I*CARE Roundtable with Dr. Anthony Back Video Transcript

 

Interpersonal Communication And Relationship Enhancement (I*CARE)
Roundtable with Dr. Anthony Back
A Conversation with Walter Baile, M.D. and Anthony Back, M.D.
Date: October 21, 2008
Time: 17:28

Anthony Back, M.D.
Professor of Medicine, Division of Medical Oncology
University of Washington, Fred Hutchinson Cancer Research Center

 

Dr. Baile:
Hello, I'm Dr. Walter Baile and I'm pleased to bring you I*CARE Roundtable; a discussion with leaders in the field of communication skills in medicine, sponsored by the M. D. Anderson program on Interpersonal Communication And Relationship Enhancement. Today our guest is Dr. Tony Back, Professor of Medicine at the University of Washington in Seattle. Tony is Director of the Cancer Communication and Palliative Care programs at the Seattle Cancer Care Alliance and the Fred Hutchinson Cancer Research Center.

Tony is a medical oncologist by training and practices gastrointestinal oncology. He was a faculty scholar on the "Project on Death in America," and has written extensively in the area of communication skills in oncology. Tony has been the principle investigator for two important educational grants: Oncotalk and Oncotalk Teach. Both NCI funded programs for teaching communication skills first to medical oncology fellows, and now to train medical oncology faculty to actually teach communication skills. Welcome Tony.

Dr. Back:
Thank you.

Dr. Baile:
You know I just wanted to go back to something you had said, which sort of traces your line of thinking a bit about organizing these communication skills training for fellows and faculty, and that was a discussion about changing the culture of medical oncology, and I wonder if you could tell us a little bit about what you were thinking and what the idea was?

Dr. Back:
Yeah, absolutely. The culture change aspect, I think, is a consequence of the way that the nature of oncology practice has changed. It's become so much more complicated. I think the biomedical aspects of just the anticancer technology are at a point where they become overwhelming for both the patients and even the oncologists who are trying to explain it to them. You know, I do GI oncology so if you take for instance metastatic colon cancer, 10 years ago there was one drug and we used to kind of argue about what schedule to have it in. But now there is a whole array of drugs, there's a whole array of schedules, there's all these new ways of evaluating what the outcomes are, there are ways of even predicting who's going to respond to what drug with these KRAS mutations. And that level of medical complexity has made all the basic aspects about deciding what treatments are worthwhile, what treatments are really doable, and how patients feel about treatments. It makes all those basic issues much more complicated because there's this whole layer of other stuff, and so the culture change I see is integrating the biomedical complexity with the approach to the whole person. That... integration and inclusion of those things together is the culture change that I think is waiting in the wings. I think it's starting to happen. I certainly see it in the lay press. You guys might have seen the New York Times recently, Pauline Chen had a blog about do doctors have time for empathy, and the response is overwhelming. She writes this one little thing in there... and gets 200 responses by the next day. And so I think this is something that really is on the minds of patients and families.

Dr. Baile:
Do you think that patients today also really want to be better informed and have information about their illness, even things that weren't talked about like prognosis.

Dr. Back:
Yeah it's interesting. I think it cuts both ways. I see there's this group of patients who want lots of information, they want to know all the details. There's another group of patients who still, they want to keep a little bit at arm's length. They want to be able to trust the doctor to help them with the big decisions. They don't want to be uninformed. I'm not talking about people who are completely in denial, but they just don't want to look at all the complicated, sobering, worrisome stuff. I have patients now who tell me that they limit how much they look at the web and that when they first got diagnosed they did a lot of reading and they were like, oh my gosh, and they've stopped. I even have a friend who's an expert cancer blogger who advises other patients on the web about what to do, and she actually advises newly diagnosed people to be very abstemious about their reading, very selective, and she points them to just a couple of places and says stop there and go talk to your doctor.

Dr. Baile:
So information can be a double edged sword?

Dr. Back:
Absolutely.

Dr. Baile:
... for patients, and in fact some can be totally overwhelmed by what they read and then it can be very confusing. So one of the new jobs of the oncologist is really to be able to explain at a level of the patient, what's going on.

Dr. Back:
Meeting the patient where they are in terms of the level of detail they need, the level of understanding and complexity that they need. That's more important than ever, especially with so much information on the Internet that it's so variable in quality. Some of it is great but very technical, some of it is great but for a given patient might be too basic, and some of it is just who knows where it's coming from?

