Did They Get It? Video Transcript

Interpersonal Communication And Relationship Enhancement (I*CARE) Lecture
Dr. Epner
Did They Get It? Strategies for Making Sure Patients and Families Understand Your Message
Date: October 26, 2011
Time: 55:46

Daniel Epner, MD
Associate Professor
Department of General Oncology
Medical Director, International Center


Nita Pyle: We are really delighted to have Dr. Epner here. He is an associate professor in the Department of General Oncology at MD Anderson. He graduated from Baylor in 1986 and he completed a medical oncology fellowship at Johns Hopkins Oncology Center in 1994. He began his career as a basic research scientist about a medical scientist whose goal was to cure cancer. But after practicing for a number of years, he began to focus more on healing illness rather than curing disease. He's come to appreciate the power of caring and compassion in medicine and now realizes that allowing patients to be truly heard is very therapeutic. He spends most of his time diagnosing--I mean discussing. He spends most of his time discussing end of life prognosis and other sensitive topics with cancer patients and teaching others how to engage successfully in such conversations. Dr. Epner practices integrative oncology here and serves as a liaison and advocate for international patients at MD Anderson primarily those from the Middle East and the Latin American countries. Dr. Epner works closely with Dr. Walter Baile to develop communication skills, training programs for a variety of health care providers. And I'd like you to join in a warm welcome for Dr. Epner.

[ Applause ]

Dr. Epner:Thank you Nita

Nita: Uh-huh.

Dr. Epner:Thank you for your kind introduction. And also thank you Louise Villejo for inviting me to do this. I am really pleased and honored. I can't tell you how excited I've been to do this. So I think this can be a lot of fun, at least for me, hopefully for you as well. I also want to thank Lorene Payne for her help in creating this seminar today. So as Nita was saying, today we are going to talk about making sure patients understand our messages, make sure that they get it. As Nita was saying I have a very diverse clinical practice here at MD Anderson. I am in the Department of General Oncology, but on a day-to-day basis, I have a lot of different patients that I see and just about all the patients I see have very difficult situations and often engage in very challenging conversations with me. So in the Integrative Oncology Clinic we talk about supplements. We talk about mind-body things. Many patients in Integrative Oncology are really at the end of life as well, so there are sensitive conversations. I'm Medical Director of the International Center and, of course, cultural issues come up from people who come from overseas. And, as Nita was saying, I work as a sort of consultant or guest attending on the Phase I Inpatient Service and as you know, patients in Phase I trials are oftentimes close to the end of life. They've received a lot of therapy so we engage in end of life conversations and very sensitive topics. And also I work very closely with Walter Baile who is a Professor of Behavioral Science and the head of the I*CARE Website here, the I*CARE Program. And he and I and sometimes him alone and me alone, we work to teach others communication skills.

So we often say that communication skills can be taught and learned and we make the analogy that proper communication with our patients is kind of like playing tennis or playing piano. Some people are very gifted. They are child prodigies. You know Mozart was a child prodigy musician. He honed his skills through practice and a lot of work. Some people are natural tennis players. Others aren't, but with practice, everybody, just about everybody can learn how to hit the ball over the net or play a basic song on the piano. And communicating with patients is no different. It can be taught and learned and there are some basic, key concepts that we bring to bear to help us with these challenging conversations. So that's why I am here today.

So the goal or at least the goals that I put forth today and of course you can have your own goals, hopefully are to develop strategies to number 1, to assess a patients baseline understanding and information needs. So I would imagine or I've been told, that the attendees here are nurses, dietitians, social workers and then some other people as well. So today we are going to talk about a clinical scenario that involves instructing somebody on how to take chemotherapy, a chemo pill. As we go through these proceedings, think about how what we talk about applies to your own unique practice setting. So assess a patient's baseline understanding and 2, to continuously monitor a patient's understanding as you are meeting with the patient. And 3, of course, we have such busy clinics and we are running all the time, so we want to get the most value and efficiency from every patient encounter. So we want to be very efficient. It doesn't mean rushing, but we want to get the most value from that time together.

