Do pediatric hematology/oncology (PHO) fellows receive communication training?

PURPOSE

The Accreditation Council for Graduate Medical Education (ACGME) has established communication as a core competency for physicians in training. However, data suggest that most pediatric residents perceive inadequate training in the delivery of bad news and the majority of former trainees in pediatric oncology received no formal training in the delivery of bad news during fellowship. The study examines communication training in ACGME accredited US pediatric hematology-oncology (PHO) fellowship programs.

METHODS

An online survey was distributed to 315 PHO fellows in training via the American Society of Pediatric Hematology/Oncology (ASPHO) fellow email registry. Each fellow received an initial request to participate and 2 reminders, while participation was encouraged through a random incentive drawing.

RESULTS

One hundred and ten fellows (35%) responded. Eighty percent of respondents perceived communication training to be important to fellow education, however only 32% reported receiving communication training (other than direct observation). The most common reported teaching method of fellowship communication training was formal lecture (42%). Twenty-three percent of respondents reported neither communication training nor frequent feedback on their communication skills from faculty observation. This same group was the least satisfied with their programs' approach to teaching communication (P < 0.001).

CONCLUSIONS

There is limited communication training in PHO fellowships despite ACGME requirements and fellows' interest in this training. Didactic learning remains the most frequently described training method, yet educational theory identifies the limitation of didactic lectures alone. Communication training employing novel teaching methods and emphasizing communication challenges identified by fellows should be developed and evaluated.

Nonverbal accommodation in health care communication

This exploratory study examined patterns of nonverbal accommodation within health care interactions and investigated the impact of communication skills training and gender concordance on nonverbal accommodation behavior. The Nonverbal Accommodation Analysis System (NAAS) was used to code the nonverbal behavior of physicians and patients within 45 oncology consultations. Cases were then placed in one of seven categories based on patterns of accommodation observed across the interaction. Results indicated that across all NAAS behavior categories, physician-patient interactions were most frequently categorized as joint convergence, followed closely by asymmetrical-patient convergence. Among paraverbal behaviors, talk time, interruption, and pausing were most frequently characterized by joint convergence. Among nonverbal behaviors, eye contact, laughing, and gesturing were most frequently categorized as asymmetrical-physician convergence. Differences were predominantly nonsignificant in terms of accommodation behavior between pre- and post-communication skills training interactions. Only gesturing proved significant, with post-communication skills training interactions more likely to be categorized as joint convergence or asymmetrical-physician convergence. No differences in accommodation were noted between gender-concordant and nonconcordant interactions. The importance of accommodation behavior in health care communication is considered from a patient-centered care perspective.

Development and preliminary evaluation of a training workshop for the collection of patient-reported outcome (PRO) interview data by research support staff

This paper describes the development and initial evaluation of a didactic curriculum to prepare research support staff with the core knowledge and skills required to collect patient-reported outcomes (PROs) via interviews. Research support staff members (N = 77) were recruited for eight separate workshops, each consisting of a didactic presentation followed by role-play scenarios with trained actors depicting common scenarios they may encounter as part of patient interaction. Trainees were observed and received feedback on their performance from trained facilitators and peers. In comparison to their pre-training assessment, trainees showed significant improvement in their confidence to conduct a research interview, handle a distressed participant, manage a wandering interview, ask participants sensitive questions, and handle irritated patients. Training research support staff in the effective collection of PROs via patient interviews can improve the confidence of these individuals in interacting with patients, which can ultimately lead to increased accuracy of data collection.

Teaching patients how to talk with biomedical providers about their complementary and alternative medicine use

OBJECTIVE

The goal was to examine the feasibility and impact of a face-to-face communication skills training intervention based on a current public health campaign to encourage patients to talk about complementary and alternative medicine (CAM) with their biomedical health providers.

METHODS

Current CAM users were invited to complete a survey about current/past CAM use and communication with biomedical providers before beginning a communication skills training workshop. In the 6-month period following the training, participants were asked to record information on any CAM conversations with those providers.

RESULTS

Of the 38 participants who received training, 32 finished the entire study. Over half of those participants reported discussing CAM in post-training visits with biomedical providers. Participants initiated the conversation in most cases, and were more likely to disclose CAM use than they were to ask questions about CAM. Participants who talked about CAM were significantly more likely to perceive CAM as relevant to their visit, compared with individuals who did not talk about CAM.

CONCLUSIONS

Participants positively evaluated this patient communication workshop. Consistent with previous research, most CAM conversations were patient-initiated.

PRACTICE IMPLICATIONS

These findings reinforce the importance of patient education interventions for improving patient-provider communication in general, and CAM communication specifically.

