Susan Block, M.D., FACP
Professor of Psychiatry and Medicine
Harvard Medical School
Dr. Baile: Hi, I'm Dr. Walter Baile, Director of the MD Anderson Program for Interpersonal Communication And Relationship Enhancement. It's my great pleasure today to welcome Dr. Susan Block. Dr. Block is chair of the Department of Psychosocial Oncology and Palliative Care at Dana Farber and Brigham & Women's Hospital in Boston and Co-Director of the Harvard Medical School Center for Palliative Care. Dr. Block is Board Certified in both fields and in palliative medicine. Throughout her career Dr. Block has had a strong interest in improving the care of patients with life threatening illnesses and in medical education reform. She's been a leader in the development of the field of palliative medicine nationally and has developed innovative nationally recognized educational programs for medical students, residents, fellows and faculty. She's the conceptualizer, founder and national program director of the Project On Death in America, Faculty Scholars program and is the recipient of numerous awards for medical education and education research and also for her contributions to the field of palliative medicine as a leader, educator, and mentor. Dr. Block has received funding from the National Cancer Institute, the NIMH, as well as multiple foundations and is the author of more than a 130 published articles in the area of palliative care and psychosocial oncology. Susan, thank you for coming.
Dr. Block: It's a pleasure.
Dr. Baile: So, in thinking of your career, I noted that you as I started out in psychiatry. So I wonder if you could tell us a little bit about how you got interested in palliative care as a specialty.
Dr. Block: Yeah. Well I think that my interest in the field of palliative medicine goes back to experiences I had as a medical resident, an intern, where I was just appalled and upset by the experiences of patients who were facing the end of their lives in the hospital. And, and felt uneducated and kind of helpless to make them better. And in my helplessness I think in some ways I learned something about the power of a relationship to help a patient through a really hard time. I wouldn't say I had the knowledge back at that time you know, effectively treat pain or manage symptoms. But I could see and feel the power of a relationship. And I think I went into psychiatry from internal medicine with the idea of wanting to sort of develop my own competencies as a, as a healer, as a listener, as somebody who could really understand what it was like for people going through really hard times, particularly with illness.
Dr. Baile: And of course the whole area of palliative medicine has I would say, almost exploded in the last 5 years in terms of it recognition, acknowledgement and the number of trainees entering the field, so I guess that was a very good decision on your part to really establish a foundation for understanding the dynamics of human relationships and how that applies to palliative care. I wonder if you could talk a little bit more about the importance of the issue of the doctor-patient relationship in palliative medicine.
Dr. Block: Well, you know I think the doctor-patient relationship in all of medicine is a crucial component of healing and helping patients live better with whatever they're confronted with. And I think it's particularly important in chronic illness, in life threatening illness where people are you know emotionally destabilized by the experience. Where they may be dealing with high levels of anxiety, fear, uncertainty and so on. And my sense is that the doctor-patient relationship can be a, you know a kind of a safe haven in a way for people to kind of work through some of the challenges they are facing with serious illness when it works well. And that in many ways our healthcare system, with the fragmentation, and with the kind of decline of primary care that we've seen in the past years, that we've lost some of the structures that help people contain and deal with challenging experiences of illness with many specialists involved, nobody knowing the patient as well as one would hope and so on. I think one of the places where the doctor-patient relationship is actually very alive and well is in cancer care. Because of the sort of intimacy of the relationship that often gets established between patients and doctors. I think another place where we have really emphasized the importance of that relationship is in palliative care.
Dr. Baile: So communication skills and team work are an important component of the educational model which you bring to the palliative care service in your institution. Could you tell us a little bit about how your psychosocial oncology and palliative medicine department is organized?
Dr. Block: Our department is organized into 5 divisions. We have an adult and pediatric care program and an adult and a pediatric psycho oncology program and then a research division. And we have a lot of integration kind of from adult and pediatric the clinical services and across the adult psycho oncology and palliative care program and the pediatric programs. Because we share patients the patients often come to psycho oncology earlier than they come to palliative care because they're distressed for example about their illness and subsequently may develop more symptoms and then there's collaborative care between the two programs or even handoffs of care between the two programs. That we found that it is a real advantage to have psycho oncology and palliative medicine working so closely together. The other thing that we do is each program teaches the other. So, our palliative medicine physicians and team teach our psycho oncologists about how to have some of these end of life conversations that they may be less familiar with and comfortable with. They teach our psycho oncologists about some of the basics around pain management and so on. And our psycho oncologists teach the palliative care team about recognition and treatment of depression, delirium, you know anxiety disorders, how do we think about how human beings process trauma and stress about family dynamics and so on. So, it's a very sort of fruitful, rich interactions between the two disciplines.
Dr. Baile: Sounds very much like a win-win situation with lot of conversations back and forth between the two separate specialties.
Dr. Block: Yeah, it's wonderful actually.
Dr. Baile: So, how does, how do you approach the issue of training your fellows in communication skills in palliative care, on the palliative care of service? Do you have a formal program, what are the aspects of that type of training?