So as Nita was saying, today is not going to be your grandfather's PowerPoint presentation. We're going to do something quite different and here are the ground rules. So we're going to show you rather than tell you and you'll see what I mean. Now your job, that is your job is to watch very carefully to the action, really evaluate what you're seeing and hearing and process that and see what you think is done well. You're going to see a nurse or a character playing a nurse namely me interacting with a patient and the patient's husband. And I want you to see what the nurse does and see what you think is good and what you think the nurse whose name is Ben can do better. Then, we're going to stop the action and I'll step out of the role of nurse and I'll become Danny Epner again and I'll moderate. And I'm going to need your help because we're going to depend on you to tell Ben how to do things better. And then we're going to see Ben implement what you tell him. Now of course I'm not going to call on anybody but something tells me I think there'll be plenty of, plenty of opinions. So we really rely on you to build the teaching points together. And by the way, Chris Whitcher who you will see in a minute is a nurse educator and she'll be playing the role of a patient and Jane Frank [phonetic] will help us as a scribe so she'll come up here to the podium and she'll be sort of taking notes based on what you say to give Ben the nurse some ideas to how to do things better. Okay, so any questions so far about that? Okay, good. So let's set up the clinical scenario. So Ms. Jones, in fact why don't we just meet Ms. Jones right now. Ms. Jones, why don't you come on down here? Okay, so Ms. Jones is accompanied by Mr. Jones and they're here in the exam room in the medical oncology clinic. And Mrs. Jones is a 56-year old woman. By the way, Knawel I don't know if I introduced Dr. Knawel Raghav is our gentleman here who as of this moment is now Mr. Jones.

[ Laughter ]

He is a medical oncology fellow but now he's Mr. Jones, he's the patient's husband. So Mrs. Jones is a 56 year old woman with newly diagnosed rectal cancer. She was discussed in a multidisciplinary tumor board conference recently and the consensus was to offer her neoadjuvant radiation plus oral capecitabine chemotherapy and then surgery with curative intent. She presents to the medical oncology clinic where she's currently sitting with her husband Mr. Jones to discuss the treatment plan. And her doctor, Dr. Smith already examined her and discussed the kind of Kind of overall grandiose picture but he's going to let his nurse Ben sort of pick up--pick up the details about the instruction. Okay, so what I'm going to do now is I want you to literally spend about one minute to 90 seconds, I want you to turn to whoever is closest to you, two or three people. If you are not close, get physically close to other people.

And I want you to imagine yourself in your clinic whether it's dietary--dietician, social work, nurse, or whatever walk of life and imagine yourself needing to go to a patient and instruct the patient about whatever it is that you instruct patients about or talk to them about. And I want you to think about and discuss for the next minute, during this interlude, what strategies you would bring to bear, number one, and number two, what challenges you anticipate? So, let's go ahead and do that for about a minute and we'll resume in about a minute.

[ Inaudible Discussion ]

Dr. Epner: Okay, alright. So, very good. That was about--I think that was about a minute so I'm going to get everybody to now reflect about--I guess what I'll do is ask you openly whether--whether you can identify any particular challenges that--that you talked about. Does anyone want to volunteer that of should we just--I don't want to overwhelm Ben but—has anyone identified--yes?

Audience: I think one thing that came up like when patients are told by the physician like you said, the doctor told Mrs. and Mr. Jones, you know, the game plan, they leave then the other persons come in, a nurse or a mid level, or a social worker, and many times, the patient's understanding of what we were told, the doctor told them is not the same. So, you know, a lot of times, in the--there's a disconnect between the time the doctor leaves and the ancillary people come in and the patient's understanding is still lacking.

Dr. Epner: You mean, the patient really doesn't understand what the doctor supposedly said. So there's an information gap that the patient really doesn't understand what the doctor said, is that what you're saying?

Audience: Yeah, and not so much in just hearing what the doctor said but I guess in digesting what the doctor said or the ramifications or implications of what they said maybe was such a shock to them that they didn't have time to react to that.

Dr. Epner: It's emotionally shocking and--and they're--you don't really know how much got across is what I'm hearing.

Audience: Yes.

Dr. Epner: That's a challenge we face. Were you going to--was somebody else going to say something else? Okay. Then let me--let me introduce--let me introduce Ben. So, Dr. Smith told Mrs. Jones that the clinic nurse would return in a few minutes to kind of talk about in details. And again we don't know what was said in the room. So that's a challenge that you point out. And Ben's job is to sort of talk about the chemotherapy, capecitabine and the risks of taking it in the proper method and so forth. But I'll tell you, Ben is really feeling overwhelmed right now because he's got three patients on the--on the schedule and he's in a big rush and there's very little time to do anything. So, let's see how it goes.


[ Role Play ]

» Hi sweetie.

» Hi.

» I'm Ben. I'm the nurse here in the clinic today with Dr. Smith and I wanted to spend a few minutes talking with you about the side effects of your chemotherapy, the capecitabine that you're going to be taking. Is that okay? I'll tell you what we're going to do. Let me give this information sheet that's something I've printed out for you and I'd like you to read that at your convenience when you home this evening. But for now, for the next few minutes, what I'd like to do is just sort of tell you the most important side effects of the chemotherapy and what's most important about taking it, okay?