Toward a greater understanding of breast cancer patients' decisions to discuss cancer-related internet information with their doctors: an exploratory study

OBJECTIVE

To investigate differences between breast cancer patients who do and do not discuss cancer-related internet information (CRII) with their doctors.

METHODS

70 breast cancer patients completed questionnaires regarding internet use, discussions about CRII, and the doctor-patient relationship.

RESULTS

No significant differences were noted across patient, disease, or visit characteristics, or physician reliance between those who intended to discuss CRII and those who did not. Patients who intended to discuss CRII rated significantly higher pre-consultation anxiety levels. No significant differences in satisfaction, anxiety reduction, or trust in physician were found between patients who had discussed and those who had not. Patients' reasons for discussing or not discussing are detailed.

CONCLUSION

Factors influencing patients' decisions to discuss CRII are complex and differ from those identified as leading patients to seek internet information. Future research about internet discussions should investigate the impact of patients' preferred role in treatment, the doctor-patient relationship, anxiety level, attributes of CRII, and physician trust.

PRACTICE IMPLICATIONS

Understanding the characteristics of patients who do and do not discuss internet information is important given the impact internet information has on healthcare communication and the doctor-patient relationship, including the development of interventions aimed at improving such interactions.

Testing the utility of a cancer clinical trial specific Question Prompt List (QPL-CT) during oncology consultations

OBJECTIVE

A Question Prompt List (QPL) is a proven, simple intervention to aid patients to be active participants in consultations with their physicians by asking questions. We aimed to further develop and test the efficacy of a targeted QPL for clinical trials (QPL-CT).

METHODS

Breast, Lung and Genitourinary cancer patients who were facing a discussion about a therapeutic clinical trial completed short pre- and post-consultation questionnaires and used the QPL-CT in their discussions with their oncologists.

RESULTS

30 participants were recruited from 6 oncologists. All QPL-CT questions were selected by at least one-third of participants. Participants mostly wanted and asked questions about personal trial benefit. Oncologists provided information about personal benefit to varying degrees, thus patients did not ask some questions. Patients were still left with some unasked and unanswered questions.

CONCLUSION

The QPL-CT has potential as a simple, inexpensive intervention to aid such communication. Further investigation is needed to demonstrate the efficacy of the QPL-CT in improving cancer patient outcomes.

PRACTICE IMPLICATIONS

These preliminary finding suggest that important areas of clinical trials are overlooked in clinical consultations. The QPL-CT may be an effective method to encourage oncologists to endorse patient question asking about clinical trials and prompt patient questions.

A practitioner's guide to interpersonal communication theory: an overview and exploration of selected theories

OBJECTIVE

To provide a brief overview of selected interpersonal theories and models, and to present examples of their use in healthcare communication research.

RESULTS

Nine interpersonal communication theories and their application to healthcare communication are discussed.

CONCLUSION

As healthcare communication interactions often occur at an interpersonal level, familiarity with theories of interpersonal communication may reinforce existing best practices and lead to the development of novel communication approaches with patients.

PRACTICE IMPLICATIONS

This article serves as an introductory primer to theories of interpersonal communication that have been or could be applied to healthcare communication research. Understanding key constructs and general formulations of these theories may provide practitioners with additional theoretical frameworks to use when interacting with patients.

Exposure to and intention to discuss cancer-related internet information among patients with breast cancer

PURPOSE

Previous studies have reported a significant number of patients with breast cancer seek cancer-related information from the Internet. Most studies have asked whether a patient has ever read Internet information since her diagnosis. The purpose of this study was to assess the frequency with which patients with breast cancer come to physician appointments having recently read and intending to discuss cancer-related information from the Internet.

PATIENTS AND METHODS

We asked 558 patients with breast cancer who were waiting to see their physicians about their experiences reading cancer-related information from the Internet and their intent to discuss the information in their current visit.

RESULTS

Fifteen percent reported reading cancer-related Internet information in the past month. Patients who had read such information in the past month were younger, had been diagnosed more recently, and were more likely to be attending a new visit. Of those who had read in the past month, 45% reported intending to discuss what they had read with their physician. Nineteen percent of patients reported having ever read breast cancer-related Internet information since their diagnosis.

CONCLUSION

The proportion of patients with breast cancer planning to discuss Internet information during their current physician visit was relatively small. Few characteristics were associated with recent Internet use or intent to discuss.

Communication skills training for oncology professionals

PURPOSE

To provide a state-of-the-art review of communication skills training (CST) that will guide the establishment of a universal curriculum for fellows of all cancer specialties undertaking training as oncology professionals today.

