Richard L. Street Jr., Ph.D.
Professor and Head
Department of Communication
Texas A&M University
Dr. Baile: Hi I'm Dr. Walter Baile director of I*CARE, MD Anderson's program on Interpersonal Communication and Relationship Enhancement. Today, we're very pleased to have with us Dr. Rick Street as our guest speaker in our Achieving Communication Excellence lecture series. Dr. Street is professor and head of Communication and Research Professor in medicine at Texas A&M University. He is also director of the Health Communication and Decision Making program in the Houston Center for Quality of Care and Utilization Studies at Baylor College of Medicine. Over the past 25 years Rick has developed an extensive program of research examining issues related to health care provider patient communication, medical outcomes, and strategies for increasing patient involvement in care. So Rick thanks for joining us today to talk a little bit about your work in Cancer Communication Research and I wonder if we could begin by you telling us little bit about how you got to begin thinking about research opportunities in this area specifically in communication and cancer care.
Dr. Street: Well, believe it or not Cicero. You know, that's when I was a graduate student and I was fascinated with ancient Rome and orders and in particular Cicero and the way in which he would adapt his speeches and his messages to the different audiences depending on if he is talking to the people in a forum or to the politicians in the senate. I was fascinated by the way in which he constructed messages for his persuasive and informative purposes and then later I started thinking well actually I ought to put this in the real world and so I studied, you know, what made people good conversationalists and had more satisfactory conversations. That then moved into let's look at this in interview settings and the things that interviewee's could do that would make better impressions with interviewers. And then finally 25 years ago I looked at some of the research and the study of physician patient communication and I thought, gosh there's a lot of work that needs to be done here in terms of helping both clinicians and patients to be better communicators. And so that's how I got from Cicero to what I'm doing right now.
Dr. Baile: Well, that's very interesting and I know that having just been finished reading a book on the life of Cicero, he actually he never lost a case.
[ Laughter ]
Dr. Street: That's right.
Dr. Baile: As I remember as a defense attorney. So I think this idea of being a persuasive communicator is a really, really interesting one. And, you know, and going over reviewing some of your work I know that you and Barbara Sharf had initially sort of thought of and developed this idea of patient-centered communication and introduced it in the '90s I believe. That concept began to sort of be thought about and to take hold and--how did you get to that area of thought about well gee, well maybe we need to really--maybe effectiveness in communication is associated with sort of understanding what we, what the patients' needs are and how we can give information tailored to the patient is that sort of, how did that transition to like this?
Dr. Street: Well, the early work on physician patient communication tended to focus mostly on what clinicians were doing or what physicians were doing and sometimes the patients' role in these encounters was like not important. It's as though the success or failure of a medical consultation depended on the physician's skills. But from a communication point of view that's not the way the world operates. You know, all conversations are mutually constructed by the participants and they work together taking turns to move the conversation forward. And so what we started thinking about was more about when the patient was being neglected in terms of their roles and their responsibilities in the medical encounter, that what we need to be doing is spending more of our time thinking about what they're trying to do in the ways in which they're trying to interject their perspectives into the consultation. So it ends up being that the patient's perspective is validated not only because they are the recipient of care that they're receiving but also from a communication point of view which is what the medical consultation is. They have equal standing with the clinician in terms of the success hopefully of that particular encounter. So that was where the shift was. We needed to make more of a primary role for the patient or at least and equal role for the patient.
Dr. Baile: And you've done some work looking at what impact it makes on patient care when one pays attention to patient needs and tailored the information to patient's educational level, et cetera. Can you talk a little bit about some of these outcomes that may be related to the idea of patient-centered communication?