» Okay.

[ End Role Play ]


Dr. Epner: Okay, so stop there and now I'm out of role. Now I'm myself again, Danny, and now it's up to you--what did you see? What went well there and what didn't go well? Yes ma'am?

» Mostly, is that you were standing out [inaudible] to show that you were--that you're trying to find out how she's doing.

Dr. Epner: Okay. So--

» [ Inaudible Remark ]

Dr. Epner: So I should have been sitting. I should have established eye contact. So what we're going to do, Jane, is let's go--let's go to the next slide and you can go back and forth. So, Jane is going to record what you say. So, your suggestion for what could Ben have done better is that he should have established eye contact, at eye level and sat down.

» Okay.

Dr. Epner Okay, very good. What else?

» And also thought about that --I'm not sure will sure assessing her as you--whether she looked stressed out--stressed out or--

Dr. Epner Okay.

» You know, and knowing that she needed more information, I would've asked her "What did the doctor say in regard to your treatment?"

Dr. Epner: Okay, so that's a good suggestion but here's what I'm going to do. I want to--I want to let other people--I thank you for that but I want to let other people weigh in on that who are waiting at this point. And I want you to comment mostly on what you've seen right here. Just this little snippet because we're going to move this through, we're going to progress through this. Yes, ma'am?

» I would have addressed her by her name instead of sweetie or honey.

Dr. Epner: Okay.

[ Laughter ]

Dr. Epner: So you--you would have used the, you know, Mrs. Jones, her proper name. Okay.

» And that was the comment I was going to make. You did not acknowledge the patient. You called her sweetie. You know, I was concluding on that one.

Dr. Epner: So, you would have acknowledged the patient, how so?

» By name.

Dr. Epner: Okay, with proper name.

» [ Inaudible Remark ]

Dr. Epner: Okay. And do we have somebody to hand microphones on this side as well?



» I wouldn't hand them the documentation first, I would do it at the end because then, they're looking over that and not paying attention to what you're saying to them.

Dr. Epner: Okay, so--okay, so, we have a vote for giving them the information later. That's one suggestion. Okay.

» [ Inaudible Remark ]

Dr. Epner: So what we're going to do Jane is for that, let's put down as--as an item point that consider giving the information later and discussing first. So, yes ma'am?

» [ Inaudible Remark ]

Dr. Epner: You mean Ben?

» Yeah.

Dr. Epner: Ben was sort of in a hurry.

» Yes.

Dr. Epner: Okay, so, what would you suggest would be--would be a better way to do things?

» First, you walk in and then introduce yourself and make him feel welcome, make him feel like you care for you, you know.

Dr. Epner: Okay. Okay. Anybody want to expand on that at all?

» [ Inaudible Remark ]

Dr. Epner: Are you okay? Fire away.

» In terms of expanding on that, not feeling rushed, just coming in and just building some rapport with them as a couple. And that expounds on what I was going to say, is you actually didn't introduce yourself to the husband either.

Dr. Epner: Oh, okay.

» You need to acknowledge the other people in the room.

Dr. Epner: So, acknowledge or establish relationships, acknowledge others in the room would be a key point. Establish rapport, now that's--that's a big topic, but we'll--we'll keep that in mind. We--we might overwhelm Ben but he'll--he'll do his best. Yes?

» Something I like to do is just come in and let there be just a few seconds, them taking you in and you taking them in without filling the space with any words, I mean just a few seconds.

That's such a respectful thing to do...

Dr. Epner: So just kind of create space in the room, relax and establish a contact.

» To look at you, and you at them and kind of kind of get a sense of where they are emotionally.

Dr. Epner: Yes.

» And you almost need silence for that.

Dr. Epner: Okay so that's--let me--let me ask you some very specific questions and then I want to--I want to take some of your comments and--and implement them or have Ben implement them. What do you think about her state of dress right now?

» [ Inaudible Remark ]

» She's vulnerable. She's in a gown, she wears this dress.

Dr. Epner: She's what?

» She's in a patient gown and she's vulnerable.

Dr. Epner: She's vulnerable?

» Uh-hmm.

Dr. Epner: Okay, so what would you recommend just changing into street clothing?

» [Inaudible], just let her change into her clothes and come back.

Dr. Epner: Okay.

» And give her time to regroup herself.

Dr. Epner: Okay.

» And then acknowledge the situation.

Dr. Epner: Okay, and I have another specific question, you might have noticed when I--when I came--when Ben entered, he opened the door and entered the room, was--was that optimal or could he even done that a little bit better?

» [ Inaudible Remark ]

Dr. Epner: Okay, so knock before entering. Good.

» [Inaudible] change clothes.

