November 01, 2011

Communication in oncologist-patient interactions is like the apples in apple pie. Of course it’s there and necessary, but if it’s really fine, the end product will be demonstrably improved.

"Most oncologists really care about their patients and really want to do a good job. The question is whether or not they always have the skills or know the words to do that," said Dr. James A. Tulsky in a telephone interview.

There’s no secret recipe, and hundreds of oncologists have learned through the University of Washington-based Oncotalk Teach program how to empathetically respond to distress voiced by a patient or family member. Once trained, these communicators draw on skills known by the acronym NURSE. They Name (the emotion or concern), Understand, Respect, Support, and Explore, Center.

Seems simple enough, but videotaped patient encounters show that, left to their own devices, many well-meaning but untrained oncologists tend to be terminators (changing the subject, making jokes, denying the stated emotion, or ending the conversation) rather than continuers (offering empathy and NURSE responses) when patients express concern or anxiety.

"The problem is, the courses are expensive, long, and very resource-intensive," said Dr. Tulsky, an Oncotalk faculty member, professor of medicine and nursing, and director of the Center for Palliative Care at Duke University and the Durham (N.C.) VA Medical Center. "I got to thinking, how could we do the same thing that happens in the course: modeling skills, practicing, being observed, getting feedback without the course?"

Enter audiotapes, uploads, coding of communication patterns, and customized feedback – and pretty soon you’re talking really good apple pie.

"Most oncologists really care about their patients and really want to do a good job. The question is whether or not they always have the skills or know the words to do that."

Dr. Tulsky and associates this week published results of a study in which a brief, computerized program to provide individualized feedback to oncologists about their own communication patterns not only enhanced empathetic statements but also heightened patients’ trust.

The study, published in the Annals of Internal Medicine (2011;155:593-601), shows that not all communication interventions have to be expensive or time-consuming to make a real difference.

In a nutshell, 48 medical, gynecologic, and radiation oncologists watched a one-hour lecture on communication skills. Half were then randomly assigned to receive CD-ROM training customized to offer feedback on ways in which they communicated in their own encounters with patients, based on audio-recorded clinic visits.

Trained coders listened for NURSE-type statements in the encounters and each CD-ROM was then tailored to reflect the oncologists’ real-life interactions.

For example, if an oncologist responded to a patient’s worried comment about an upcoming test by saying, "Sounds pretty scary for you…," the feedback would note, "That’s a great, empathetic response. Try using more of those."

On the other hand, if the oncologist changed the subject after such a statement, the CD-ROM might offer some suggestions of NURSE-type response statements.

Among 24 oncologists in the intervention arm, 21 listened to their customized, hour-long CD-ROMs for a median of 63.8 minutes. Twenty of 21 said that it influenced them to change their communication patterns.

In visits recorded after the intervention, the CD-ROM trained oncologists offered more empathetic statements (relative risk, 1.9 [CI, 1.1 to 3.3]; P = .024) than those who only heard the one-hour lecture. They were much more likely to specifically respond to negative emotions empathetically (odds ratio, 2.1 [CI 1.1 to 4.2] P = .028).

Moreover, patients of the oncologists who had received the CD-ROM feedback reported more trust in their doctors than those seen by the control physicians (estimated mean difference 0.1 [CI, 0.0 to 0.2], P = .036.

While this was a study, Dr. Tulsky sees easy ways to incorporate the "mostly-automated" system into quality improvement programs, certification requirements, or continuing education programs.

"The oncologists were remarkably open," he said. "We overwhelmingly found oncologists were receptive and open to learning. They want to be better."

Sounds like they all got A’s, as in … mmmm, apple.

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