Dr. Luigi Grassi
Professor and Chair of Psychiatry
Chair Department of Biomedical & Specialty Surgical Sciences
University of Ferrara, Italy
In Italy psycho-oncology was developed in 1985 with the first services created within the National Health Service starting at the National Cancer Institutes in Milano and Genova. The formation of the Italian Society of Psycho-Oncology (SIPO) in 1985 also promoted the establishment of a "culture" of psychosocial care in cancer patients and was followed by the development of more programs throughout the country in university and health care settings. A survey by the Italian Society of Psycho-Oncology, the Italian Association of Cancer Patients and the Institute of Health in 2005 indicated the existence of at least 100 Psycho-oncology Services within the National Health Service. Training courses in psycho-oncology, including masters and specialization courses, workshops on communication skill training and the psychosocial consequences of cancer and psychosocial interventions, have been developed in the University system, such as the University La Sapienza in Rome and the Universities of Ferrara, Turin, and Naples. Several multicenter psycho-oncology research projects have been carried out in Italy, frequently with the involvement of other countries, particularly those in Southern Europe and in the Mediterranean area (such as Portugal, Spain, Austria).
A report on cancer rehabilitation (White Book on Rehabilitation, 2008) by the Italian Federation of Cancer Patients Associations, supported by the Ministry of Health and Social Policy, with the collaboration of many associations including the Italian Society of Psycho-Oncology, has stressed the right of all cancer patients to receive proper psychosocial support. The most recent National Cancer Plan 2010-2012 and the document on Reducing the Burden of Cancer - Years 2011-2013, of the Italian Ministry of Health, has endorsed this position. Thus psycho-oncology and the need for a comprehensive psychosocial care of cancer patients are formally recognized and acknowledged in several parts of the Act, with a specific paragraph dedicated to psycho-oncology. Psycho-Oncology is also formally represented among the seven areas of training for all the oncology professionals (diagnosis, prevention, screening, rehabilitation, palliative care, pain treatment, psycho-oncology), which the Ministry of Health indicates as a needed essential level of training (Lefo), with specific reference to the promotion of effective communication skills.
Thus in Italy there is a true psycho-oncology "movement" promoted by the government and nurtured by the Italian Psycho Oncology Society and Advocacy Organizations and the incorporation of psycho-oncology training in schools of specialization. This has resulted in a rich research agenda and collaborations between European countries which have all promoted a truly comprehensive model of care of all cancer patients and their families.
Luigi Grassi M.D. is Professor and Chair of Psychiatry at the University of Ferrara Italy and Chair of the Department of Biomedical and Specialist Surgical Sciences. He worked as an attending psychiatrist at the Community Mental Health Services in Ferrara, then he moved to the University of Ferrara where he was the chief of the Consultation-Liaison Psychiatry Service and the Psycho-Oncology Service at the S .Anna University Hospital in Ferrara from 1993 to 2001 and since 2002, the Director of the Clinical Psychiatry Unit, Integrated Department of Mental Health and Drug Abuse, NHS Community Health Agency, in Ferrara, Italy. Dr. Grassi has served as President of the International Psycho-Oncology Society (IPOS) from 2006 to 2008. He has been the Chair of the IPOS Federation of Psycho-Oncology Societies since 2008 and of the Section on Psycho-Oncology and Palliative Care of the World Psychiatric Association (WPA) since 2005..Dr. Grassi is author of many scientific papers published in peer-reviewed journals and books on psychiatric aspects of medical illness and psycho-oncology, including the book edited with Dr Michelle Riba, Clinical Psycho-Oncology: an International perspective, (Wiley, 2012). For his work he was awarded the 2012 Arthur Sutherland Award for excellence in teaching research and clinical care by the International Psycho Oncology Society.
Dr. Luzia Travado
Chief of Clinical Psychology Unit
Centro Hospitalar de Lisboa Central, EPE
Hospital de S. José
Dr. Luzia Travado
Communication skills training for oncologists and cancer physicians in Portugal has started only recently. Up to now, medical doctors' education and training in Portugal did not require learning and training in communication skills. Specifically, doctors working with cancer patients are neither required to practice nor taught specific and useful communication skills to help them deal with the difficult moments throughout the disease process of communicating bad news to patients and families, which left this area much unattended.