Dr. Epner: Yeah street clothes, that's right. Okay I want to--okay, so what I want to do now is Ben is going to take your suggestions and he's going to run this through again. And now, we'll see how he does. Okay.

Now in this scene, I want you to keep in mind that Dr. Smith, there was a comment about giving the information later but in this case, Dr. Smith actually gave Ms. Jones the handout, the print out and gave her about ten minutes to read it. And that's another strategy that many people find useful either having the conversation and then giving it. I often find it useful, I'm speaking as myself now not Ben. I find it useful to give the information let people look at it and then come back and see what they think of it. In this case for the sake of this scenario, she has had a chance to look at the information for about ten minutes and then Ben is going to enter the room for the very first time. Okay. Knock, knock, knock.


[ Role Play ]

» Come in.

» Hello, you must be Mrs. Jones.

» Yes. Thank you for letting me put on my clothes.

» Oh no worry. No worries at all. Hi, my name is Ben and I work in the clinic here with Dr. Smith and Dr. Smith wanted me to come in and meet with you for a few minutes. Now, how are you all related?

» Oh, this is my husband John.

» It's very nice to meet you sir, Mr. Jones.

» And where are you all from?

» We're from Houston.

» You're from Houston?

» Yes.

» Okay, so you've been going through quite a bit lately.

» Yes.

» Okay. Well, you know, Dr. Smith gave you that information sheet, right? About the capecitabine chemotherapy you'll be taking. Alright, did you have a chance to read it?

» Okay. So what I want to do now is for the next few minutes is just emphasize a few points about that sheet that are the most important points that you should know, okay? First of all, I want you to remember that the common--the most common side effects from that chemotherapy include mucositis, dermatitis, hand foot syndrome, cardiac arrhythmias and GI upset. Capecitabine also make some people neutropenic so you have to make sure to call us if you have fever, okay? Now, don't worry we're here to take care of you. We'll take care of that. The other thing I want you to remember is to take this medication as Dr. Smith instructed just as he said twice a day. Okay, do you have any questions about that?

» Am I going to lose my hair?

[ End Role Play ]


Dr. Epner: Okay, so time out. Okay, so now we need your input again, and--

[ Laughter ]

Or actually Ben--Ben--first of all, the first question I have for you is did Ben do what you asked him to do? Okay so in some senses he is educable. I mean we can train him a little bit.

[ Laughter ]

So--but then what else--so he did some good things but what did you see that could be improved? Yes.

» It caused more anxiety on the patient by talking to them in terms that--or using vocabulary that the patient who is not aware of she--she doesn't know.

Dr. Epner: Jargon, you're talking about medical jargon?

» Yes.

Dr. Epner: So how would you do it? Anybody, how would you do it? How should Ben do it differently rather than using medical jargon?

» Well, he could use one of our patient education documents to explain to the patient the medication instead of using words like mucositis.

Dr. Epner: Yup.

» You can actually say what it is.

Dr. Epner: Okay so use simple, clear terminology that's at the patient's level that we know that, you know anybody with the 7th grade education or whatever would--would know. Okay good clear--clear message. Yes?

» I want to go back to before that, you said this is all overwhelming but then you didn't really say anything after that. So you could have, you know, explored a little bit more about her--her feelings rather than just saying this must be overwhelming and now I'm going to go over the side effects of the chemotherapy with you.

Dr. Epner: So I was sort of eliciting something and then I didn't give her a chance to actually respond to that to the emotional thing there, thank you. What other--what other thoughts about how we could have done this better, Ben could do this better?

» You said, don't worry and my thought is of course she's going to be worried. You did mention about you're available, you know, if there's any concern but the term "don't worry" is like a question. You tell me "don't worry" I need to worry.

Dr. Epner: So I'm actually paradoxically kind of making her more worried by telling her not to worry, so why do you think that has--I'm having--Ben would have that effect by saying "don't worry". What does that do to the patient when we do that if Ben didn't--when Ben did that?

» [ Inaudible Remark ]

Dr. Epner: It kind of shuts her down? Yes?

» I have a question you didn't ask her was she ready to receive all the information.

Dr. Epner: Okay.

» You just gave it to her and assume that she could understand it and was ready to receive the information.

Dr. Epner: I didn't really tap into her where she was emotionally and whether she was ready. I didn't ask permission to receive the message, right? Any other thoughts? Yes?

» It seems like it wasn't just one word like mucositis but it was one after another. There was almost like too much too fast and she--it looked like she just shut down. She couldn't tolerate anymore.

Dr. Epner: So I was just downloading information or Ben was downloading information rather than giving little pieces, little quantive pieces of information and you rather see him give little pieces at a time and you--the other comment was that we should sort of assess the patient's readiness, see where they're at essentially. Yes?

