why your body is not responding to the treatment in the way we had hoped.”
Many roadmaps capture the elements of shared decision-making and patient-centered communication. For some learners, mnemonics and roadmaps can be helpful tools for organizing discussions with patients, whether one on one or in a family meeting. For others, the tools associated with the other four elements of patient-centered communication will be sufficient to achieve shared decision-making. Certain mnemonics may be used as potential tools for achieving shared decision-making, including REMAP, VALUE, and SPIKES. REMAP is the mnemonic most focused on shared decision-making. The following examples illustrate its use. SPIKES and VALUE are other mnemonics that may be helpful to learners as guidelines for complex conversations.
R = REFRAME. This is a statement that signals a disruption of the current clinical status, often following the delivery of serious news.
“Given this news, it seems like a good time to talk about what to do now”
“We are in a different place now.”
E = EXPECT EMOTION AND EMPATHIZE. A learner can use the tools associated with Attending to Emotion at this point such as Active Listening, Tell Me More, and NURSE statements.
“I can see how hard this is to hear. Is it ok for us to talk about what it means?”
M = MAP THE FUTURE. The physician may outline the different trajectories and elicit the patient’s concerns, worries, and goals. This may be a place to use the skills in Managing Uncertainty to ensure a mutual understanding of the likely illness trajectory.
“Given this situation, what is most important to you?”
A = ALIGN WITH THE PATIENT’S VALUES. This is an attempt to reconfigure a new orientation to living from the patient given his or her new and oftentimes undesired clinical context.
“As I listen to you, it sounds like the most important things are being at home with your family and avoiding future hospitalizations.”
P = PLAN MEDICAL TREATMENTS THAT MATCH PATIENT VALUES. A healthcare provider may offer possible directions that match the patient’s articulated goals while underscoring continued involvement and nonabandonment.
“Here’s what I can do now that will help you do those important things. What do you think about that?”
VALUE is a mnemonic developed to improve communication between physicians and families of critically ill patients in the ICU.21 VALUE stands for Value the comments made by the family, Acknowledge family emotions, Listen, Understand the patient as a person, and Elicit family questions. SPIKES is a mnemonic developed for delivering bad news. It can be applied to facilitating family meetings and goals of care discussions with some modifications.20 SPIKES is a six-step protocol that includes Setting up the interview, assessing the patient’s Perception, obtaining the patient’s Invitation, giving Knowledge and information to the patient, addressing the patient’s Emotion and empathic responses, and Summarizing.
Interventions to promote communication skills development are largely successful in transferring new skills to learners.38 Certain teaching strategies have proven more effective than others. Teaching strategies engaged in active learning, namely those involving practice (e.g., simulated patient experience), as well as teaching strategies that include feedback in response to skills training, have consistently demonstrated effectiveness at promoting skill development. On the other hand, those engaged in passive learning, namely training involving instruction (e.g., lectures), are most effective when used as supportive strategies.38 Components of successful communication skills training programs include the following principals:
♦ Lecture-style methods alone are ineffective.
♦ Adult learning principles should be used.
♦ Teaching must include skills practice.
♦ Teaching must attend to learner attitudes and emotions.
♦ The learning environment should integrate knowledge, skills, and attitudes.
♦ Reenforcement is critical for the learning process.39
Communication skills training programs highlighted in the literature include the OncoTalk39 and GeriTalk40 programs that are comprised of multiday, small-group interventions. These skills training programs were designed around the aforementioned key educational principals and include a multimodal approach to skills training comprised of instruction, practice, and feedback.