Dr. Street: Well, I think the best way to think about that is put it in the overall context of what you hope to accomplish with medical care. And what you want to accomplish is the patient having a better outcome. Now, outcomes can be looked out in a variety of ways. You can have physiological outcomes and mortality and morbidity. You can look at psychosocial outcomes, emotional well-being, quality of life and things like that. So that's one of the issues, one of the primary things I'm interested in is the relationship between communication and outcomes. Now, I started at that point in terms of answering your question because what were trying to do nowadays is try to model the pathway through which a conversation can then lead to those improvements in health outcomes. One of the steps along the way might be quality of care as judged from maybe a couple of standards. One standard of quality of care might be the patient's perception that they received good care that means perhaps they are more highly motivated to follow through on, you know, treatment programs and things like that. Another standard of quality care though could be what we would hope that, like in the informed decision making process. What you ought to do to, you know, to succeed in accomplishing informed decision making. And so from that standpoint it's like what kind of elements need to be in place from a communication point of view in terms of informing the patient, inviting their involvement, you know, getting their agreement or their input on what the decisions might be. And so what we look at is quality of care as being kind of the stepping stone, kind of one of the proximal outcomes as you were--would think or one of the immediate consequences of the consultation that could be a stepping stone to improved health outcomes.
Dr. Baile: Do you think that we, you know, one thing I've always been interested in is how to get people like yourself who are experts in sort of the basic science of communication--
Dr. Street: Right.
Dr. Baile: Involved in this area of what are the clinical dilemmas that clinicians face and I thought that, you know, in the past there's been very little kind of, I guess, collaboration between folks who have the knowledge about well how syntax and different ways of saying things might affect the mood and affect of a patient and the folks who I guess are in the trenches and how they can use the findings from your field in order to improve the outcomes with the patient. Where do you think we are with that sort of marriage of these two fields? I know you've been involved in it. We're still a little way away from getting people in basic science of communication to say, "Hey, here's our clinical problem. Can you help us figure out what to do about it?"
Dr. Street: Right. Well, you're right. We still have gaps to bridge in that regard. They're not as bad as they used to be. That's for sure. I think the issue there and it's something that as a person from the discipline of communication I've been trying to champion amongst my colleagues and people with again, as you say educated in communication science to get them more involved and thinking about the contributions that they can make in health care settings. And it's, I think its just a matter of culture of differences in the disciplines, you know, academic medical centers where a lot of this work takes place, they're different than colleges of liberal arts or colleges of communication at, you know, universities. And it just takes a while for--I think to get more people involved in that work. Now, having said that though, I am seeing, you know, more and more people from the discipline of communication getting involved in, you know, trying to get Career Development Awards through, you know, the various and sundry agencies and what not. And more trying to get, you know, make contributions in ways that they could, you know, indeed lead and contribute to quality of care. I would say one of the things that would also help quite a bit is we need more researchers who study research in medical settings to embrace the value of communication science and to help recruit and bring some of those people in whether they are consultants, co-investigators or whatever.
And I think, for myself that was one of the things that helped tremendously, was being able to be involved in projects that were going on in those settings so I could contribute.
Dr. Baile: I was thinking as you said that, that there is still this myth in medicine to a certain extent that communication, you either have communication skills or you don't have skills. And so it becomes a little bit trivialized of course until people get to the point where they have to give bad news and--
Dr. Street: Right.
Dr. Baile: You know, frame responses to questions like, "How long do I have to live?" and then, you know, there's a real struggle around that and--but we still have a little bit of this idea well that communication is something you just either learn through experience or that you're born with it. And I think that some of current research has shown that that's really not true.
Dr. Street: Right. Skills are things that you can learn. I think we have a long--we still have quite a bit of work to do in terms of how we actually educate people about skills. When I review for, you know, I review for a number of journals and I'm often asked to review papers that have a communication skills intervention of some sort. And I think one of the things I find lacking, not always, but often lacking is sometimes people even treat the, you know, even accepting the notion that skills can be learned, they kind of treat the training process as okay, we've got the skills training intervention or we don't. So it's present or absent. When in fact, the quality of the skills intervention itself can vary tremendously and so I think we could spend more time and we need more research thinking about the science of how you become a better communicator and the way in which skills are learned. And I think that's probably an area where we could do, you know, quite a bit of work. So it's not something like, sometimes in pop psychology you think that communication skills you got your little recipe book and so now if I do this or if I do that or if I do this and that then that means I'm a good communicator and that's not the case at all. It's much more complex than that. And so I do think that, you know, we need to be spending more of our time thinking about what makes good skills training so that it does have the kind of lasting effect that we hope that it does in addition to the fact just recognizing that skills are things that can be learned.