» A lot of the questions and statements was close-ended. It's better many times if you use the open-ended then the patient has a chance to describe their feelings too.

Dr. Epner: Okay that's really important. I think I want to reflect on that for a couple of minutes. So open-ended questions really allow the patient to be engaged and to start--we know where the patient is emotionally and also as far as their knowledge--somebody--could somebody give Ben some ammunition? Since Ben wants to go back in there and ask some open-ended questions to engage Mrs. Jones, what are some things that he could say when he's trying to train or teach Mrs. Jones about chemotherapy? Give some examples, some ammunition for what he could do that's very open-ended.

» Well I think asking her--you ask her if she read the sheet and obviously her response was, "Am I going to lose my hair?" So you're going to be asking her so out of what you read what is the most concerning to you on that side effect and letting her say of course the first and foremost thing was, "Am I going to lose my hair?" That way you could address that issue talk to her about it and then you can kind of delve off of that to kind of Kind of see where she--you want to go next.

Dr. Epner:Okay, so Ben should take a more natural free-flowing approach to the conversation and see where the patient takes him rather than sort of imposing his agenda on the patient and be open to what the patient's concerns are. So what are some really, really simple phrases like open-ended questions that Ben can use when he enters the room again? When--just imagine he's entering the room as he will in a moment, and he's going to ask, reengage Mr. Jones. So what--how should he begin the conversation after he kind of establishes rapport and introduces himself?

» I would ask then and tell me what do you know about your treatment plan?

Dr. Epner:Okay.

» What has the doctor discussed with you and--

Dr. Epner:Okay.

» So--

Dr. Epner:Okay, so you would take it really open-ended and just say kindly tell me--tell me what you understand about your situation. Tell me what Dr. Smith explained and just kind of tell me what you know and then see what comes from there. Great. Open-ended and follow that. Okay good. Who in this room has actually been in the position of teaching a patient or patients about chemotherapy like in fact oral chemotherapy? Okay. How many--well how do you actually--I guess the question is, here we're in a cancer center but do you ever get the feeling like me, Danny Epner, does that sometimes when I say that word, people don't even know what that word means? Who has experienced that? The word chemotherapy? We used the word but I found that sometimes people--a lot of people have confused radiation with chemotherapy. So how might or how has somebody done this before to establish kind of what people understand about that word? How would Ben--how could Ben do that?

» [ Inaudible Remark ]

Dr. Epner: Okay something really simple. It's--it's not a trick question. I think the--the comment was I'll repeat it. You said, Ben can say, "What's your understanding of chemotherapy?" Simple. Or, you know, a lot of people use the term chemotherapy. When I use that word, what does it mean to you, and see what comes back. And a lot of times, me as the--as the doctor I'll say, "Chemotherapy is simply a word that describes medications to treat cancer." Simple. Okay, so good. So we've got some suggestions for Ben.

» I have a comment.

Dr. Epner: Yes?

» I'm trying to say that we are often put in an awkward situation because people understand chemotherapy is that cancer is treatable and often cured. There's a tendency to equate chemotherapy with a cure. When we know if they have a stage 4 cancer that it may not be cured. So intrinsically, many times, nurses are put in an awkward situation because you know they have a stage 4 cancer.

Dr. Epner: Yes.

» Because But, you know, to ask the patient what exactly do you understand. "Well, I'm going to get chemotherapy, therefore my cancer is treatable and therefore I'm going to do a lot better."

Dr. Epner: Well I don't--I can't imagine. I can't imagine where they got that idea.

[ Laughter ]

» You know and not all of our patients get a red pen.

Dr. Epner: Yeah. No, you're right. I mean and then often times I think the professionals, the providers who are not doctors are kind of Kind of caught in between because you don't know what the doctor said. You don't know what the patient received or absorbed and it is awkward. So what we'll do is why don't we sort of say that. That's a great point and we'll come back to that. I think we'll have time in a few minutes to come back to that concept and kind of Kind of how to handle that. But for now, I think I don't want to overwhelm Ben. One more thing and then I'm going to let Ben do his thing because I don't want to get overwhelmed.

» It's just another comment to add about the doctor. The doctor has not giving too many options for decisions to the patient or the patient to make her own decisions. It's just--this is the treatment that we're going to do and that's it.

Dr. Epner: So it's a very sort of paternalistic. This is the plan for you, we've established for you. This is what we're going to do for you. Right, instead of what are her choices--

Okay. That's an excellent point. Thank you. Okay so let me just make sure I have this all straight as Ben. So Ben is going to keep the message really clear. He's going to avoid medical jargon. He's going to try to give little pieces at a time and use a very open-ended approach to the conversation.