Dr. Baile:
You've been involved a lot in palliative care. In fact, it's one of your specialties - end of life communication. Could you talk about just a few of the issues regarding the importance of communication at the end of life, some of the decisions that patients and family members, need to make, and what's been missing in end of life discussions?

Dr. Back:
You know what - I think that in the past few years, there is this increasing acknowledgement on all sides; doctors, patients, and families, that some kind of end of life planning is important because I think there's this growing realization that without some confronting of the issues, without some preparation, that you can get to the end of life and run out of time - run out of time to talk to your family, run out of time to say the important things, run out of time to make a will or make preparations, and it leaves everybody in this just horrible frenzy. I think that is becoming more and more well known. I think the thing that's not as well known now, is how, as the clinical team, you can start to prepare people in small ways; small steps, and keep those kinds of things moving. I've worked with lots of trainees and they'll talk to patients and say, oh she's in denial and kind of throw up their hands like that's the end of it, we're not going to do anymore. And yet the challenge I see is how do you continue to engage with that kind of person, and not to keep confronting them? There's this study of oncologists that Chris Dougherty had already talked about how the oncologists felt like they were "hitting the patient over the head" because that's the only way they know how to go about it and it turns out that's wrong. There are other ways, and I think those other ways about how to engage people in these processes of thinking ahead need to be more widespread, more taught, more a fixture of the culture instead of us just saying - us the clinicians just saying - you know so and so's inappropriate. If I hear that one more time, I'm going to flip.

Dr. Baile:
So let me go back to the point because I think it's a really important one, and maybe start with the perception that many doctors, oncologists, generalists, have that idea that communication is something that either you're good at or you're not good at. And that well, some folks have communication ability and other folks don't, and it's something you really can't learn and I wonder whether you could speak to the point of... is communication really a skill?

Dr. Back:
Sure, sure. So, what all the empirical studies show is that you can improve, with a certain kind of teaching. It's not the kind of teaching we all grew up with, it's not the see one, do one, teach one. It's a much more interactive, faculty intensive, close attention kind of dialogue and feedback with a learner. And that kind of skill is definitely learnable. I mean certainly we all start out in different places with communication because we've all had different life experiences. But the fact is, we can all improve and my feeling is that the average level right now, it's a little too low. The average level ought to be higher.

Dr. Baile:
So tell us about Oncotalk and how that came about and what you've learned from Oncotalk, and sort of how this process really went for the learners?

Dr. Back:
So Oncotalk was a project funded by the National Cancer Institute to give an intensive communication skills intervention to medical oncology fellows. These were mostly fellows in their second and third year of fellowship, so they're really finishing a long process of acquiring biomedical expertise.

Dr. Baile:
And they've had some experience with taking care of the...

Dr. Back:
... had some clinical experience. They've had some experience watching their mentors etc, etc, and we brought them to a small group, intensive workshop in Colorado. We work with them with actors who came in playing patients at different points in the trajectory of illness every day, and we had every fellow practice every day with a patient and they learned to give feedback, they learned to be supportive, they learned where they get stuck, and we had expert facilitators as you know since you were one of them, who helped make that process engaging and non judgmental and kind of fun. And so that was a five year project, we trained about 200 fellows, and had very interesting results from it. There are a couple of things we planned and a couple of things we didn't plan. One of the things we planned was an evaluation looking at what these trained doctors actually say when they talk to simulated patients. So we tested at the beginning of the retreat and at the end of the retreat, and we looked at the kind of things they said like, when the doctor gives the bad news do they wait for the patient to react before they go on? We measured that. Did they say the word cancer when they're talking about the bad news? We measured that. And a whole variety of those kind of content- based cues, and those who really responded and improved quite dramatically after...

Dr. Baile:
And those were actual audio recordings?

Dr. Back:
... audio taped recordings, right, that we had blinded coders read and evaluate both pre and post and that was done by James Tulsky at Duke who developed the content-based coding system and the web program that goes along with it. And those changes are very impressive, P values .001, etc.

Dr. Baile:
And what kind of feedback did you get from the fellows about Oncotalk?

Dr. Back:
Well that was the part that we didn't expect actually. The fellows were... many of the fellows felt like this was a side of their practice they had not explored before, and many of the fellows were quite grateful that they had a chance to sort of think about this. The parts that I didn't expect, which I was alluding to earlier, was that for the fellows it created kind of a social network of people who kind of know each other, they see each other now at other meetings. I usually have a little night out at a bar at the annual ASCO meeting where people can kind of get in touch. And there's this interesting kind of network of people, and it made me think that what we've done in some sense is create this niche and culture within oncology of people who are concerned about these issues.

