Enhancing Communication Between Oncologists and Patients with a Computer-Based Training Program
A Randomized Trial
James A. Tulsky, MD; Robert M. Arnold, MD; Stewart C. Alexander, PhD;
Maren K. Olsen, PhD; Amy S. Jeffreys, MStat; Keri L. Rodriguez, PhD;
Celette Sugg Skinner, PhD; David Farrell, MPH;
Amy P. Abernethy, MD; and Kathryn I. Pollak, PhD
Annuals of Internal Medicine Article
Imagine a 63 year old former truck driver with extensive liver and lung metastases who has received many cycles of front line, salvage, and third line chemotherapy. He presents to your office with rising bilirubin despite a functional biliary stent and decline in performance status. He spends essentially all day in bed or on a couch. He is no longer a candidate for chemotherapy. Extensive leg edema prevents him from walking. You assess his understanding of his condition and ask him "What are your goals?" He responds "I just want is to be able to get up and move around. I used to be so active, driving my truck, loading and unloading cargo, moving around all day, seeing the countryside. I haven't seen the sky in 3 weeks. Coming here to the clinic today was a great adventure." He is visibly sad and mourns the loss of his independence and vitality.
What is the appropriate response to his statement "I just want is to be able to get up and move around"? This is fundamentally an emotional statement that reveals sadness and grief over loss of independence and vitality. Studies have shown that responding empathically to emotion is healing, since it shows patients we care and are tuned in to their concerns. Examples of empathic responses in this case might include "I can imagine your illness has been a major adjustment for you. I know you were very active, strong, and independent before. It must be difficult for you to be stuck at home". Despite the power of empathy, the literature shows most oncologists would instead respond factually by saying something like "we will refer you to physical therapy to get rehab" or "let's talk about a diet to increase your albumin level to reduce leg swelling." These responses are not wrong per se, but they represent missed empathic opportunities; missed opportunities to show compassion.
Fortunately, studies have shown that oncologists can improve empathic skills by attending multiday communication skills courses that incorporate small-group practice with simulated patients, observation, and feedback. However, the drawback of such courses is that they are time- and cost prohibitive. Improving oncologists' skills requires alternative educational venues that are easily accessible, not disruptive to clinical practice, inexpensive, and brief. The current paper describes a computerized, interactive, tailored intervention that meets these requirements.
The current study was a randomized single blind controlled study of two communication skills training interventions. Participants included 48 medical, gynecologic, and radiation oncologists and 264 patients with advanced cancer at two academic medical centers. All participants were video recorded during encounters with at least 4 advanced cancer patients before and after the intervention to which they were randomized. Control participants heard a one hour lecture about communication skills, whereas experimental participants received tailored feedback in the form of a CD ROM based specifically on recordings of their actual clinical encounters. Investigators compared conversations before and after training to determine whether intervention improved doctors' empathic skills. A secondary objective was to evaluate the effect of the intervention on patients' perceptions of their oncologists.
Results and Conclusions
Oncologists in the intervention group used nearly twice as many empathic statements and were more likely to respond to negative emotions empathically than control oncologists. These results were statistically significant. The experimental CD-ROM is the first computerized communication teaching intervention to show improvement in physician outcomes. In addition, patients of intervention oncologists reported significantly greater trust in their oncologists than did patients of control oncologists. This is the first physician communication intervention of any type to demonstrate improvement in patient trust.
More physicians should receive communication skills training that includes individualized, reflective feedback. Before this study, the gold standard was to provide such feedback in the context of a long course with small-group teaching. The degree of behavior change among physicians observed in this study is similar to that seen in intensive multiday courses that use small-group teaching. The brevity of the intervention offers an important advance over the small-group model. Once this technology is refined, it has multiple potential applications for physician training and quality improvement programs. It could reach a broad population of oncologists for relatively little cost, and similar programs could be designed for other specialties.
The study had two main limitations. First, long-term effects were not examined. Second, findings may not be generalizable outside academic medical centers. Nonetheless, this study is important, since it shows a brief computerized intervention improves how oncologists respond to patients' expressions of negative emotions.
Daniel Epner, M.D.
Associate Professor, Department of General Oncology
Dr. Epner received his medical degree from Baylor College of Medicine and completed his clinical and research fellowship in medical oncology at Johns Hopkins School of Medicine. Dr. Epner's primary clinical focus is on the international oncology patients seen in the International Cancer Assessment Center (ICAC). Dr. Epner has published several articles in peer-reviewed journals and is developing research and educational programs to improve communication between cancer patients and their providers and to study the role culture plays in oncology practice.