[ Role Play ]

» Knock, knock, knock, knock.

» Come in.

» Hi Mrs. Jones.

» Hi.

» I'm Ben. I'm one of the clinic nurses here. I work with Dr. Smith and he asked me to come in and speak with you for a few minutes. Is that okay?

» Yes.

» How are you all related?

» Oh this is my husband John.

» It's very nice to meet you Mr. Jones. So Dr. Smith said that he gave you the handout with the chemotherapy description on it there. Did you have a chance to read that?

» Yes.

» Okay.

» We've been looking at it

» [ Inaudible Remark ]

» So what was your understanding of that? What did you take away from reading that?

» Well, you know what? I'm so overwhelmed right now. This is--I mean this is cancer medicine and I'm going to have to have radiation? How am I going to get here every day? I don't know--I don't--

» It's okay. Everything will be just fine, really.

» How am I going to do it? I--

» Everything will be just fine.

» I'm just so overwhelmed, and the doctor said, I might need a colostomy. I just don't get any...

[ Silence ]

» --and really, really--well, you're going to--Mrs. Jones you're going to have to be kind of tough here because you have to be really strong.

[ Laughter ]

» Mrs. Jones, okay so come on.

» I should've had the colonoscopy. The colonoscopy is--when I was 50, I didn't have it. I just feel so stupid?

» Well, no it--you shouldn't feel stupid, everything will be just fine and--and we're going to take care of everything. You're going to have to be really tough, okay? And, you know, as far as getting here, look, the logistics of--of getting here every day, I know its five days a week, but look, you got to have--I'm sure you have neighbors or friends who can take you here.

» I have rectal cancer? I can't tell them that...

» Okay, so I'll take a time out there

[ Laughter ]

[ End Role Play ]


Dr. Epner: So--so, you know, I think--I think maybe Ben should have gone back to the medical jargon actually.

[ Laughter ]

Dr. Epner: He kind of Kind of --he kind of Kind of opened up a can of worms here.

[ Laughter ]

Dr. Epner: I can see why he went with the medical jargon now. So first of all, did Ben--did Ben follow our--your suggestions? Did he--well we don't have the--we talked about keeping a clear message, asking open-ended questions, avoiding medical jargon. Did he do those things?

» [ Inaudible Remark ]

Dr. Epner: Okay and he introduced himself. He didn't really establish that much rapport given her time element but he at least was polite and so forth. Now, what could Ben have done better if anything? I thought Ben did a great job frankly, but--

[ Laughter ]

Was there anything in your mind that could have done better there?

» He didn't acknowledge her feelings at all when she started talking about how she didn't have ride, she didn't know how she's going to get here every day. She couldn't tell her friends that she had rectal cancer. He just kept saying everything is going to be okay. Everything is going to be okay but, you know, I mean you have to let her process it and then you have to start finding out questions like does she have a ride? Does she need financial assistance to get her back and forth? You know, do they not live close to the hospital. So--

Dr. Epner: Okay, so I'm going to stop you there because you made--you made a couple of really important points. But I think the first one you said is the most powerful. If I understood correctly you said that he didn't acknowledge the emotion.

» Right.

Dr. Epner: He just bull rushed right through the emotional part and he went right on to business as usual and reassuring. So we'll come back to Holly in a minute but what effect, and this is an open question. What effect did he have on Mrs. Jones when he sort of failed to acknowledge the emotion?

» As if he wasn't listening.

Dr. Epner: He wasn't listening.

» To what she had to say.

Dr. Epner: He wasn't--okay, and you--yes?

» [ Inaudible Remark ]

Dr. Epner: So it actually had the opposite effect rather than shutting it down, it should--she couldn't--she couldn't let it out and so it--it increased her anxiety and fear and sadness is what you're saying, right? Yes?

» I think she felt as if, you know, she--there's no support for her like when you--when Ben talks to her. There should be some form of expression that it's like a teamwork that you are going to be--the MD Anderson people are going to be with her.

Dr. Epner: Okay.

» And, you know, have to take care of her. So when she starts crying maybe as a team member, we can assure her that we'll all be doing it together and it will be fine.

Dr. Epner: Now, I want to--I want to respond to that because I agree and I disagree. I do agree that supportive statements as you say are very, very powerful and useful. But I think now speaking as myself not Ben, I think those supportive statements as you said are often most powerful at the end of the conversation, because as multiple people have pointed out giving the patient a chance to simply express themselves and being heard is really important.