Early in our efforts to address this problem, we generated data from the Southern European Psycho-oncology Study (SEPOS) that showed that not only Portuguese cancer physicians but also their colleagues from Italy and Spain reported having received minimal training in these skills during their education. And although they tend to perceive themselves as skilled in communicating with patients, they express less confidence in specific skills such as dealing with denial and managing uncertainty, assessing anxiety and depression, promoting patient-family openness and breaking bad news (Travado et al., Psycho-Oncology, 2005).
Moreover, the study revealed a relationship between communication skills, expectations of communication outcome, psychosocial orientation and burnout. Lower confidence in communication skills (poor communication skills) correlated with higher expectations of a negative outcome following communication with patients, which associated with a lower psychosocial orientation and higher level of burnout. The results suggested training cancer physicians in communication could potentially enhance a psychosocially oriented approach to patients in cancer care but also positively affect doctors professionally in the Southern European countries (ibid.).
In conducting communication skills training in the studies mentioned above, we developed a specific educational and experiential model (12 hours divided into two modules) involving formal teaching (i.e., journal articles, large-group presentations), practice in small groups (i.e., small-group exercises and role-play), and discussion in large groups. This training was developed with the aim of improving not only cancer physicians' communication skills but also their ability to detect emotional disturbances in their cancer patients (e.g., depression, anxiety, and adjustment disorders) and refer them to specialists (e.g., psycho-oncologists). The training course was conducted in hospital settings in several southern European countries and was well accepted by most participants who expressed general satisfaction and a positive, subjective perception of the utility of the course for clinical practice (Grassi et al., 2005). The model has proved to be a feasible approach for oncologists, and is easily applicable to various oncology settings (ibidem).
The model has been used by this author in teaching communication skills in Portugal since 2004. The first group of trainees consisted of general surgeons who were responsible for the treatment of breast and other types of cancer patients and was the pilot training group. Because of the positive reactions to the training the Chief of surgery, a colleague in the breast cancer multidisciplinary treatment unit at Hospital S. Jose, Lisbon Central Hospital Centre, today advocates this training for every doctor. He also has gained more confidence in Breaking Bad News to patients in a sensible humanistic way, tailoring the approach to each patient's needs.
In an effort to reach more physicians and provide an easy-to-use learning tool (for self-learning and/or use in workshops), in 2006 together with Prof. Joaquim Reis, we made a two set DVD on Communication and Relationship Skills for Health Professionals - which included basic and advanced skills and an introduction to the breaking bad news protocol (SPIKES) - with the sponsorship of Novartis-Oncology. This DVD was launched in a GIST (society for Gastrointestinal Stromal Tumors) Symposium with Professor Walter Baile giving a conference on 'The importance of good communication skills in clinical oncology and its training,' and its first edition was offered to the oncologist community.
The formal SEPOS training was then modified to include a module on how to break bad news (BBN) and some illustrations of the DVD were also used. In 2007, this new format of training for oncologists was rolled out by our group in collaboration with the Portuguese Oncology Society, and was very well received.
In 2009, a pilot program on communication skills training for cancer physicians was launched at a national level. The National Coordinating body for Oncological Diseases (CNDO) in Portugal, high Commissariat for Health, under the Ministry of Health, undertook this program with the aim of improving communication with cancer patients and families in clinical oncological settings. In an effort to improve cancer care and also respond to European and international recommendations that suggest communication skills training is a core skill for medical practice, particularly relevant for oncology doctors, this program also envisioned to provide an opportunity to solve this gap in medical education. The program was launched with a symposium in which professors, Leslie Fallowfield, Luigi Grassi and Walter Baile were invited speakers to talk about the 'Importance of communication skills training in clinical oncology' and was attended by over 100 oncologists and palliative care physicians (view presentations). Subsequently the communication skills interactive program was subsequently begun and included 3 programmed workshops in Lisbon, Oporto and Coimbra throughout the year, targeting oncologists, surgeons, radiotherapists and other physicians working in cancer clinical settings directly with patients and families. We will report on the progress of our efforts in the near future.