Lectures and written handouts are useful teaching strategies when used as part of a multimodal training program. In our experience, the use of lectures and handouts provide an avenue to introduce the fundamental communication skills concepts that can be built on as more advanced teaching strategies are employed. For example, a training session to develop the communication skill of attending to emotion should begin with a lecture introducing the NURSE mnemonic tool and a handout with examples of NURSE statements, followed by an opportunity for the learner to practice these skills. The use of instructional teaching strategies increases the learner’s knowledge of different communication skills and use in different contexts.41
Modeling is another form of communication instruction and refers to learning by watching and imitating others.42 For communication training, modeling occurs when a expert performs a particular communication skill for the benefit of teaching learners a specific behavior. This can occur in a live or videotaped setting utilizing real or simulated patients.42,43 For this strategy to be successful, it is imperative to identify the specific skill that is being modeled prior to initiating the interview. The learner should be instructed to observe not only what is said and how it is delivered but also the impact of the delivered skill on the patient—including both verbal and emotional responses. For example, when using modeling at the bedside that will likely include breaking bad news, the learner could be instructed to specifically observe for emotive statements used by the physician in response to patient distress. After leaving the patient’s room, the physician and learner should discuss the encounter, including the physician’s actions, the patient’s response, and suggestions for alternative approaches. The modeling teaching strategy, much like the other instructional techniques described here, has not proven effective when used in isolation but is successful in transferring skills to learners when combined with other techniques.42
Practice teaching strategies are simulated scenarios in which participants act out situations to allow learners to practice specific communication skills.42 Included in this category are simulated patient experience and role play.
The benefits of these strategies include providing a safe learning environment for learners to experiment with new skills, allowing opportunity for repetition, feedback, and replay.41 For the palliative care learner, this safe learning environment is essential when developing skills to lead family meetings and goals of care discussion, as these conversations can be emotionally charged for both the patient and the learner. Additionally, these learning strategies provide exposure to multiple scenarios less frequently encountered during clinical practice, such as discussions regarding artificial nutrition and hydration and requests for hastened death. Successful role play and simulated patient encounters require facilitator training to provide a safe training environment and a culture of effective feedback.41 Lack of learner engagement due to performance anxiety can be common with both approaches.41,44
Simulated patient experience refers to the use of a trained actor portraying a medical scenario conducted for purely educational purposes.44 Simulated patients are different from standardized patients. Definitions vary in the literature, but, in general, a standardized patient provides consistent verbal, behavioral, and physical responses to the stimulus provided by the learner.44 Standardized patients are best utilized for summative evaluation. Comparatively, simulated patients deliver a less structured performance, allowing variability of responses and behaviors in response to learner performance, thereby providing more flexibility during communication skills training.
In our experience, simulated patient training is best performed in a small-group setting, comprised of multiple learners, a trained facilitator, and a trained simulated patient. Learners should have the opportunity to familiarize themselves with the case and ask question prior to initiation of the simulated patient experience. The room should be organized such that learner and simulated patient can engage in a physician–patient type encounter (i.e., two chairs facing each other or a hospital bed and chair) with the observing learners and facilitator sitting within close range to see and hear the interaction. The observing learners and facilitator should be observing not only what is said but body language, facial expressions, and emotions. The facilitator can stop the simulation if the learner becomes “stuck” or at other opportune times to provide feedback and engage the observing learners in group discussion about what went well and alternate approaches to the simulation. This provides an opportunity to allow the learner to “retry” the simulation to incorporate the feedback.
A successful simulated patient experience hinges on creating a learning environment that feels authentic and fosters successes for learners, so they remain engaged and willing to participate. Learner resistance is common and is often due to performance anxiety. It can be alleviated by creating a safe learning environment, which includes a semiprivate, quiet setting without much distraction or observation from others outside the group.41 The importance of the “time-out” cannot be underrated, as this not only provides security to the learner but also provides an opportunity for immediate feedback and group discussion. Finally, simulated patients need adequate training to foster success for learners. Simulated patient training can be a complex and time-consuming endeavor and often requires help from the leadership of a simulation center.
Role-play refers to the use of the learners as both patient and physician during a simulated scenario, alternating roles with other learners.41 There are many similarities between role play and simulated patients. The same elements described previously that are pertinent for successful simulation apply to role play (excluding the training of the simulated patient). Additionally, the same setup and ground rules apply as well.
Compared to simulated patients, role play provides the benefit of allowing the learner to experience the perspective of the patient during the simulated encounter.41 Without the constraint of the simulated patient cost and training, role play allows for more flexible and inexpensive skills education that can be beneficial to smaller or impromptu training sessions. However, learners often report that role play with other learners feels “unnatural,” and success of this training strategy relies heavily on the learner’s willingness to play the role of the patient authentically.41
Feedback refers to providing learners with information describing their performance with the intent of guiding future performance.45 Feedback is endorsed by all major medical education organizations (Liaison Committee on Medical Education, ACGME, Alliance for Clinical Education, American Medical Association) as essential to physician training. In general, it is an informed, nonevaluative, objective appraisal of performance intended to improve clinical skills, in this case communication.45 Feedback helps learners identify areas of high performance and gaps between their performance and the standard. The literature on formative feedback in medical education shows that it enhances student satisfaction as well as improves clinical performance, patient satisfaction, and self-assessment accuracy.46,47,48,49,50 In the absence of explicit feedback, learners “infer” about their abilities, often incorrectly.