Dr. Baile: I think that's a really important point and, you know, there's no real shortcut to learning some of these skills as they're the same thing as a surgical procedure - doing a spinal tap. You need to have a road map and you need to have skill practice with coaching. So giving someone a paper and saying here go read this and then go out and give a patient bad news really doesn't work does it? Or even listening to somebody give a motivational speech on that, it doesn't work either.
Dr. Street: It doesn't work either.
Dr. Baile: So I think that the medical profession in the area of communication is coming to an awareness that simulation and simulation types of experience where people have encounters with standardized patients might be the way to go in terms of learning to really be immersed--having immersion in the experience. What--did you think that that's--
Dr. Street: Right. An analogy I like to use is that, you know, writing is a form of communication. I look at that as composition. Oral communication however is more like performance.
Dr. Baile: Right.
Dr. Street: And it's live. It's in real time. It's on the spot. And the thing is that we need to understand about communication is that it's both an art and a science. So the science part is, we know enough about what tend to be behaviors and practices that tend to work well from a conversational point of view. But the art of it is, is like it's like a dance. That's what any conversation is. You know, you're coordinating with your partner. You all could go a number of different kinds of ways in terms of the course of the dance just like the course of the conversation. So part of the skill is your ability to adapt, select, and move along as you move forward through that conversation. The way in which you get those kinds of skills are not only having them in your repertoire of the things that you could do but also being able to engage them on the spot as needed in simulations, practice those are the things--those are the activities that are by far the best way to get people to learn new skills and to retain them.
Dr. Baile: So creating like a basket of repertoire of skills that you can pull out in a specific circumstance like even asking an open-ended question is something that we need to help people recognize is a skill.
Dr. Street: It's a skill and then they can use it as needed. And so I think the thing that we need to recognize is that learning that skill is only part of the process. It's being able to use it at the appropriate time.
Dr. Baile: Let me--I think we wandered off what I originally wanted to talk to you about even though these are very interesting issues, and that is what are you doing now in communication research? You've done a lot in cancer research. Tell us a little bit about what your current projects involve.
Dr. Street: Well, I'm just really committed lately to studying like I'd mentioned earlier the relationship between communication and outcomes. In my opinion we have not done a very good job studying those relationships. A lot of that evidence that shows that when people communicate in a certain way subsequently the patient has better you know, blood pressure control or quality of life or something like that. Most all that evidence is correlational, suggestive and we really don't know why that's the case. And if we are going to think about communication and ways in which you can find the relationships and what unfolds so that you can link that to better health outcomes. Then that really could inform communication skill interventions as well in terms of saying, here is what we need to focus on in terms of what patients or clinicians need to be doing in order to improve health outcomes. So modeling those pathways, that's something I'm involved with throughout several studies lately trying to figure out what those are. The second thing I'm spending a lot of time with is measurement issues and that is how do you measure study and analyze communication. And that's a very, very complicated situation because communication is very complex. You know what a person does and what that means could mean any number of things to any number of people. And so trying to capture, you know, the study of communication and what counts as good communication is also a challenge from a measurement point of view. So we're also working at coming up--trying to come up with the measures that might be not only reliable but have a bit more validity both in terms of standards of good communication as well as how those might be also perceived by patients or stake holders.
Dr. Baile: So tell us a little bit about what some of the technological challenges might be like in studying a medical encounter, where you're trying to look at what the downstream outcomes might be of for example, you know, a communication where a or an encounter where a physician is empathic or not empathic is that--how hard is that to do?