Grassi L., Travado L., Gil F., Campos R., Lluch P., Baile W:. A communication Intervention For Training Southern European Oncologists To Recognize Psychosocial Morbidity in Cancer Patients. I - Development Of The Model And Preliminary Results On Physicians' Satisfaction.. J Cancer Education, 20(2):79-84 (2005)
Travado L., Grassi L., Gil F., Ventura C., Martins C. and the Southern European Psycho-Oncology Study (SEPOS): Group Physician-Patient Communication Among Southern European Cancer Physicians: The Influence of Psychosocial Orientation and Burnout.. Psycho-Oncology, 14, 661-670 (2005)
Yosuke Uchitomi, Maiko Fujimori, Yuki Shirai and Yu Yamada,
Psycho-Oncology Division, Research Center for Innovative Oncology,
National Cancer Center Hospital East, Kashiwa Japan
Dr. Yosuke Uchitomi
In 2006, the Cancer Control Act was approved in Japan. Through this legislation, the Japanese government has greatly expanded a number of national initiatives to promote cancer control programs, to enhance efforts in cancer prevention and early detection and to disseminate information about palliative care and promote excellence in this area and to promote cancer research. In 2007, the basic plan to promote a cancer-control program now approved by the Japanese cabinet also provided opportunities for basic palliative care training for physicians who engaged in the treatment of cancer patients. This effort also addressed the issue of improving physician’s communication skills in the areas of disclosing the cancer diagnosis and other communication aspects of supporting the patient and families affected by cancer.
The number of the physicians who are actively engaged in cancer care in Japan is estimated to be about one-third of all physicians, approximately 100,000. In cooperation with the National Cancer Center, the 351 Certified Local Cancer Center Affiliated Hospitals, the Japanese Society of Palliative Medicine and the Japan Psycho-Oncology Society (JPOS), the Japanese Ministry of Health, Labor and Welfare has actively promoted a basic, introductory palliative care training program. This 12-hour program includes lectures on depression/delirium (one hour) and breaking bad news (one hour) and a two-hour workshop on communication skills. The aim of the workshop is to help participants acquire some basic communication and interpersonal skills which would allow participants to practice techniques such as giving bad news to cancer patients and addressing their and their families’ concerns.
Thirty physicians at a time usually participate in the workshop. Techniques used include didactic lectures and role-training in which doctors divide into small groups of three where they alternative play the roles of doctor, patient and observer. In this way not only do they have the opportunity to practice communication skills but also to “step into the shoes” of the patient and also observe the interactions from a neutral position. In order to support these efforts by training facilitators for the workshops we have held train-the-trainer workshops for 47 prefectures-recommended psychiatrists held three times in 2008.
In cooperation with the Foundation for Promotion of Medical Training the Japanese Psycho-Oncology Society (JPOS) and the Japanese Ministry of Health, Labor and Welfare we have also conducted advanced communication skills workshops for highly motivated oncologists since 2007. The workshop is learner-centered and focuses on building enhancing the strengths of each participate in communicating with cancer patients. Each cohort of learners consists of 16 oncologists who learn breaking bad news, discussing refractory cancer, informing of disease recurrence and stopping anti-cancer treatment. Based on our communication skills research, empathy skills are especially emphasized.
In our format participants work in small groups consisting of four oncologists, two facilitators and a trained simulated patient. Each oncologist participant interviews the standardized patient for a total of two hours in two task-focused sessions such as discussing end of anti-cancer treatment. Facilitators, one psychiatrist or psychologist and one oncologist, trained as a pair for 40-hour training by the JPOS facilitate each small group and coach individuals through the learning tasks. In 2008, these workshops were held in five cities in Japan.
The expected outcome is an increase in the number of the physicians participating in both workshops during the subsequent five-year period. We are looking forward to reporting the results of our efforts in the future.
Fujimori M., Parker P.A., Akechi T., Sakano Y., Baile W.F., Uchitomi Y. Japanese cancer patients' communication style preferences when receiving bad news. Psycho-Oncology. 16:617-25, 2007.
Fujimori M., Akechi T., Morita T., Inagaki M., Akizuki N., Sakano Y., Uchitomi Y. Preferences of cancer patients regarding the disclosure of bad news. Psycho-Oncology. 16:573-81, 2007.