David W. Kissane, M.D.
Chair, Department of Psychiatry & Behavioral Sciences
Jimmie C. Holland Chair
Memorial Sloan-Kettering Cancer Center
New York, NY
Dr. Baile: Today, we're pleased to have for our I*CARE round table discussion Dr. David Kissane. Dr. Kissane holds the Jimmie C. Holland chair in Psycho-Oncology and is chairman of the Psychiatry and Behavioral Sciences Department at Memorial Sloan-Kettering Cancer Center and attending psychiatrist at Memorial Hospital for Cancer and Allied Diseases. He's also a professor of psychiatry at the Weill Medical College of Cornell University. Dr. Kissane obtained his initial medical degree and later research doctorate from the University of Melbourne in Australia. Across his 40 year medical career, he's trained in family medicines, psychiatry of the medically ill and palliative medicine. His academic interests include group, couples and families psychotherapy trials, communication skills training, studies of existential distress and the ethics of end-of-life care. His research has been extensively published in these areas. Dr. Kissane served also as the president of the International Psycho-Oncology Society from 2000-2003. His work was recognized by that society in 2008 with the prestigious Arthur Sutherland award. Thank you for coming David.
Dr. Kissane: Thank you, Walter, great to be here with you.
So you've been at Memorial now for how long?
9 years, and I remember when you first came that a lot of your focus was on developing a communications skills laboratory. I think you call it Comskills Lab, right?
So can you tell us a little bit about the lab and how it started and where things are at now with training of psychiatrists and medical professionals in communication skills?
Sure. We've been doing communication skills training over a couple of decades of course. And particularly in Australia, I became a fan of that and its impact on surgeons and medical oncologists. We had a large national training program through the National Breast Cancer Advisory Group. And the idea of developing this at Memorial I think was to bring something of a psychosocial peace to the whole cancer center. So that we could help all clinicians, be they surgeons, medical oncologists, of whatever discipline, nurses too in fact do a little more in the psychosocial support that they offer people. Which I think is the benefit of communication skills training. So the idea was to establish a lab which means a physical space that has a theatre for presentations, has a series of small group rooms which enable 3 or 4 clinicians to meet together with an actor playing a simulated patient and with facilitators. And is equiped with video cameras that allow for instantaneous video playback so that the clinician after talking with a patient, a simulated patient for 4-5 minutes can pause, reflect upon what has happened and can then watch the video and see in detail ways that things were expressed, strategies that were attempted and can in fact learn what they like as a communicator and work to improve that. So we developed a particular model as you call it, the Comskill model. And it puts some emphasize on trying to break up into segments what we teach. So we have a goal for each communication module where our module is taking up half of what might be a clinical consultation and focusing in on that path. Examples would be to discuss prognosis or to move towards the discussion of a recommended treatment approach. So we will focus on module on a part of a consultation like that. And for each module, we take a goal that the clinician would have as their objective for that encounter. And we see that goal being achieved through a series of strategies which we define as the sequence steps that would flow in a natural clinical manner--manner to accomplish the goal. Each strategy in turn is able to be accomplished through by skills and tasks. Skills, we--we think of as verbal utterances. They're the pieces that come from the mouth and that can be critiqued and the wording can be fine tuned, the information framing can be practiced. Processed tasks are more--the background behaviors, the body language, the nonverbals. Occasionally, we'll have a very complex component of communication that we might say also represents the task. So if you took the idea of discussing randomization for a clinical trial let's say that construct randomization is complex, and we create a task around how you do that. Essentially then, the clinician is being taught in these communication sessions to create in their mindof the language of the skills they use to become an observer of the tasks and then to follow a series of strategies that will make up the accomplishment of the goal for that particular module.
I really like the idea that your teaching has sort of been driven by a conceptual model which has broken down the communication steps into digestible units so to speak.
You know, so many people think that communication skills is something that you learn by the seat of your pants or your--were born with it, weren't born with it or you see someone who does it well and that's enough. But it's very [inaudible].
[ Simultaneous Talking ]
It's a real skill development.
It's really skill development, isn't it?
Yeah, it is.
And so your model allows clinicians to actually have a conceptual idea of what they need to do and when they need to do and what they need to say which I think is very useful for folks who aren't familiar thinking about communication like that. And giving them the words seems to me to be also very important.
When they come out of a program like this, one of my goals is that they've developed a reflective ability in their own mind to monitor what their communication style is like to be able to take stock of what works, what's been challenging and when they've had a patient that's presented some kind of challenges to them that they can--then use that reflective repertoire to work out, "Okay, next time I could do this or I could try that." And that's the benefit of putting names to skills, defining more of what we teach, and what these strategies are so that people can look back and see how they could in fact personally improve things. So it's a lifetime of learning to continue to improve this communication.