Dr. Street: Well, I think there are 2 sets of challenges. One is if you're looking at a particular type of behavior or in this case a particular attribute that the physician has like let's say empathy. One of the challenges is does empathy really matter? Sometimes it most certainly does. And sometimes it's not particularly relevant. Therefore the challenge is trying to find the circumstances under which that empathy would really contribute well to the success of the encounter, the patient's perception of care, their sense of well being or whatever outcome it is that you're interested in. So that's one of the challenges. Then the other challenge you have is what counts as empathy? And see, that's where--what counts as empathy is in, one would argue might be--the best judge of that might be in the patient's mind. So you can have somebody who as the patient's talking that clinician is doing something like this, nodding their head, making a face like that, and that patient may think that doctor understands me.
Dr. Baile: Connecting to him.
Dr. Street: I can tell. They connected and they understand what I'm going through. You could also have a situation in which a clinician--patient might be talking and a clinician might be saying, "Oh, I understand. I understand that how that might be real difficult for you." And yet in the patient's mind they may think, they're not being sincere when they're saying that, they're just saying that and that can happen sometimes too. The point being that not that the statements like I understand, I can see where that would be real difficult for you.
The question there is not that that's either a good or bad thing. It's that it counts as empathy to the extent that it's attributed to sincerity and that's the real intent behind it. When your person perceives that sincerity then that's an excellent form of empathy. Just like--and so that's an easy one to code, easy one to study, easy one to teach. The head nodding and those kinds of things that are a bit more subtle, well that may be more of something that the patient constructs in terms of how they make sense out of the way that you know, that you're reacting. So that's the challenge that you have. So if you're coding from the outside and a clinician engaged in the behavior that should count as "Oh, they did that behavior", that counts as an act of empathy from a coding scheme, that would might certainly be the case. Another real judge of whether or not that was the case is how the patient, you know, perceived that. And that's where--in the terms of research that we're doing, we try to triangulate sometimes coder assessments, patient perceptions, and things like that, they're not always on the same page.
Dr. Baile: So taking the medical interaction one step further than assuming that because someone makes an empathic statement, it has an empathic effect on the patient. Actually having the patient look at a video or a registration of that encounter and say, you know, what was going on with you when the doctor said that? Did you think that was really sincere? Did you feel that it was connected with you, gives you an extra piece of validity for that kind of statement, gives you more data of course, what more accurate data.
Dr. Street: Right, and what you've talked about there is a technique that I wish we would start using more. We're calling it stimulated recall, you could call it any kind of thing that you want. You have observer assessments. They're listening to audio tape, they're watching a video tape, they're coding the behavior, recording some coding scheme. So in their mind they're looking for behaviors. A patient's perception of what's going on may be along the same communicative dimensions, they're making their own judgments about what's going on. Those 2 coders' assessments, the patient's perceptions, they're often not always related to one another or if they are it's only marginally because it's the difference between a coder trying to code something based upon what they observed and a patient making sense out of something based upon what it means.
Dr. Baile: Right.
Dr. Street: So what the stimulated recall does that you've just talked about there is it allows us to point to a particular act that the patient noticed the behavior and then they attribute the meaning that was assigned to it. So what you have is that opportunity to bring those two together. So for example then to get back to you know, a comment that I wanted to make about training. To be able to say I understand that must be very difficult for you. What--a person who is trying to learn that skill needs to understand is that is vacuous unless you sincerely mean it. And if you sincerely mean it that will show and people are good at picking up on whether or not people are sincere or not. So that's how that kind of information might help both the skills training and improving that, and at the same time in terms of measurement issues how we try to bridge the gap a little bit between what people are doing and what that means.
