James A. Tulsky, M.D.
Professor of Medicine and Nursing
Chief, Duke Palliative Care
Dr. Walter Baile: Hello I'm Dr. Walter Baile, Director of the MD Anderson Program on Interpersonal Communication and Relationship Enhancement. Today, we're very pleased to have Dr. James Tulsky as our roundtable guest. Dr. Tulsky is chief Duke Palliative care, and professor of medicine and nursing at Duke University. Dr. Tulsky attended Cornell University as an undergraduate, completed his medical degree at the University of Illinois College of Medicine in Chicago and received his internal medicine training at the University of California San Francisco. He continued at UCSF as chief medical resident and subsequently as a Robert Wood Johnson clinical scholar. In 1993, he joined the faculty of Duke University. He was in the first cohort of project on death in America Soros Faculty Scholars and is the recipient of a Robert Wood Johnson Generalist Physicians Faculty Scholars award, a VA Health Services research career development award, the 2002 Presidential Early Career Award for scientists and engineers, which is the highest national award given by the White House Office of Science and Technology for Early Career Investigators and also the 2006 award for research excellence from the American Academy of Hospice and Palliative Medicine. Dr. Tulsky has a long standing interest in doctor patient communication, and quality of life at the end of life and is published widely in his area. His current research focuses on the evaluation and enhancement of communication between oncologists and patients with advanced cancer, as well as identification of clinical psychosocial and spiritual trajectories of patients at the end of life. He's also has an earning interest in the development of self-management interventions for patients with life threatening illness and evaluating the role of palliative care and congestive heart failure. So James welcome.
Dr. James Tulsky: Thank you. It's great to be here.
Dr. Baile: What people don't know is you and I go back a long way.
Dr. Tulsky: We certainly do.
Dr. Baile: And we're involved with two national cancer institute grants for teaching first medical oncologist fellows and then medical oncology faculty in the area of communication skills. And that brings back really great memories of working together. So now you've kind of moved on a little bit and are involved, as we talked last night, in more of a leadership and administrative function with Duke Palliative care. So maybe you could talk a little bit about what you're doing and what Duke Palliative care is.
Dr. Tulsky: Sure. Duke has given us an incredible opportunity. As you may know, Duke University Health System actually covers a wide range, it's an integrated system that has three hospitals, outpatient clinics, primary care practices, we own a hospice, and what we've now done as of July is created Duke Palliative Care, which is the goal is to create comprehensive integrated palliative care across the health system. We like to say from cradle to grave, from home to hospital. And it's been an exciting opportunity to really do this sort of integrated palliative care.
Dr. Baile: Well, palliative care has really come into its own and in the last, I would say five or six years especially, in relationship to the Affordable Health Care Act. And I wonder if you could say something about that relationship because it's so important now that physicians develop good communication skills around patients especially with advanced cancer.
Dr. Tulsky: Absolutely. One of the things that the Affordable Care Act and other new regulations for Medicare are doing is encouraging hospitals and health systems to provide better care to a population of patients, and to look for things like readmissions to the hospital, to you know reduce costs where possible when you could also increase quality. Palliative care is really serving that sweet spot right now in that we provide the kind of care that patients and families really want, and we're able to do it often at lower expense and to help patients focus on the goals that they really want to focus on, which frequently means also reduced costs. So for that reason, palliative care is being funded by a lot of health systems, which see it as a win win, providing higher quality and potentially reducing costs.
Dr. Baile: So in light of this, what do you see as the main challenge in communication for oncologists around end of life issues with cancer patients.
Dr. Tulsky: I think oncologists have many challenges when they talk to patients. First of all, I think life of oncologists is not easy and I think the work that they do is tremendously challenging and so much focus has to be on treatment and on helping patients get through these very very difficult treatments toward a cure that is often very possible and when things don't go well, when a cancer cannot be cured any longer, making that shift can be very, very difficult. And in finding a way to do that and still maintaining a relationship with the patient, still feel like you're providing hope, still feel like you're journeying with them can be a challenge. And I think knowing the words to say, as well as being able to personally sort of get over that transition yourself as a physician can be hard.
Dr. Baile: Now the folks who are seeing this interview might be interested in knowing that there are a number of techniques for teaching communication skills and you and I were involved with this project where we brought people actually to a residential setting in Aspen Colorado where they spent three or four days learning communication skills and of course that was pretty intensive, labor intensive, big time commitment, and I know that you've sort of moved on to try to develop some more efficient and more user friendly ways of teaching communication skills. And I know you're going to talk more about that today at the ACE lecture. But I wonder if you could summarize for folks some of the research that you've been involved with in the last couple of years in teaching oncologists communication skills.