And telling--when I told Mrs. Jones or when Ben told Mrs. Jones, everything is going to be okay, that show I'm trying to show--or Ben was trying to show his support for her, but it sort of shut her down, it shut down the expression rather than letting it come out and acknowledging the emotion. What else?

» And I think that she probably can use a tissue if she didn't already have one, I would offer that.

Dr. Epner: Okay. So that would've--you offered.

» And then also offered to acknowledge, you know, just the fact, I know that this is overwhelming and this is a lot for you. Perhaps if we talk about it at another time would be better.

Dr. Epner: Okay.

» You can't bring her back or you could offer to call her on the phone and set up another time when you feel--when she felt like she could deal with it better.

Dr. Epner: Okay. So I want to reflect on that. So offering the Kleenex, most people in literature shows it's a very useful thing because it acknowledges and validates the emotion that says, it's okay to cry. This is normal to cry under these circumstances. These are difficult times and often times saying that explicitly is really good.

» So when you were talking about going with business as usual like you kind of kind of seem like all this other stuff, the first stuff like how to get there and once she told her neighbors it wasn't your business like you have your--you have your business and she has her business and hers is separate, right? So we're saying that there's like ways to find strategies we have for patients that don't have rides or have issues with telling other people about their--and about their cancer. And they'll have to--you don't have to bring it up now that saying that there are options they have that also allows.

Dr. Epner: You mean talk about, so you're talking about bringing other resources into their--whether it be social work, psychosocial psychology, clergies, exactly. Support groups, absolutely.

» I think it's important to instead of saying it's going to be okay that you say, we will work it out, you know. That way they'll know that they're not doing it on their own.

Dr. Epner: Okay.

» You know, we as MD Anderson and other resources and patient and family members we will work it out.

Dr. Epner: Okay. Okay.

» [Inaudible] Ben was working on his own. You didn't--I mean he's not--he was not utilizing the available resources at MD Anderson.

Dr. Epner: Yes.

» And you could have mentioned especially for the transportation issues. I can--you know, we can call the social worker--

Dr. Epner: Okay.

» Fill in the resources we have in the institution.

Dr. Epner: So let's take a time out now. And I know that there's a lot of good suggestions, but what I want to do is move the action forward one more time. And then you can watch that and then they'll have additional--we'll have additional time hopefully for additional questions. We have a special scenario back there about curing cancer. So we can talk a little bit more about those issues if that's okay, okay? So Ben's charge now as I understand it is to acknowledge the emotion in the room, give space in the conversation, you know, and then basically--well, we actually--there's one other thing that Ben doesn't have right now that he needs. He needs ammunition because he's going to go in there and acknowledge the emotion. But often times it's useful to have the next--to say the next thing. So how do you recommend Ben after he acknowledges emotion, how can he--what should he do at that point? What should he be offering? Yes Nita.

» Oh I think that he could ask how can I help you.

Dr. Epner: Okay.

» What can I help you with first?

Dr. Epner: Okay.

» So that focuses her--she can still have the feelings but now she has to do something.

Dr. Epner: So let her set the agenda. But specifically when it comes to absolutely true, when it comes to emotion, emotional content, Ben needs ammunition, he needs words to say now to acknowledge the emotion.

» I would say that you've acknowledged her true emotions, but now like you're saying, you need to affirm her that we are here to help her in any way that she needs to be helped. You need to affirm--

Dr. Epner: Okay.

» --that she feels safe being in our care. And somehow--I don't know, I mean I've had a doctor, you know, tell me we are team, you know, we're going to help you through this, you know. And when we get stuck, we will also get our--you know, our assistance where we need it. But I've had doctors tell me, you know, we're going to help you through this, you're not alone.

Dr. Epner: Okay, so supportive statements. That is a form of empathy. So empathy is getting in the other person's shoes, trying to imagine what it's like to be Mrs. Jones. So what we're going to do, I know you have a comment but hold it because you can probably--you probably be able to help Ben even after this scenario. Let's run through it again and Ben is going to follow your suggestions and let's see what happens. And then I want you to really listen carefully and watch the action--yes.

» I had--I just have one statement as we, you know, what about poor Ben himself because you already said that Ben was rushed, he had 3 other patients and as that's last thing that you expect because a physician has been in there and then you sit down and is like, oh my God.

Dr. Epner: That's right.

» You know, and now I need to take--you know, I need to step back and kind of gather my thoughts on what exactly. So Ben himself needs a lot of support in the scenario also. It's not just the patient because it's happened to--I'm sure it's happened to a lot of us and then all of a sudden you go in and is like you just hit with this barrage of emotion and it's like--

Dr. Epner: Yeah

» Oh my God.

Dr. Epner: Exactly.

» What am I going to say now?