Dr. Baile: I think that's a great example of the basic science of communication and sort of trying to take some of the a priori conclusions that we come to that a particular thing that we say to a patient, a statement is empathic. And sort of saying, well you know, that this really feels empathic to the statement and I'll bet there are some discrepancies at times between what patients are experiencing and what the clinician may be intending or may be feeling that this is just a mechanical chore that she has to do.
Dr. Street: Right, right, you know another way I think of again to put in the context of communication skills training, if you look at models of communication competence and there are a variety of models that we could look at and use that deal with competence communication, efficient communication production and things like that. But one of the ones I like is very simple and that is there are 3 components to being a competent communicator. One is the motivation and that sometimes is the one that we don't spend enough time on. It's amazing when people want to be good at something, how they are able to find ways to try to be good at something if they get, you know, the support, the help, the advice, the feedback that they need. People are good at that. And so it's got to be some sincere interest that a person has in learning communication skills. Then of course the knowledge that you would have and that is trying to understand what to do, strategies you might use, what kinds of behaviors you might use, the circumstances in which that they might be applicable. But knowledge is cognitive. Communication is behavioral. So the link between cognition and behavior then comes out through the skills. And the skills are the things you actually demonstrate and those are the things that will come through as we talk about experience, practice, feedback, more practice, more experience, more feedback and the like.
Dr. Baile: I think the motivation is really an important issue and you know, how we can get our training directors of oncology programs for example to sort of really understand that these behaviors on the part of trainees and doctors really make a difference on patients. And I wanted to hop for a second to talk a little bit about outcomes, downstream outcomes research. Because I think this is really the sort of piece that's going to make a difference to our colleagues in terms of their saying, "Hey, this really improves patient care." And I was thinking things like compliance and maybe use of resources or time spent in the intensive care unit, and I think we still have a little ways to go before we can show that specific communication competencies result in some of these outcomes. Maybe I'm wrong. Are we at a place where we're starting to push that envelope of studying some of the downstream effects of communication in cancer specifically, and how hard is that to do?
Dr. Street: Well, that's part of what I was talking about in terms of what I'm really committed to these days in my own research program. It's looking at the relationship between communication and outcomes. And again I consider adherence or compliance or whatever it is that we're going to call that kind of an intermediate outcome. I mean the idea is you got to do that in order to get better.
Dr. Baile: Right.
Dr. Street: So yes, are we pushing this more downstream? I think we finally are. I think prior to this we were given a lot of lip service to that. And I think, to be honest with you, I think some of our communication and outcomes research historically has been not very sophisticated even from a science point of view. And what we need to do is, you know, do more rigorous work in trying to explore those relationships. So when you're talking to clinicians they want to answer the so what question, you know, how does this make patients better?
Dr. Baile: Right.
Dr. Street: And you know, and how can we incorporate this within the flow of our work routine and what not so it doesn't take time away and we've got these time pressures and how can we do this in a way that's efficient but effective? Those are legitimate questions.
Dr. Baile: I think they're very important.
Dr. Street: And we need to be addressing those. So when we talk about you know, well we need to improve metabolic control and we need our patients to adhere and all of those kinds of things. That's where I keep thinking about this notion that I keep referring back to. The idea about the pathway through which communication is going to lead to better health. So for example, if you want a patient to have metabolic control, yeah I want the communication in some way to have them have better metabolic control or lower A1cs for diabetic patients. Then what you would ask is well, what's the mechanism by which that's going to happen? They need to stay committed to a diet and exercise program and to take their medications as needed. So the key to success is what you're talking about is that commitment to those things. Alright, so if that's the commitment let's work backwards in terms of what you're going to try to do in the consultation that might lead to those things that subsequently might lead to lower I mean to better metabolic control. So I think those are, you know, and those questions need not be very difficult but yet it puts it in the context of the relationship between what happens when a doctor and a patient talk. And then ultimately down the road what you hope it is that's going to be an outcome and what's got to happen along the way in order for that to happen.