Self-assessment is an important element of feedback particularly related to communication training. Self-assessment comprises learners’ self-evaluation of their abilities against perceived norms. Although there are many challenges to self-assessment and little evidence that it changes clinical practice, it provides a window into a learner’s insight and is more likely to generate learning goals than feedback provided by an observer.51,52 Asking for learning goals requires students to think about their own developmental stage and to bring effort to deliberate improvement.53 Finally, the opportunity for students to reflect on their experience and to enhance their self-assessment improves their ability for self-directed learning in the future.
The literature on feedback describes a mismatch in perceptions of its utility by students and teachers.54,55,56 Both learners and faculty value feedback but are often ambivalent about receiving or giving it.46,57,58 Faculty report feeling ill equipped to provide it due to lack of training, inadequate time, fear of retribution, and the underlying belief that feedback does not necessarily change behavior.59,60
Feedback becomes more challenging when the focus is on communication. All physicians come to training with ingrained habits related to communication from years of interacting with friends, family, and other professionals. Learners may perceive feedback as a personal attack on a communication style as opposed to a comment on a learned skill.61 Moreover, learners who have integrated habits from watching previous role models may feel that feedback on their style denigrates the skills of a prior respected role model. Many learners and educators see communication skills as innate and immutable rather than as skills that can be identified and improved.
Despite its challenges, feedback regarding communication skills is a necessity for learners and an attainable skill for educators.62,63 Much has been written on how to improve the efficacy of feedback. Here we highlight a few of the essential elements compiled from multiple sources:45,64,65,66,67,68
Establish an Appropriate Climate
First, educators should find an appropriate location and time for providing feedback. A private, quiet space where the learner does not have competing responsibilities is preferable. An appropriate climate is one in which feedback is an intrinsic part of the supervisory role. The educator should explicitly inform learners that feedback is expected and clearly state its purpose, timing (preferably immediately following an encounter), and likely mode of delivery (e.g. checklist, verbal feedback, etc).
Set Specific Goals
Goals for the communication task should be specific enough that they are manageable in scope (ideally focusing on only one or two skills) and achievable. Moreover, goals should be learner-centered, such that the choice of a communication goal is negotiated and mutually agreed upon by the learner and teacher.
Utilize Learner Self-Assessment
Prior to an educational activity or encounter, educators should ask the learner to identify his or her likely communication challenges to help establish specific shared goals. After the encounter, educators again should ask the learner to identify his or her successes and challenges with achieving the desired goal. This will allow the educator to gain insight into the learner’s self-perception and help guide further learning activities. Finally, the opportunity for students to reflect on their experience and to hear their self-assessment in juxtaposition with the comments of faculty can improve their ability to evaluate their own performance. For example, prior to a family meeting with discordant family members (mother and son) of a critically ill patient, a learner may reveal his discomfort with emotional conflict. The mutually agreed-upon goal for feedback could be attending to emotion. After the encounter, the learner reflects that he was able to name the son’s frustration but did not know how to handle the mother’s tears. The educator may consider a role-play in the future to practice attending to sadness.
Feedback should be targeted to the behavior related to the specific learning goal that was identified before the encounter. It is helpful for the educator to convey how the learner’s skill affected the interaction positively to (a) increase the learner’s awareness of that specific skill and (b) increase the frequency with which the learner uses it. When a learner has achieved the identified learning goal of attending to emotion and the patient reengages eye contact, the feedback may be: “You listened to the patient and used an empathic statement, when she seemed sad. I noticed that after your empathic statement, the patient lifted her head and looked at you again.”