Dr. Tulsky: Sure. The program that we did together Oncotalk I think remains the gold standard for teaching communication skills. You're in a small group, you're working with people face to face, you have an opportunity to give real time feedback, to work with simulated patients, stop and start and all of that. The problem is as we both know it's very time intensive and it's very costly. So the question is can we take the same principles from that kind of work, which are directed feedback, which are the ability to role play, and can we put them into a setting, or into a format that might be more accessible. So what we've done is we've developed several different computer programs, these are web based programs, the first one is called “Scope.” We have some others as well where we teach oncologists online how to communicate better, we show them the videos, we give them principles of communication, we do all of that. So far, that's not very different from a lot of other CME type programs that are on the web. What's different with us is that we then audio record the conversations that these oncologists have with their real patients in clinic, we then process these recordings, we give tailored feedback on what they've done, based on the principles of communication they've learned, and we give that back to them in the program. So when they're watching this program they learn about the skills and then they say why don't you see where you use this technique in your own practice? And we show them examples of where they did it, or perhaps opportunities for improvement. And we think that the ability to actually hear your own conversation and not be able to say somebody else does it that's not me makes a big difference. What we found in doing that is that a simple one hour online program like this was able to double the number of empathic responses given by the oncologists to their patients, which is actually fairly close to what we were able to achieve in Oncotalk.
Dr. Baile: So how labor intensive is it to for example take a recording between an oncologist and a patient and tease out excerpts of a dialogue that an oncologist may need to think about how they might improve or to reflect on and to give them that feedback. Is that something you can do with a program?
Dr. Tulsky: So right now we have a program we've built that gives us the template on which to do it, but it still requires human coders. So we have a person who will listen to the recording, knows what they're looking for, marks those segments of talk that meets the criteria we're looking for, and then after that everything else is automated. So the truth is we're paying one coder, takes about the amount of time, maybe one and a half times the amount of time of the actual encounter. So if an oncologist sees a patient for twenty minutes in clinic, it might take us thirty minutes to code that twenty minute segment, and that's done by someone who honestly is you know not a very high paid individual so it's not really costing a tremendous amount of money, and then we process it afterwards. If you think about how that compares to what it costs to do a course, which is thousands of dollars per oncologist, it's a bargain.
Dr. Baile: So the goal of your project was really to get oncologists to improve their communication skills, but I know you also measured some outcomes and I think that you know people today are very, very interested in outcomes and you know the question often comes up, well, now we've improved the oncologist communication skills and so what? And you know I think there are very, very few studies that show first of all that the course or the intervention actually can result in people making changes in clinic and then secondly whether or not that affects patient care at all and I don't think that there was any study until yours came along in a way that showed that some of these changes are really possible in terms of transfer of learning to the clinic or in patient outcomes and I wonder whether you can say something about that because those studies are really hard to do.
Dr. Tulsky: Sure, that was the most exciting part about what we did. Not only did we find that we were able to influence the oncologists behavior and get them to talk differently with their patients, which already as you know is a big feat, but we found that the patients, this was a randomized control trial and the patients who were in the control arm of the oncologists who did not receive the communication intervention, versus the patients in the arm of the oncologists who did receive the intervention, the patients who were taken care of by oncologists who were trained were statistically significantly more likely to trust their doctor than those in the control arm. In addition, they were more likely statistically significantly to feel the doctor understood them as a whole person and to believe their doctor had been empathic. So these are important changes. They're recognizing something in these doctors and to actually express itself in trust is huge. A lot of us feel that trust is really at the core of a good doctor patient relationship and if we can engender that that's a big difference.
Dr. Baile: So I think this is one of the few studies that have really demonstrated a concrete outcome. And of course there are always people who say well can you show that patients were more compliant etc. but as you know very few oncology patients are non-compliant so we don't have that problem so much. So what do you think where are you going to bring things with your project because all of this was very exciting, I know you have published on this so what's next?
Dr. Tulsky: Well, I would say two things; first, we have an ongoing study now which is really the follow-up study to the one we did to try to do the same thing for patients. One of the things that we learned in our study was that patients were not bringing up their concerns very often and that surprisingly these were patients who were at advanced cancer, who ought to have high levels of distress and yet the number of empathic moments, opportunities we call them, when they would express a negative emotion were few. We believe part of the reason for that is because when they do bring up those emotions so often they get sort of squelched by the doctor who doesn't respond so they're sort of trained out of it. So we felt, we actually want to be able to raise the number of empathic opportunities raised by the patients. So we now have another program called Cope where we're doing the same thing with patients that we did with doctors, where we are training them through an online format to how to bring up their concerns to their doctors, how to overcome the kinds of push back the doctors sometimes give to make them feel like they don't want to hear this, and then to be able to practice it and what we do is we audio record their visits and we give them feedback again on their actual conversations and where they've made improvements. So that study is ongoing. We have enrolled about two hundred and fifty patients out of four hundred. We should be finishing that study in the next year and then it's also a randomized control trial and then we'll see whether or not we've been able to influence patients in the same way that we influence the doctors.