METHODS

Extensive literature review including meta-analyses of trials, conceptual models, techniques, and potential curricula provides evidence for the development of an appropriate curriculum and CST approach. Examples from the Memorial Sloan-Kettering Cancer Center CST program are incorporated.

RESULTS

A core curriculum embraces CST modules in breaking bad news and discussing unanticipated adverse events, discussing prognosis, reaching a shared treatment decision, responding to difficult emotions, coping with survivorship, running a family meeting, and transitioning to palliative care and end of life. Achievable outcomes are growth in clinician's self-efficacy, uptake of new communication strategies and skills, and transfer of these strategies and skills into the clinic. Outcomes impacting patient satisfaction, improved adaptation, and enhanced quality of life are still lacking.

CONCLUSION

Future communication challenges include genetic risk communication, concepts like watchful waiting, cumulative radiation risk, late effects of treatment, discussing Internet information and unproven therapies, phase I trial enrollment, and working as a multidisciplinary team. Patient benefits, such as increased treatment adherence and enhanced adaptation, need to be demonstrated from CST.

Patient preferences for shared decisions: a systematic review

OBJECTIVES

Empirical literature on patient decision role preferences regarding treatment and screening was reviewed to summarize patients' role preferences across measures, time and patient population.

METHODS

Five databases were searched from January 1980 to December 2007 (1980-2007 Ovid MEDLINE, Cochrane Database of Systematic Reviews, PsychInfo, Web of Science and PubMed (2005-2007)). Eligible studies measured patient decision role preferences, described measures, presented findings as percentages or mean scores and were published in English from any country. Studies were compared by patient population, time of publication, and measure.

RESULTS

115 studies were eligible. The majority of patients preferred sharing decisions with physicians in 63% of the studies. A time trend appeared. The majority of respondents preferred sharing decision roles in 71% of the studies from 2000 and later, compared to 50% of studies before 2000. Measures themselves, in addition to patient population, influenced the preferred decision roles reported.

CONCLUSION

Findings appear to vary with the measure of preferred decision making used, time of the publication and characteristics of the population.

PRACTICE IMPLICATIONS

The role preference measure itself must be considered when interpreting patient responses to a measure or question about a patient's preference for decision roles.

Developing and implementing an advanced communication training program in oncology at a comprehensive cancer center

Cancer patients report significant levels of unmet needs in the realm of communication. Communication skills training programs have been shown to improve clinical communication. However, advanced communication skills training programs in oncology have lacked institutional integration, and thus have not attended to institutional norms and cultures that may counteract explicit communication skills training. We developed and implemented an advanced communication skills training program made up of nine teaching modules for faculty, fellows, and residents. Training included didactic and experiential small group work. Self-efficacy and behavior change were assessed for individual participants. Since 2006, 515 clinicians have participated in this training program. Participants have shown significant gains in self-efficacy regarding communicating with patients in various contexts. Our initial work in this area demonstrates the implementation of such a program at a major cancer center to be feasible, to be acceptable, and to have a significant impact on participants' self-efficacy.

The Nonverbal Accommodation Analysis System (NAAS): initial application and evaluation

OBJECTIVE

To describe the development, initial application, and evaluation of the Nonverbal Accommodation Analysis System (NAAS). Grounded in Communication Accommodation Theory, this coding system provides a method for analyzing physician and patient nonverbal accommodation behaviors within medical consultations.

METHODS

Video recordings of 45 new visit consultations at a comprehensive cancer center were coded using the NAAS. Inter-rater and intra-rater reliability were assessed. For validation purposes, two independent coders rated all consultations for theoretically related constructs.

RESULTS

The NAAS demonstrated high levels of reliability. Statistically significant correlations were observed across all 10 behavior categories for both inter-rater and intra-rater reliability. Evidence of content and construct validity was also observed.

CONCLUSION

The current study presents the initial application and evaluation of a coding system meant for analysis of the nonverbal behavior of physicians and patients within medical consultations. The results of this initial trial and psychometric evaluation provide evidence of the NAAS as a valid and reliable nonverbal accommodation coding system.

PRACTICE IMPLICATIONS

The NAAS enables researchers to investigate the way in which physicians and patients manage social distance through nonverbal behavior within medical interactions from a theoretically-informed perspective. Such efforts can aid in the development of communication skill interventions.