And I know that--I think that the aspect of videotaping and slowing down the process if you need to in reviewing the videotape enhances this reflective ability so that folks begin to think about communication as a skill and think about what they said and didn't say and what they might say next time. So this reflective piece is just absolutely essential, I think for folks to become aware of how they communicate and what they could do differently and what worked and what didn't work for them.
Exactly. And hence, it's not able to be learned in a lecture. It's very experiential. Peter McGuire I would give credit to recognizing this back in the 1980s at the Christie Radiation Center at Manchester in the United Kingdom, I think he was the first of communication researchers who showed the value of the video, the playback and established that it really enhances what is learned, what is gained subsequently. And it's a vital part of the title process.
So I think it's important that everyone understand that you're not training psychologists and psychiatrist to be more effective communicators. You are training the people who are in the trenches.
That's the idea.
The oncologists and the surgeons--
And so how has that gone for you?
Well, one of the principles that we very much believe in is that it shouldn't be a psychiatrist training a surgeon. So it's discipline-specific and we invited our surgeons to be the facilitators of other surgeons who are training whether they're attendings or whether they're fellows. And similarly, medical oncologists to teach a medical oncologists or a nurse to train nurses. So that means you need a facilitation training program first of all to obtain a group of faculty--we've got about 50 faculty at Sloan-Kettering who in fact are facilitated trainers and who come regularly each year to work with a discipline-specific group and contribute to the training program.
That's pretty amazing that you were able to recruit medical oncologists and surgeons into this area. I think that belief is common that maybe those folks really aren't that interested in communication skills especially at a very high powered place like Memorial where folks are really--you'd think, I guess the impression is very interested in the science of molecular biology and genetics and things of that sort. So, that's been quite a success.
This is--this is caring for the human side of a person, and there are such caring doctors. And I see that, in fact, if they facilitate this, you know, if you can teach something then you understand it well, and you practice it very well. And so the people who are good communicators enjoy actually facilitating an improvement in communication style in their colleagues. And then in having that enrich the practice of medicine and quality of the care that's delivered.
So, in essence, this is a train the trainer program--
But I noticed that you also had put on some workshops for physicians who want to improve their communication skills.
We do. We run city based, state based and national programs. And at present we have a program for all of the fellows that train at Memorial. We've got about 250 fellows in each year who are young surgeons, young physicians learning about cancer and building their experience, often over a two, three, or four year program. And the American Council for Medical Education accredits training programs. And communication is one of the core requirements of a standard that needs to be achieved for a program to be accredited. And so our communication training program has now become the ACGME pathway to accrediting the standard of communication of any fellow that eventually receives the certificate or training at Memorial. So, it means it's a mandated program, and our fellows come into the unit, some in their first years, some in later years. In fact, there's quite a benefit in having them revisit the laboratory because one of the principles that's become clear is the dose of training. Darius Razavi from Belgium has done some very fine work in this area. And it had been relatively common practice for people to put on one or two day workshop for communication training. Well, they might offer eight hours in a day or sixteen hours in total. But he's shown in his studies that it often takes thirty hours of communication skills training to produce sustained benefits over time. That if you follow people out to two years, to three years, the same level of empathic responsiveness is there in their relationship with their patients. In nurse training, in Belgium, they've got as far as offering a hundred and five hours of communication skills training to nurses with huge benefits. And so, it's a substantial commitment for educational programs. But it's a lot of a part if you think of programs that are educating this practioners today to allocate a hundred and five hours of total training out of a program that might be a few thousand hours of education and still a small piece. It's always a burden for clinicians if you say to a surgeon, that's a common training, communication. It's seems like eight or sixteen hours is a big commitment. In fact, it's an important commitment. And I can say now that we've had the experience of having department chairs refer a few clinicians who are struggling with patients. Clinicians who'd get complaints, who seem to be the recipients of--a greater level of difficulty than some of their peers in relating easily to patients, and we've taken these individuals into the program. We've put them through the curriculum as has been developed as a comprehensive Comskill curriculum often giving them sixteen to twenty hours of training, and then we follow up with personalized supervision on a monthly basis. Sometimes over a four to six month period of time. And we find that that's been able to really correct habits and behaviors that work against these clinicians. Typically, we teach people to be more empathic. And you might think empathy is something that people are born with, that's naturally part of their makeup. But we believe you can train people to have empathic responses where they can learn to read the emotional affect, the emotional status of the person before them, and then they can respond more appropriately and empathically in a supportive manner. And that's a skill that people can develop. And invariably, once you get that as a course skill then you find that the difficulties these clinicians have with patients start to just fade. And they become much more confident in handling the person who's more readily frustrated, who's perhaps a little irritated or who's distressed at their diagnosis, angry at what's happening. They learn how to ameliorate those responses and help support the person through that so they end up with a much happier patient, a patient who feels more supported. And the quality of clinical care is enriched.
