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Doctor–patient communication critical to patient care, expectations often not met
Good communication skills can be learned and should be learned by all physicians.
A cancer diagnosis is devastating for patients, but inadequate communication with their physicians can be almost as devastating as the diagnosis itself.
Doctor–patient communication is a crucial component of all medical specialties. Cancer, along with other life-threatening diseases, often carries a stigma of painful death. Patients without the proper knowledge are affected by more than just the physical pain – they must also deal with emotional and mental effects of facing the unknown.
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Previous studies have shown that patients with terminal illnesses benefit from good communication with their physicians. However, the quality of the communication they actually receive is nowhere near the ideal quality of communication.
“We assume that doctors just have these skills, when actually they need to be learned,” Elizabeth Rider, MD, assistant professor of pediatrics at Harvard Medical School, said in an interview. “These are a set of skills that can be learned. Studies have shown that 71% of medical malpractice suits are the result of communication problems. It’s a tremendous advantage for physicians to learn these skills, both for themselves and for their patients.”
The lower risk for malpractice complaints is not the only benefit of good communication skills. In oncology, good physician communication has resulted in improved quality of life and decreased distress for the patients. It also has led to reduced physician fatigue, Rider said.
There are ample evidence-based articles demonstrating that good communication is associated with greater quality of care, greater symptom improvement and better patient and physician satisfaction, said Rider, director of programs for communication skills at the John D. Stoeckle Center for Primary Care Innovation of Massachusetts General Hospital in Boston.
Good communication also improves efficiency of care and contributes to a patient’s decision to remain under a particular physician’s care.
Challenging skills
The doctor–patient relationship is important to patients, who often view their oncologists as the ultimate source of both information and support. Patients do not view their oncologists simply as a provider of a cure but also a provider of care. All patients seek a trusting relationship with their physicians.
“These are challenging skills for oncologists because very often doctors do not know what to say,” Walter Baile, MD, professor of behavioral science and psychiatry at the University of Texas M.D. Anderson Cancer Center and director of I*Care, M.D. Anderson’s program on Interpersonal Communication and Relationship Enhancement, said in an interview. “It makes them uncomfortable to have to tell very bad news, for example, especially since they have their own feelings also. Doctors need a strategy to deal with their own feelings and manage them so they don’t affect the patients.”
In a survey of more than 500 oncologists, 50% admitted to having feelings of failure, guilt or disappointment when anticancer treatments fail patients, according to Baile. This relationship is stressful to physicians and patients.
In communication courses, Baile and colleagues teach physicians not only to recognize patient emotions but also how to deal with their own emotions. It is difficult to discuss the treatment options and future plans when emotions are conflicting, said Baile.
Managing feelings is especially important for physicians because patients often reflect the feelings and attitudes exhibited by their physicians. As oncologists, one of the most difficult things to do is to support patients with terminal disease, said Bob Arnold, MD, professor of medicine at the University of Pittsburgh School of Medicine and director of the university’s Institute for Doctor-Patient Communication.
Researchers reported in the Journal of Clinical Oncology that patients’ anxiety is decreased after watching a video in which physicians offered even just 40 seconds of empathic behavior, Arnold said.
“Patients often reflect the emotions of their doctors,” Arnold said in an interview. “Because of this, the most important thing is for doctors to be aware of their emotions. It is OK to use emotions to be a better doctor. Doctors should actually be clearer about their emotions.”
Teaching the doctors
The concept of communication as a set of skills that can be learned is not typically part of a physician’s repertoire, Baile said. There are modalities that represent techniques for acquiring communication competency with difficult situations such as family conflicts, giving bad news and making decisions.
The quality of physician communication skills is starting to be addressed with more diligence. To be accredited, residency programs and medical schools have to teach and evaluate communication skills, Rider said. These are effective skills that can be learned, and they are being taught to a greater extent in medical schools.
“Doctors who have been out of school for more than 10 years haven’t been taught the communication methods that newer physicians are being taught, such as teaching, self-reflection and self-awareness,” Rider said. “Some older physicians are not aware of the evidence-based literature on the positive effects of good communication. They have a tremendous amount of experience to go on.”
In a report published in the Archives of Internal Medicine, Baile, Arnold and colleagues discussed the success with their Oncotalk program, which is a residential communication skills workshop for medical oncology fellows. The four-day workshop includes overviews, simulated patients for skills practice sessions and then reflective discussions.
When evaluating the results of the program, the researchers found that after the workshop, the participants demonstrated significant skill acquisition in communication involving giving bad news and transitions to palliative care.
The efficacy of teaching models is not specific to fellows. Rider has seen great success with the Program to Enhance Relational and Communication Skills (PERCS) program, a program developed by clinicians and educators at Children’s Hospital of Boston, Harvard Medical School and the Education Development Center. Rider is the course director for “Difficult Conversations in Healthcare: Pedagogy and Practice,” a PERCS course, which provides faculty training for health care professionals responsible for teaching communication skills in their own institutions.
PERCS offers full-day courses in a range of areas including intensive care, anesthesiology, primary care pediatrics, medical error and other areas, designed to refine skills of engaging in difficult conversations and other communication skills for physicians, social workers, nurses and other health care professionals. The PERCS faculty training course Rider directs has drawn participants from around the world.
“It’s really an international requirement that physicians learn communication skills,” Rider said. “It’s important that communication education is ongoing throughout physicians’ careers. It’s helpful to find a group of physicians skilled in communication and to provide an atmosphere to teach these skills for faculty development.”
The future of communication
As more organizations become aware of the importance of physician communication skills, competency in these skills becomes a standard that physicians must attain. In addition to the best technical and medical treatment possible, patients also want a supportive environment and a medical team that cares about them, Baile said.
“Being a caring person is not incompatible with being a good physician,” Baile said. “We can’t make bad news better, but we do need to be thoughtful in what we say to the patients. Focusing on only curing the disease may not lead to professional satisfaction, but having the satisfaction of supporting a patient through their illness has a lot of gratification.”
Baile and Rider both stressed that cancer is a journey for both patients and physicians, and physicians should realize that the journey does not end when technology and science fail. The outcome may not change, but patients want, need and deserve a continuity of care until the end.
Quality of care starts with good communication, and the most important impetus of good communication is, of course, the patient.
“Doctors should consider what the patients’ goals are, what they want to talk about and what’s important to the patients,” Arnold said. “Often, we don’t talk about issues because we think the patients don’t want to talk about them, when they really do. Make sure you ask your patients ‘what are you worried about? What are you thinking about?’ The most important thing that doctors can do is be open to the questions.” – by Emily Shafer