Evaluation of a pilot communication skills training intervention for minority cancer patients

The aim of this study was to pilot test in a minority cancer patient population a communication workshop to improve doctor-patient communication skills. Thirty-two patients participated. Eighteen evaluated a face-to-face workshop, while 14 completed surveys only. Participants in the workshop group completed the Patient Report of Communication Behavior (PRCB) before and after the workshop and a course evaluation. Participants did not differ on baseline PRCB scores. Posttest scores were significantly higher than pretest scores (p < 0.01). All participants agreed or strongly agreed that they would use the communication skills; 93% agreed or strongly agreed that the skills would improve their health care.

Using the Extended Health Belief Model to understand siblings' perceptions of risk for hereditary hemochromatosis

OBJECTIVE

this research focuses on individuals' reactions to news that a sibling has been diagnosed with hereditary hemochromatosis (HH). We used the Extended Health Belief Model (EHBM) to frame our analysis of siblings' perceptions of risk for HH and decision of whether to obtain diagnostic testing.

METHOD

60 patient and 25 sibling interviews were transcribed and thematically analyzed for the six components of the EHBM.

RESULTS

patient and sibling reports of siblings' perceptions were categorized into the six components of the EHBM: susceptibility, severity, benefits, barriers, cue to action, and self-efficacy.

CONCLUSION

In the case of HH, siblings' perceptions of HH are varied and include a range of motivators and barriers that may impact family-based detection. Family-based detection can often play an important part of effective public health strategies to address inherited risk of disease. Further research should examine the EHBM with other genetic conditions.

PRACTICE IMPLICATIONS

this analysis using the EHBM suggests areas of importance for message development for both medical personnel and HH patients to promote diagnostic testing of at-risk siblings.

The implementation and assessment of a comprehensive communication skills training curriculum for oncologists

OBJECTIVE

The objective of this paper is to report the implementation and assessment of the Comskil Training Curriculum at Memorial Sloan-Kettering Cancer Center.

METHOD

Twenty-eight attending physicians and surgeons participated in communication skills training modules as part of a train-the-trainer program. Doctors were video recorded in clinical consultations with patients two times before training and two times after training, resulting in 112 video recordings for analysis. Recordings were coded using the Comskil Coding System.

RESULTS

Communication skills related to two of the six major skill sets, Establishing the Consultation Framework and Checking, increased following training. Limited changes emerged in three skill sets, while one skill set, Shared Decision Making, did not change. Doctors who attended more training modules had higher levels of change. Female participants demonstrated three skills more frequently than males post-training.

CONCLUSIONS

The intervention produced significant communication skills uptake in a group of experienced attending clinicians, mediated by the amount of training. Future research should focus on the dose of training necessary to achieve skills uptake and the effect of skills training on patient outcomes.

Doctor-patient communication about cancer-related internet information

This article explores the effect of doctor-patient communication about cancer-related Internet information on self-reported outcomes. Two hundred and thirty cancer patients and caregivers completed an online survey regarding their experiences searching for and discussing with their doctors cancer-related Internet information. Participants who assertively introduced the Internet information in a consultation were more likely to have their doctor agree with the information. When doctors showed interest and involvement and took the information seriously, participants were less likely to report a desire to change the doctor's response. Taking the information seriously was also associated with greater satisfaction. This preliminary evidence that the doctor's response is associated with patient outcomes indicates the potential for improving patient-centered communication. In an effort to maximize patient-centered communication, doctors should be encouraged to take their patients and the information they present seriously, as well as show their patients that they are interested and involved.

Seeking informed consent to Phase I cancer clinical trials: identifying oncologists' communication strategies

PURPOSE

Phase I clinical trials are the gateway to effective new cancer treatments. Many physicians have difficulty when discussing Phase I clinical trials. Research demonstrates evidence of suboptimal communication. Little is known about communication strategies used by oncologists when recruiting patients for Phase I trials. We analyzed audio recorded Phase I consultations to identify oncologists' communication strategies.

PATIENTS AND METHODS

Subjects were consecutive cancer patients from six medical oncologists attending one of three outpatient clinics at a major Cancer Center in the United States. Sixteen patients signed informed consent for audio recording of their consultations in which a Phase I study was discussed. These were transcribed in full and analyzed to identify communication strategies.

RESULTS

Six communication themes emerged from the analysis: (1) orienting, (2) educating patients, (3) describing uncertainty and prognosis, (4) persuading, (5) decision making, and (6) making a treatment recommendation. As expected, although there was some common ground between communication in Phase I and the Phase II and III settings, there were distinct differences.

CONCLUSIONS

Oncologists used persuasive communication, made explicit recommendations, or implicitly expressed a treatment preference and were choice limiting. This highlights the complexity of discussing Phase I trials and the need to develop strategies to aid oncologists and patients in these difficult conversations. Patient centered communication that values patient preferences while preserving the oncologist's agenda can be a helpful approach to these discussions.