Dr. Block: Yeah. We do have a formal program that combines beside observation and feedback that is very, very intensive throughout the year. It's, you know, with every single patient in the first part of the year and then on a regular basis each fellow receives feedback about their clinical interactions throughout the rest of the year. We have a curriculum that focuses on a whole variety of communication topics, big parts of which are taught in an interactive small group format, some with standardized patients, some with role plays, some with group discussions and so on. And then we have a daylong advanced communication skills retreat for all of our palliative medicine fellows that takes place every year where they have the chance to step away from the clinical environment and daily life and do a combination of you know challenging skill building exercises with reflection. And I think what we feel in some ways proudest of in our program is that we feel that we provide our fellows, you know, absolutely first rate communication skills training and that we have a team of faculty who do it and reinforce each other that we have a kind of shared model about what good communication is. And what our fellows say is that learning about communication is the most transforming element of their fellowships. And, so that seems like the things we value and the things that they get out of it, are very aligned which is a wonderful thing.
Dr. Baile: So that transformation that you talk about, just to kind of clarify that, it would be fair to say that's the transformation of folks who might be more technically oriented focus on symptoms into the issue of being a healer and how to be a healer... is that sort of the transformation that you were thinking about?
Dr. Block: I think that's one component of it and it's a very important component but I also think that learning good communication skills opens up whole new worlds in the practice of medicine, about understanding and connecting at a deep level with patients and so I think the other really important world that gets opened up for people is a kind of world, about the intimacy of the doctor-patient relationship. And what they can learn from it and how they can grow from it as well as how they can be a healer for their patients.
Dr. Baile: And so you know the literature on communication skills is replete with you know discussion of what some of the barriers are to acquisition and training of communication in post graduate programs and programs such as yours and one of the things that really emerges is you know how do we train people to be good teachers? And I was wondering, do you have ongoing professional development for your faculty in the area of communication skills and interaction with your fellows, is that something that you feel is important?
Dr. Block: I think it is really critically important and one of the things that we have done in a very mindful way has been required all of our faculty to go through a national faculty development program that we offer that's a 2 week course focused intensively on teaching communication, on building communication skills, and on other sort of pedagogy that supports palliative care practice. And so we expect all of our faculty to go through that program first as learners, so that they can develop you know deeper competencies in their own skills and then a large number of our faculty teach in that course and I think the process of teaching others about communication in a very sort of structured course with feedback from the senior faculty is something as well as coaching from the senior faculty is something that allows them to continually get better as educators. In addition we do kind of onsite local faculty development where we focus both on real time problem solving like how does one work with a trainee who is so emotionally overwhelmed by patient feelings that she can't go there with her patients or more didactic kinds of presentations such as reading articles or talking about new developments in the field so we do it in a variety of different formats.
Dr. Baile: So the faculty continue their professional development by talking about examining their teaching skills, maybe how they manage difficult fellows or fellows who are struggling with a patient interaction, and at the same time the fellows learn from the faculty about the essence of communication skills on an ongoing basis.
Dr. Block: Yeah. It's a win-win. Again because I think the faculty keep growing it and I think that one of the most sustaining parts of palliative care practice for people, and it's a hard practice, is deepening one's communication skills. Allowing for sort of richer more meaningful relationships with patients which kind of feed back into a more satisfying kind of professional life.
Dr. Baile: You know there's been a lot written from the time of Avery Weismann who is up in your area and I think he was at Harvard for a long time...
Dr. Block: Yeah.
Dr. Baile: ...Which talked about how one dealing with dying patients must come to grips with their mortality. Do you find that's an issue that comes up with the fellows or with your faculty at all? Is it discussed or is it something that folks take for granted someone's doing on a more private basis?
Dr. Block: No I think it's an explicit focus of our training program and of our kind of you know faculty climate. I mean first of all we see in our setting a tremendous number of young people. Tremendous number. And you know it's a comprehensive cancer center, such as this one is, that attracts people who are younger and really want to do everything possible to fight their illness. So I think that the issues about identifying with the patients about, we have many faculty who are young parents with young children who are watching other parents facing the end of their lives worrying about their children or facing children who are dying. So I think that the issues are really in your face and that you can't avoid it, or you shouldn't avoid it because I think that it leads to people becoming sort of demoralized, overwhelmed, shut down and other kind of dysfunctional ways of coping so that we talk about it very explicitly on rounds, in teaching conferences, in our fellow conferences, at our big monthly seminars, and in individual meetings, mentoring meetings with our trainees and I would say it's a ubiquitous topic of discussion.
Dr. Baile: Thank you. You'd mentioned early on that one of the divisions that was a component of your department was the research.
Dr. Block: Uh, huh.
Dr. Baile: ...division. And I know you, lately you've had some very exciting results come out in the literature or around end of life discussions with patients and families and I wonder if you could talk a little bit about some of your work in that area, because I think it really provides very crucial information that was missing from the literature about the impact of end of life discussions on patients and families and one of the great fears I think of some of the clinicians is that talking about death, talking about dying is going to send patients into despair and especially when they come to a center like yours and ours where you know the focus is so much on getting a good result.