And I'll bet that the level of burnout that those physicians would've experienced otherwise diminishes significantly.
These are the people who are struggling.
You know, they're aware of these letters of complaint coming in. They're wounded by that. They're deeply distressed and often as you say feeling exhausted, feeling burned out, not knowing how to improve their clinical practice.
Well, certainly this program has reached a lot of folks on very many different levels among the faculty and other staff at Memorial and to be congratulated for having this very, very unique program and facility. But I know you have a lot of other interests too and I know that you're a very well-known researcher in the area of grief and the area of psychotherapy. And I wonder if you could tell us a bit about some of the projects that you have going on now.
I just like to finish off the communication piece by culminating that with setting a standard which for the future across America will mean that comprehensive cancer centers will have a communication skills training in research program as a standard part of every cancer center.
I think you're right.
That would be a great goal for the future.
It would be great.
So yes, I have enjoyed being a psychotherapy researcher through my career. And originally that began with some group therapy trials. I developed a model of cognitive existential group therapy for women with early stage breast cancer. And it's built on the idea that although cognitive therapy was very much in vogue. Psychologists were using this as typically their first approach in supporting a person with a deep view of her accounts. Existential dimension was still important because patients are grieving. They had deep fears, fears of death, fear of recurrence. The uncertainty of the journey was very much a challenge. And so to combine these two modalities of therapy, the cognitive and the existential into a single program of group therapy was one that made a lot of sense. We tested that around 300 women with early breast cancer and it should that we could significantly reduce their fear of recurrence, reduce their anxiety, and improve their quality of life as a result of that. Moving to advanced breast cancer took us to a different type of group model where emotional expressiveness is really very important. It's essentially an existential meaning-centered model, well-developed at Stanford, initially by Irv Yalom back in the 1970s. And it's really a wonderful approach to supporting patients. Eight years I personally had, you know, a research trial leading a supportive expressive group for women with advanced breast cancer, its one of the best clinical experiences of my career, lovely women, courageous women and a really fine experience. People might think, you see, it's going to be a very morbid session full of tears but it's not like that at all. There is this tremendous creativity, humor, the group transforms the experience of these women, so they're really focused on what's meaningful in their life. And they optimize their living to the very end. So that group work has been a lot of fun and I'm proud of the fact, if I may that our supportive expressive group is the first study to show that we could actually prevent the development of depression in cancer patients through their cancer journey as a result of belonging to that group experience.
Very interesting. Again, you know, I think that one of my heroes and maybe yours too, Peter McGuire kind of started out showing that when people hold in their concerns and their anxieties that depression is very likely to follow in the subsequent period of time after the diagnosis. So I think that--
Letting people talked about the unspoken and things that--
They wouldn't feel safe talking to a family member for example is just extremely important.
So that's a good way--good segway into a family center therapies because another piece of work that I developed was it was an interesting family grief, and working with families in the cancer setting. And appreciating their bereavement care ought not begin once the cancer patient has died but that really it's part of psychosocial care much earlier than across the last year of life. So we looked at families and from my doctoral work, I developed a typology of family functioning usually in the setting of grief and bereavement. When we looked at the--where our family relates, something that has been well developed and taught through medical schools. But families can be well-functioning groups resilient or robust. Others will have great difficulties relating to each other. And you can pick families that are having trouble, say through the 3 Cs of family relational life, how a family communicates, how cohesive they are, and what their comflict is like, the 3 Cs. Communication is easy but it's the expression of feelings process as well as of ideas that's at the core of effective family communication. Cohesions about family teamwork, how they pull together and mutually support each other. And conflict is there, it's okay for families to fight. Normal families do have their battles, but there are some families that resolve conflict easily and are adaptive in that sense and others that get stuck in their differences. So that they carry resentment, they're wounded, they have a breakdown in communication and conflict can be very problematic. So we discovered that in advance cancer cure about 15 percent of families have great difficulties in these ways of relating, about another 30 percent intermediate in their functioning style where their ability to relate is more middling. And that these two sub groups are well worth intervening with. And we developed a model of supportive family- centered care where we identify the families early on as they're entering preoperative care, as they're entering that last 6 to 12 months of the cancer journey and the clinicians realize that one day they're going to lose this person. You can screen families. You can use these 3 Cs of family relational life to identify those at risk. There's a screening scale that could be used and some programs do. And so you can target families at risk and just bring them together saying that we find it helpful to meet as a family, to work together. We like to have the family talk about the illness, talk about how they're helping the patient manage that cancer illness, and define what's hard, where are the challenges. And we looked to specifically see if the family's have challenges in their communication, in their teamwork, in their way of dealing with differences of opinion. And if we find that, these issues, then we say the family, "Well, would you like to work on these issues? And these concerns such that we could have a few sessions, few family meetings to help you with these." So we set up a program of family therapy that unfolds often with the cancer patient being present for 3, 4, 5 sessions before they end up losing their life. And then we continue that family work be--beyond into the first year. And depending on the level of dysfunction in the family, you may need 10 or 12 sessions of family work. For families that are more intermediate in and nature sometimes just 4 to 6 sessions does the job. But the goal is to open up the communication channels, help our families to develop techniques and strategies to deal with conflict more adaptively, and to really mutually support each other. So its a model of shared family coping and shared grieving. So its interesting because most of the bereavement work had been either individually centered or group centered.