Dr. Baile: I think that's--dissecting that process is really, really important. You know it's a little bit of a, I guess a difference I think, that when you're talking about oncology versus primary care and other disciplines. And I've been very interested in some of the research or articles in the literature that really talk about the emotional burden of having difficult conversations on the part of the physician.
Dr. Baile: Right.
Dr. Street: Giving bad news, talking about end of life issues and you know, how the emotions of the physician sometimes get in the way of having conversations that might be really tough.Like talking to the patient about the end of chemotherapy and discussing resuscitation and not a whole lot of--I think a whole lot of research hasn't quite yet swung to focus in oncology on this inner life of the doctor that represent barriers to communication.
Dr. Baile: I'm kind of wondering what your thoughts about that? Is it something you think we can study or is it important in factoring into some of the interaction that occurs around these really tough conversations with between doctor and patient?
Dr. Street: Of course it is because it affects what one is able to do in the consultation and how one is able to perform as a communicator. I think, what you're talking about is a very difficult kind of situation. I mean in your own work and studying how you break bad news and things like that. You know these are extremely challenging consultations both in terms of the emotional burden on the clinician, on the patient, the different ways that they cope with at that point in time and things like that. I think the way in which we might be able to answer your question or at least to think about your question or at least how we might approach your question, is we could conceptualize that emotional burden twp ways. One way might be that emotional burden the clinician is facing is a barrier to providing patient-centered care, and therefore how do we overcome it. That could be one perspective. The other perspective is that emotional burden is part of the care process that's being delivered at that time. And I know you're familiar to some extent with some of the work that now people are talking about, relationship-centered care. And what relationship-centered care is, as I understand it, it's not just serving just the patient. The doctor's feelings, the doctor's motives, all of those things have equal play in that consultation as well because medical care is something that's jointly constructed. So the care that's being provided to the patient is as much--it's as important how the doctors respond to that him or herself with regard to that emotional burden. How they are trying to cope with it and what it is that they are trying to do in terms of trying to come up with as satisfactory an encounter as possible under these kinds of circumstances. I think if you consider a barrier or it's part of the process you would approach how you might talk about that and study that and intervene in some different ways. And so I think, you know, that's obviously an area we've got so much more work to do in studying those issues.
Dr. Baile: Yeah, I think it's a very exciting area because it touches on emotional self regulation and a lot of things that folks in communication and psychology have been, you know, studying for years but perhaps not really understood or had the opportunity to apply it to some of the tension that can exist in the medical encounter when those difficult conversations take place. And you know, I think that the microscope is focusing more and more on those end-o- life conversations because patients when they don't have opportunities to talk about their preferences may have healthcare outcomes such as spending times in the intensive care unit.
Dr. Street: Right.
Dr. Baile: Or getting treatments that aren't necessary that are not really favorable. So the area is really ripe for that I think.
Dr. Street: In oncology we've spent a lot of time in screening and campaigns to get people to screen, the physician's efforts to get people screened. We've spend a lot of time looking at the diagnosis, the how you need to go about making decisions, your initial decisions for treatment. We have spent so little of our efforts from the communication science point of view trying to study survival, survivorship as well as transition in palliative care and end of life.
Dr. Baile: Well, it sounds like some of your work can hopefully kind of create a pathway to get other people interested in sort of investing time and energy and some thought in that area. So thanks so much for chatting with us today and today we've been talking with Dr. Rick Street about some of his research and key areas in communication research and oncology that we'll hopefully be seeing more results and more interesting papers and studies emerge in the future.
Dr. Street: Thank you Walter.
Dr. Baile: We'd like to thank Dr. Rick Street for joining us today and for a very informative discussion of research in the important area of cancer communication. For more information about Dr. Street's work you can visit his website. To obtain the monograph "Patient-centered Communication and Cancer Care,", you can download it at this address or web search patient-centered communication in cancer care. For more information about the I*CARE program and cancer communication and to view other Achieving Communication Excellence video programs, you can visit us at www.mdanderson.org/icare. Thank you for being with us today.
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