Dr. Block: Yes. Yeah. Well the first thing to say is that our research division is directed by Holly Prigerson who is the principal investigator on these major studies that have come out of our institution and Holly I would say, is a brilliant social scientist who's done amazing work so I'm talking about her work here of which I'm maybe you know a very tiny piece. But I think that the work that she did and that was published in the JAMA with Alexi Wright as the first author was the one focused on the associations between end of life discussions and outcomes at the end of life. And what they found were that in a population of patients with advanced cancer who turned out to be on average of four months from death, that the patients who, I'm not saying this quite right, that with a population of patients with very advanced cancer, about 30% only remembered having conversations with their physicians about end of life issues. And that patients who had had these conversations had a series of outcomes that were different and I think, most people would agree, considerably better than the patients who didn't remember having these conversations. And so that the patients who had the, reported having had these conversations had better quality of life at the end of life, less use of the hospital and the intensive care unit, more use of the Hospice services, that their family members had better bereavement outcomes, the patients were more likely to have their goals of care honored at the end of life and that this whole process led to considerable reductions in the cost of caring for patients. And also in this study Holly and her colleagues were able to show that these conversations are not associated with more anxiety and distress among the patients and that the, if anything these conversations amplified and intensified the physician-patient relationship. And that was done, that was in work published by Jenny Mack.
Dr. Baile: That's very reassuring of course because the great fear on the part of many clinicians is that conversations about dying would really damage patients psychologically. So that's really good to hear.
Dr. Block: Agreed, yeah.
Dr. Baile: The other thing that I remember maybe 15 years ago when the issue of telling, well, the issue of whether we should tell patients now goes back to the 50's and then in the 60's we started talking to patients about cancer diagnosis, and now there's not really much discussion about whether you should tell patients that have cancer but sort of the discussion now is talking about prognosis, outcomes of care and I remember Jimmy Howlette wrote a nice article in Cancer many years ago, which I think the title was Its not whether we tell, but how we tell. And I know you've been very interested in that whole aspect of how we teach oncologists how to talk to patients about end of life issues could you say something in general about your interest there and...?
Dr. Block: Yeah. Well you know I think the issue about prognosis is a very challenging one. Because prognosis is uncertain and we're not that good at predicting how long somebody is going to live and yet in order for patients to make the most appropriate decisions about what kinds of care they want and don't want, prognosis is a really critical piece of information to have. And the literature again shows that patients who think they have a poor prognosis are much less likely to choose aggressive care. And so if a patient thinks they can be cured they're more likely to choose something that is very aggressive and there are times when patients falsely believe in more optimistic outcomes for themselves. And I think in some ways the, we know also that we tend to be as physicians, overly optimistic in our prognostications and then patients hear our prognoses and they multiply those optimistic prognoses with their own optimism. And so patients think that they have often much more time than they actually have and with that people are less likely to do appropriate end of life planning to achieve goals of life closure that might be important to them, because they feel that, oh, I can do that tomorrow. I don't need to deal with that today. And also they make choices for treatments that are predicated on the idea that the treatments might help them, when indeed there is a certain point at which for example, going to the intensive care unit does not prolong survival and results in a much poorer quality of end of life experience. And so it makes all the sense in the world to go to the ICU if you think it's going to help you. But for more cancer patients they get to a point where going to the ICU is not going to have a benefit in terms of survival and so that's where it's a really, I think of the prognostic information is being kind of the frame around which, within which patients can define the things that are important to them and set their own goals and values.
Dr. Baile: There's been some, I think, attention given more recently to the economic consequences of over treating patients and end of life care that may not be appropriate for them without a discussion having taken place with the patient and it's been astounding to really know that in this era of economic challenges that we're in now, that many of the bankruptcies are due to unpaid medical bills, and so I was thinking about your research and some of the very practical applications of the burden of cost of care that falls on the family for example when a patient dies, and has spent a month in the ICU because they haven't had a discussion of end of life its, it's pretty striking.
Dr. Block: I agree. And I think that you know patients, that's another beautiful example of how patients might make different choices and say they would make different choices around spending money if they understood more about their prognosis. But I think it's also really important to emphasize that our goal in trying to improve conversations between doctors and patients and so one really needs to focus on what is a benefit to the patient rather than on the idea about cost cutting. It would be nice if we were able to save money, but the goal here, the goal in my work is around improving the experience for the patient and for their families.
Dr. Baile: Well I can see that your group and yourself have really been adopting this concept of patient centered oncology which is also rather new in terms of the patient really being informed and participating in decisions that involve, involve their care. So I think that's a really important thrust that you've brought into the literature and hopefully into the practice of oncology. We've been talking today with Dr. Susan Block from Harvard Medical School about her clinical program and her research in palliative medicine. Thank you very much Susan.
Dr. Block: My pleasure, thank you Walter.
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