Have you founded that actually helps the dysfunctional families grieve better--
--and we could put it that way?
Yes. But in an Australian trial and a current study that's been supported by the National Cancer Institute, we've got a nice outcome data showing that we help families, we prevent the development of complicated grief where one in these in five might come to be termed prolonged grief disorder. We prevent depression in bereavement and we help the families to be mutually supportive of each other. So that you can see lots of instances where individuals at risk through getting the support of their family are protected and gain sufficient benefit. That family model might sometimes compliment some individual work, couple work, even a person or a bereaved spouse going to a bereavement group, that's fine, but the family model is a very nice head on and in many instances by itself it's sufficient. So that's very cost effective.
And working with the family, your right is cost effective because you reach more than one person at once. Yes
So I know now that you've kind of moved on a little bit to--also to survivorship work and have funding to pursue helping survivors transition into the survivorship role.
Could you say something about that? I think that--that's very exciting.
Yeah. I think currently, of course, the way the model is being rolled out by the NCI survivorship office across the country is putting an emphasize on people who had 2, 3, 5 years post cancer treatment. And it's transforming a number of these people into dedicated survivorship clinics. That's not what we've been about. We've got the idea that there's a place quite early on after remission is achieved, there is a place for the oncologist to begin to talk about survivorship and introduce the patient to the many aspects of health promotion and care over the ensuing 5, 10 or 30 years of life that are relevant to survivorship then and we'll improve the care of the person. The institute of medicine has recommended the adoption of care plans where oncologists offer at the end of treatment a summary of the oncological care and then a care plan for the future where they lay out all of the preventive and health promotion steps that could be important for patients. So it's a great idea translating it into clinical practice is quite a challenge. Now that's where a communication module that focuses on this has benefit so we've designed such a module and we're launching a study where during this here with MD Anderson as a site. And our goal is to try in the first instance lymphoma doctors. In the conduct of a new consultation, you might call this an introduction to cancer survivorship and rehabilitation as a concept. And in this consultation, the doctor will pause and say, "You know, we've got you into remission." I'd like to take 10 minutes to just introduce some ideas about the rest of your life. Let's put this cancer in its journey in context. Let's identify all that's happened and make sure you've integrated an understanding of that. Know what our future monitoring plan is going to be. Understand what the health promotion things will be that will be important. If for example you've had radiation therapy, say if you're chest is part of the treatment of Hodgkin's disease. We'll not need you to realize that, that radiation brings a risk of late effects and that in 20 or 30 years time, you might have an increased risk over your peers for the development of a thyroid cancer in your neck or breast cancer or head-neck cancer, so there are monitoring steps that we need to develop in the years ahead to look after you through this journey and ensure that you're healthy throughout your total survivorship. So this idea of a new consultation focused on survivorship is not part of current oncological practice but I would suggest that there's a lot of merit in it so we are going to work to try to establish the evidence for that and then have that evidence to role out across oncological care.
It sounds enormously exciting. I know for a fact because in treating patients in the clinic that there is that period in transition when patients leave active treatment--
--to survivorship where they have this kind of sense of abandonment or lost.
Yeah. they feel a little lost.
And so I would imagine that this will have an additional impact perhaps on some of those-- I hope so.
For people who have that type of experience, not everybody, but many do. We think this is the kind of conversation that will, in fact, help them to make sense of the journey, appreciate that there is a change going on now and that they're moving out of active care into long term monitoring and what that represents.
Well, you know, these are all very exciting things going on your area, in your department, so there's a lot of evolution now and we'll be looking forward to your coming back and kind of telling us more about how things went and some of the outcomes of some of the exciting research and educational programs that you have. Thank you very much for visiting with us.
Thank you, Walter. It's a pleasure to chat with you and congratulations also on your own contributions on cancer communication through the years you have been a stoic contributor and we value that.
Thank you so much.
Psycho-Oncology is a young discipline and there's a lot of work to do, isn't there?
There is. Well, thank you again, David.
We look forward to it.
Today, we have been visiting with Dr. David Kissane of Memorial Sloan-Kettering Cancer Center and hearing about the very exciting work that he's done and his exciting research that will surely impact the field of Psycho-Oncology and cancer care in the future.
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