The educator should also describe the gap between what was observed and what was expected, related to a specific learning goal that was not achieved during an encounter. For example, the learning goal may be to set up the room for a difficult conversation with a family of an ill patient. However, the conversation with the family was interrupted multiple times by the learner’s phone ringing. The feedback may be: “I noticed your phone rang frequently and interrupted you when you were talking with the family. Please silence it when you are in a patient or family interview to minimize distractions and ensure that the family feels heard.”
Offer Suggestions for Improvement
Feedback is not complete without an action plan to continue to improve performance. When possible, educators should build upon the skills that the learner employs competently with deliberate practice (i.e., repeated goal-setting, practice, feedback) and subsequent further practice while offering more challenges to the skill. For example, a learner received feedback that her empathic response helped to reengage a tearful patient after breaking bad news. An action plan may be to try empathic statements in other contexts, such as code discussions or goals of care discussions, with planned feedback on this learning goal for the rest of the week.
Be ready for a Learner’s Emotional Reaction to Feedback
Learners may have strong emotional reactions to receiving feedback that is not aligned with their self-perceptions regarding their communication skills. Be ready. An empathic response from the teacher may help the learner absorb the need for more practice.
Strategies for Providing Formative Feedback at the Bedside
In the clinical setting, feedback is often overlooked and forgotten—partly due to time constraints and poor training in how to provide effective and efficient feedback.64 Checklists are the preferred method for providing feedback in the clinical setting. Checklists are a frequently used and effective method of providing feedback during communication skills training. They consist of a list of specific communication skills or behaviors that allow an observer to record the presence or absence of the skill/behavior being performed.69 A versatile tool, checklists can be used to provide feedback in a variety of settings, including direct observation of interactions with real patients or simulated patient encounters and videotaped real or simulated encounters.70
A variety of published checklists is available that are specific for communication skills training, including the Kalamazoo Consensus Statement,71 Calgary-Cambridge Observation guide,72 and SEGUE Framework.73 The American Academy of Hospice and Palliative Medicine recommends the SECURE Framework as the tool of choice for assessing communication skills for HPM fellows.74 This checklist was adapted from the SEGUE framework for use in HPM and highlights specific communication tasks and observable behaviors essential to a communication encounter (Table 43.2). While the SEGUE framework has been validated, the SECURE has not.73,74
Table 43.2 SEGUE and SECURE Frameworks Compared
SECURE—Palliative Care Framework
Set the Stage
Set the Stage
Understand the Patient’s Perspective
Understand Patient and Family Perspective
Respond to Emotions
While checklists can provide a useful tool for providing formative feedback at the bedside, there are also inherent challenges in their use. The efficacy of the checklist in promoting skills development largely depends on the users’ (both observer and learner) engagement with the tool. Without adequate buy-in or proper training to utilize the tool, the benefits of using this tool may not be realized.69 The SPIKES protocol for breaking bad news is another tool that can be used to guide the provision of feedback.64 The elements of effective feedback listed here can be transposed onto the elements of SPIKES, as shown in Table 43.3.
Table 43.3 SPIKES Protocol for Breaking Bad News, Adapted for Giving Feedback
Breaking Bad News
S = Set up the interview
Private, safe environment
P = assess Perception
Diagnose the learner, self-assessment
I = obtain Invitation
Warning shot: Can I give you some feedback on what I observed?
K = give Knowledge and information to the patient
Describe the behavior
E = address patients’ Emotions with Empathic responses
Address emotions; use empathy
S = Strategize and Summarize
Make an action plan about what the learner will think about next time and follow-up
Communication in Hospice and Palliative Medicine Practice
Facilitations of family meetings are frequently required of HPM physicians and are often triggered by serious changes in a patient’s clinical status. Family meetings provide an opportunity to share medical information, reach consensus on treatment plans, facilitate advance care planning, resolve conflict, clarify roles, and attend to anticipatory grief. The crux of any family meeting should be patient- and family-centered communication and eventually result in shared decision-making based on patient values. The tools necessary to facilitate a family meeting effectively are those already described in the proposed conceptual model and do not require new or different skills.
Facilitation of family meetings, however, can be a demanding context within which learners try to employ their communication techniques. The elements and skills described in the conceptual model need to be applied not just to the patient but to multiple family members who have their own reactions and perspectives. Educators should normalize the inherent challenges to facilitating family meetings so that learners do not feel overwhelmed by their complexity.