What indicates competency in systems based practice? An analysis of perspective consistency among healthcare team members

In many parts of the world the practice of medicine and medical education increasingly focus on providing patient care within context of the larger healthcare system. Our purpose is to solicit perceptions of all professional stakeholders (e.g. nurses) of the system regarding the U.S. ACGME competency Systems Based Practice to uncover the extent to which there is agreement or discrepancy among key system stakeholders. Eighty-eight multidisciplinary personnel (n = 88) from two academic medical centers were invited to participate in one of 14 nominal group process sessions. Participants generated and prioritized resident characteristics that they believed were important for effective System Based Practices. Through content analysis the prioritized attribute statements were coded to identify embedded themes of resident roles and behavior. From the themes, three major resident roles emerged: resident as Self-Manager, Team Collaborator, and Patient Advocate. No one professional group (e.g., nurses, attending physicians, social workers) emphasized all of these roles. Some concepts that are emphasized in the ACGME definition like using cost-benefit analysis were conspicuously absent from the healthcare team generated list. We showed that there are gaps between the key stakeholders prioritizations about the ACGME definition of SBP and, more generally, the behaviors and roles identified by healthcare team stakeholders beyond the U.S. This suggests that within the process of developing a comprehensive working understanding of the Systems Based Practice competency (or other similar competencies, such as in CanMEDS), it is necessary to use multiple stakeholders in the system (perhaps including patients) to more accurately identify key resident roles and observable behaviors.

Assessing facilitator competence in a comprehensive communication skills training programme

OBJECTIVES

Evidence suggests that the most important component of communication skills training (CST) is experiential learning through role-play sessions that rely on facilitators to guide learners. However, there is little published evidence about processes of assessing facilitator competence in CST. This paper reports on the development and application of procedures to assess facilitator competence in a large-scale CST programme.

METHODS

Thirty-two novice facilitators in a large CST programme were audio-recorded while facilitating small-group CST training sessions in order to explore whether the training they had received had prepared them to competently facilitate. Audio-recordings were assessed using the Comskil facilitator assessment coding system. Facilitators were rated as having achieved basic competence, advanced competence or expert competence.

RESULTS

Facilitation tasks that were most frequently coded as being used always included inviting the learner to give feedback first and inviting all group members to give feedback. The facilitation task coded least frequently as being used always was involving group members in solving problems. Of the 32 facilitators, 18 reached at least a basic level of competence. Psychosocially trained facilitators and MD facilitators differed in their use of five facilitation tasks.

CONCLUSIONS

Modest training and minimal practice does not result in complete facilitator competence. Some facilitation skills appear to be more easily acquired than others. These findings highlight which skills should be prioritised in the further training of novice facilitators. A long-term project currently underway will study whether facilitator competence improves with practice and regular feedback.

Impact of communication training on physician expression of empathy in patient encounters

OBJECTIVE

To examine whether an educational intervention that focused on physician communication training influenced physician empathic expression during patient interactions.

METHODS

This study used a quantitative research method to investigate the influence of communication training on physician-expressed empathy using two measures (global and hierarchical) of physician empathic behavior.

RESULTS

The differences in global empathy scores in the physician training group from baseline to follow-up improved by 37%, and hierarchical scores of physician empathic expression improved by up to 51% from baseline scores for the same group.

CONCLUSIONS

The results strongly supported the hypotheses that training made a significant difference in physician empathic expression during patient interactions demonstrated by both outside observer measures of global ratings and hierarchical ratings of physician empathic behavior.

PRACTICE IMPLICATIONS

These findings have significant implications for program design and development in medical education and professional training with the potential to improve patient outcomes.

Models of health and models of interaction in the practitioner-client relationship in acupuncture

The doctor-patient relationship has been widely studied in biomedicine. However, little research has focused on similar provider-client relationships in holistic healthcare forms. Based on ethnographic research with acupuncture clients and practitioners, the authors found that participants used specific models of health to understand and develop subsequent models of interaction, and in doing so, provided a clear critique of biomedicine. This article offers a brief overview of major models of healthcare, including biomedical, biopsychosocial, and holistic. The authors present current models of interaction that have been used to understand the biomedical doctor-patient relationship, and discuss the utility of both sets of models as they relate to the ethnographic observations. Although a particular model of health (biomedical or holistic) does not necessitate a particular model of health interaction (paternalism, consumerism, or collaboration), participants' attempts to tie these 2 realms together are important to understanding practitioner-patient relationships in all healthcare situations.