Dr. Baile: I think there are just a few studies out there that tried to make an intervention such as preparing patients for their first visit and what to ask, but bringing up concerns is really another issue and I think that the literature, at least if we go back to some of McGuire's work, shows that the more concerns a patient has, the more likely they're to be anxious and depressed. So that would be an interesting outcome. Are you going to be looking at?
Dr. Tulsky: We're going to be looking at those things. We're looking at their affective levels, we're looking at depression, we're looking at anxiety and so we'll see whether or not it affects those things.
Dr. Baile: Well, that sounds very exciting. The other thing is is that if I remember well that patients hint a lot, that they're worried about something, and they beat around the bush to see whether or not in a way the oncologist or clinician will bite. Is part of your intervention to help them more clearly articulate what's on their mind?
Dr. Tulsky: That is exactly what our intervention teaches. And in fact we have videos where what we do is we show the patient talking to the doctor, hinting, trying to get something out, the doctor doesn't hear it and it goes on, we then it then stops, there's a direct camera with the patient who says that didn't go well, I need to be a little more pushy here. They try something different and then afterwards they say that feels and then the doctor responds and then they say that feels much better. We're trying to do the same thing where we actually capture their conversations. We're trying to give them feedback where we can show them places where they were more direct and as a result the doctor was more responsive. Because it turns out that the, it's not really surprising, the more emotion that a patient raises and the sort of higher volume of it, the more likely the doctor is to respond. Sometimes they just don't hear it. So and obviously in a way that's constructive.
Dr. Baile: Well that's also another interesting piece of research whether or not when patients are direct, it results in the physician trying to probe further or respond to that because you know the I think the belief is that the doctors are afraid to open this Pandora's box and explore things but maybe that isn't so because no one has ever really tried to get patients to say things in a way that they wouldn't you know have to go and find a way to go down the road with the patients hint. But if patients are more direct perhaps that's a really important cue for them to help them respond.
Dr. Tulsky: I hope so. We actually are training the patients to say I need your help, which is very direct. It's interesting we've listened to these recordings now and you hear patients saying it after they've gone through the intervention. It's very neat. We'll see how it actually turns out in the study.
Dr. Baile: And you have a wonderful research group that has stayed intact over the past five or six years maybe even more of folks who have worked on this issue with you.
Dr. Tulsky: I couldn't have done this work without my colleagues and these are not physicians for the most part. Cat Pollick [assumed spelling] is a social psychologist who works closely with my on this work, Stewart Alexander is a health communications specialist who works closely with me. I've continued to work with Bob Arnold on some of these studies who is one of our colleagues from Oncotalk, another physician and you do this for the team and the team work makes a difference. I did want to get back to one other piece that we're hoping to do at some point in the future. What I believe the intervention, the scope intervention allows us to think about for oncologists, is a way to create quality improvement programs, or maybe maintenance certification programs for certification for example their oncology boards where we can actually analyze the communication, give them feedback, and make that you know part of the process. So what I imagine is that it's a doctor could go to clinic, could pull out their smartphone, put it on the counter, push a button, record the conversation that's happening between him or her and their patients, when they're finished push another button and that uploads it to somewhere that does this sort of processing. And then within a short period of time a couple of days later they get a message on their phone that says it's now available for review and they could listen to where they did or didn't accomplish certain goals in their communication. This is entirely feasible right now. It's a matter of trying to bring this to scale, it's a matter of trying to insert this into for example maintenance and certification. So that's another area that we're actually exploring.
Dr. Baile: But beyond even maintenance certification how about helping fellows demonstrate that their communication skills have improved and for the fellowship training programs that would be a real boon because everyone is struggling now to provide some concrete outcomes to the accreditation council for graduate medical education that you know we're measuring these things and showing that our fellows during their training improve in their communication interpersonal skills.
Dr. Tulsky: You're absolutely right, that would be a fantastic way to use that.
Dr. Baile: Well, thank you very much. That's been a really wonderful kind of look at some of all of these issues which are interconnected, training and practice and helping patients at end of life care. So we've been visiting today with Dr. James Tulsky from Duke Palliative Care, a very good colleague of mine and just an astounding researcher and clinician. So we invite you to watch Dr. Tulsky's Achieving Communication Excellence Lecture entitled Teaching Oncologist Communication Skills from Micro processing to Microprocessors, which you can all view at our I*CARE Website at www.mdanderson.org/icare.
Roundtable with Dr. James Tulsky (20:43)
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