A few unique elements are integral to facilitating family meetings and are not explicitly stated in the conceptual model. First, family meetings often are for patients with complex medical issues that have required multiple consultants. A preparatory pre-meeting is essential and should determine who should be present at the meeting (e.g., whether the patient has medical decision-making capacity and, if not, who the legal decision-maker is; which family members would like to participate, which medical teams should be represented at the meeting, etc.) and confirm medical facts, including prognosis, with the other members of the medical team to ensure that accurate information is conveyed to the family.
Second, family members often have different understandings and perspectives of the clinical situation and perhaps even the patient’s wishes and values, which sometimes may lead to conflict. Learners need to use various tools from such elements as “assessing patient perspective” and “attending to emotion” to clarify family members’ differing interpretations, handle conflict, and build consensus. This is further complicated when patients fully lack decision-making capacity. The HPM physician needs to describe the goal of substituted decision-making (i.e., to speak on behalf of the patient by making choices that the patient would make if he or she could speak). Learners should be encouraged to use their toolbox of skills to elicit from each family member what they believe the patient would choose if he or she could speak in an effort to build consensus.
Occasionally, conflict exists between family members and the medical teams. Conflict can usually be attributed to misunderstandings of information or personal factors. The misunderstanding can be about the diagnosis, prognosis, underlying causes, or conversations that may have occurred. Personal factors of distrust, grief, guilt, or secondary gain may be at work. Occasionally, there is a genuine value conflict over either goals or the worth of a treatment. This may be couched in terms of religion, belief in miracles, or the value of life. In general, it is useful first to explicitly identify that there seems to be conflict and then seek to understand the various points of view. In this context, educators should help learners acknowledge that conflict negotiation between family members and between family members and medical teams is considered a higher level communication skill that will take practice.
Third, oftentimes, family members will ask the physician not to tell the patient the diagnosis or other important information. While it is the physician’s legal obligation to obtain informed consent from the patient, a therapeutic relationship also requires a congenial alliance with the family. Rather than confronting their request with “I have to tell the patient,” we recommend the learners assess the family perspective by asking them why they do not want you to tell the patient, what it is they are afraid will be said, and what their experience has been with medical information. Inquire whether there is a personal, cultural, or religious context to their concern. Learners may need practice in going to the patient with family members to ask how much the patient wants to know about his or her health and what questions he or she might have.
E-Health and Telemedicine
As technology changes, a new challenge is how best to foster good communication techniques when not physically present with the patient and family. E-health, defined as “health services and information delivered or enhanced through the Internet and related technologies”75 and telemedicine, defined as the “the use of medical information exchanged from one site to another via electronic communication to improve a patient’s clinical health status”76 are two emerging means of providing palliative care. Although there is a paucity of data to provide direction for teaching communication skills in such settings, new technology does not necessarily require new communication skills. The same approaches used in face-to-face encounters can be used on the telephone, via text or email, or in a telemedicine unit with video capabilities. However, learners must be aware that the absence of nonverbal cues from the physician and the patient and/or family can lead to misunderstandings and miscommunication. Moreover, tools such as compassionate silence may feel more awkward when on the phone or via telemedicine. Verbal statements of empathy and compassion are likely to be more effective in this context. This is an area that deserves more research to determine specific communication strategies, as e-health and telemedicine become more prevalent in palliative medicine.
In this chapter, a conceptual model of patient- and family-centered communication has been detailed, as well as various approaches to teaching these skills to physician learners who provide care to patients with serious and advanced illness. As shared decision-making is often the crux of most discussions with such patients and their families, the elements and tools described here can be employed for all types of common HPM discussion (e.g., breaking bad news, goals of care discussions) in a variety of contexts (e.g., one-on-one patient encounters, family meetings, and e-health), with the understanding that certain discussions will require more of an emphasis on a particular element of the model than others. Communication skills education should include a multimodal approach comprised of instruction, practice, and effective feedback. Quality communication in HPM patient encounters is often complicated and emotionally charged, such that it may feel unattainable to learners. Thus it is important for teachers to normalize the challenges of acquiring new communication skills and help learners build upon their successes. For learners and educators, remember that quality patient-centered communication is a learnable skill with deliberate practice over time. We hope the tools described in this chapter are helpful in planning for and facilitating communication training for new HPM physicians.
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