Dr. Baile:
Interesting, I remember that James Tulsky, one of the co-investigators who did the analysis of the audiotapes, had mentioned exponential affect on patients of training 200 fellows and the downstream affect that... over the course of the 30 year career of the trainees that perhaps one could see a million and a half patients, and so the impact of training could be substantial.

Dr. Back:
Yes.

Dr. Baile:
That's really important.

Dr. Back:
It's huge actually.

Dr. Baile:
Now Oncotalk was a five year program, and now you've launched into something a little bit different?

Dr. Back:
Yes.

Dr. Baile:
And that is to extend Oncotalk in a way, to teach oncologists how to teach communications skills and...

Dr. Back:
Yes.

Dr. Baile:
.I wonder if you could talk a bit about it.

Dr. Back:
It gets back to the thing you mentioned earlier about how do people learn, and the usual gig in medical education is see one, do one, teach one. In communication, it turns out that just doesn't work. It's like Bob Arnold says, one of the other investigators, would you expect to improve your golf game by watching Tiger Woods on TV? I don't think so. So really the issue is you need practice, and if you look at the expertise literature about how professionals acquire expertise, it takes many hours of practice but it takes a certain kind of practice; not mindless practice where you just repeat the same thing over and over, it's practice with feedback. And that's what we're trying to create. So that's in a way, what we learned in doing Oncotalk, was the importance of that kind of teaching because we had videotaped and audiotaped ourselves as teachers as part of that project, and analyzed them in great detail. And so now we've taken that methodology and transformed it into something that oncology faculty can do in clinic, in real time when they're precepting fellows, and that's what we're trying to teach them. So the new program is called Oncotalk Teach, it's for oncology faculty who work at cancer centers that involve oncology trainees, and we're trying to equip them with a new set of teaching skills about how to improve fellow communication. And so it raises a bunch of interesting issues in the faculty's relationship with the fellows, and how they see fellows' professional development, and how talking about communication can actually be part of that even if the fellow is really headed towards a career in basic research.

Dr. Baile:
And some of the contacts that the faculty will have with fellows are very brief, so this is really making the most of your five to ten minutes with the fellow and how to do teaching on the run a little bit?

Dr. Back:
That's right because the teaching environment is so complicated now in the academic centers, people have so little time, they're pressed for lots of other things, and we've received a certain amount of skepticism from faculty who haven't participated, that I'm never going to have time for this. Well the reality is they're spending a considerable amount of time with fellows already, and the important thing is how they can they make that small amount of time really count, make it a learning moment for the fellow instead of just another blah blah blah case? That's the issue...

Dr. Baile:
And so far you've done two cohorts?

Dr. Back:
Yeah. We're halfway into our second cohort.

Dr. Baile:
How are things going?

Dr. Back:
You know, it's been really interesting. The faculty have been very engaged in this, and we've had some really interesting, thoughtful, deep conversations about what it means to be a person who ushers other people and mentors them into the process of becoming an oncologist... the kind of oncologist we'd want them to be, the kind of oncologist who can talk about the biomedical stuff, the kind of oncologists who can at the same time talk about healing, the kind of oncologist who pays attention to the whole person.

Dr. Baile:
And there's an evaluation piece to this project also?

Dr. Back:
Yes, and parallel to Oncotalk we are looking at the acquisition of teaching skills and we're using James' content-based coding again, because what's interesting and striking is that if you look at the medical educational literature, there's just so little empirical research about how to actually improve communication skills. I think of this as a complex psychomotor of clinical skill. There's so little data about how to do that. I thought this was really important.

Dr. Baile:
And so this is an ongoing project and has 3 more years to the project, so people who want to find out more about it, medical oncologists, could... where could they go?

Dr. Back:
Yeah, the website is www.Oncotalk.info and they can find everything there or they could give us a call.

Dr. Baile:
Great. Well thank you much for sharing your wisdom and these very exciting programs with us.

Dr. Back:
Thank you.

Dr. Baile:
And we'll just wait to see the outcomes and I'm sure this will be a great benefit to the faculty.

Thank you Tony. By the way, to hear more about communication skills and cancer, be sure to go to the I*CARE website homepage and click on ACE, that's A-C-E, lecture series to watch Tony's lecture on what to say when the chemo did not work. It's really a fabulous talk.

 

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