Dr. Epner: That's a great point because Mrs. Jones' emotions are not the only emotions in the room. Ben has his own emotions. He's anxious, he's giving difficult news, and he's also overwhelmed with work and he's in a rush. He doesn't have very much time. So you're absolutely right, that's a great point. Okay, let's run through this one more time and then we'll stop and we'll have a few minutes to debrief about that and also talk about maybe some specialized situations. Okay.


[ Role Play ]

Knock, knock, knock.

» Come in.

» Hi, you must be Ms. Jones.

» Yes.

» I'm Ben.

» Ben.

» I'm one of the nurses here in the clinic I work with Dr. Smith today. And I wanted--he asked me to come in and talk to you about your chemotherapy, is that okay?

» Yes, yes.

» How are you all related?

» Oh this is my husband.

» John.

» Oh, Mr. Jones, very nice to meet you sir. So I understand that Dr. Smith gave you the information sheet about the chemotherapy, did you have a chance to read that?

» Yes.

» And what did you think? What did you take away from reading that?

» Oh, I was overwhelmed, I'm just--I mean I can't hardly even understand it. And I'm thinking about the radiation, how I'm going to--how am I going to come every day to the radiation. Can I--can you not--can I not take the pill first and then have a radiation?

» So it's--

» Why do I have to do it all together? And I might need a colostomy.

» I understand. I know this is a lot to go through all at once. I know this is hard. You know you've been hit with a lot of information, a lot of really difficult stuff all at once, right? It's okay to cry, do you need some Kleenex? Here. Okay.

» [ Inaudible Remark ]

» I just don't know what I'm going to do, I don't know how am I going to get here.

» Oh, don't worry about that. You--I can take some time off. We can manage that, don't worry about that at all.

» Yeah, your husband is there for you.

» I don't know, I could--I know I could do this. It's just so much.

» It is a lot. You're going through a lot and you know, you were minding your own business and none of this is your fault.

[ Laughter ]

» I can do this.

[ Pause ]

» So tell me--

» So, are you ready to talk more about the treatment? Okay. Are you sure you want to--you want to talk now about the treatment? Okay. So tell me kind of Kind of what you--what you understand so far about what Dr. Smith told you and what you read. What's the treatment plan?

» Oh I got to take a cancer pill every day. I'm going to have to come to radiation every day.

» Okay.

» And I'm going to have a surgery maybe.

» Possibly, yeah. So you know that you're taking chemotherapy pills and you have radiation every day. And did Dr. Smith tell you how many pills to take?

» No, I don't have the prescription yet.

» Okay, okay.

» Is this the--is this chemotherapy? Because one of my friends got some chemo but he use to get an infusion or an IV.

» Okay. That's a great question. Most people think of chemotherapy as stuff that goes in your vein.

» Now the word chemotherapy--well, sort of tell me, tell me more about what you understand about chemotherapy. You said that you had a friend who took chemotherapy.

» He got so sick.

» He got really sick.

» And he died, it was just awful, awful, I can't imagine that I'm going to go through that.

» Sorry.

» Oh God.

» Sorry you went through that. You've been through a lot lately, you saw him--you saw him die from cancer.

» Yes.

» I'm sorry you had to go through that.

» So how can it be a pill?

» So, right, so chemotherapy just means--the word just means medication to treat cancer. And the pill actually, this is a pill that's chemotherapy kind of Kind of like the stuff that people get in their veins. But in your case, you'll take it as a pill form, okay?

» Will it poison my home, do I--I mean, what--I need to be cautious.

» You're right.

» I can't have this poison.

» Well, it does have side effects. You raise a good point. Now it's not going to hurt anybody else to have it in your home as long as you keep it secure. Just don't let anybody else get it or take it. So when you're talking about the side effects, tell me more about what you understand based on your knowledge of the sheet as to what some of the side effects are?

» Diarrhea? I've had diarrhea and having that, it's going to make it worse? I'm just worried about that.

» Okay.

» And nausea. Blisters on my hands and feet? Why?

[ End Role Play ]


Dr. Epner: Okay, I'm going to stop there, good. So how did--I guess how did Ben do there? Did he follow your suggestions?

» [ Inaudible Remark ]

Dr. Epner: So what did he do when there was emotional content? We--do we have a microphone?

» [ Inaudible Remark ]

--He affirmed her through, you know, the general touching on her shoulder. But he didn't say anything. He was just quiet to let her cry a little bit.

Dr. Epner: And you think that's a good thing?

» Yes.

Dr. Epner: Okay. So he just gave her space and so what do you--do you think Ben should have left the room and said, well, I'm going to let you cry and I'll come back in a few minutes when you're done?

» No.

Dr. Epner: Okay, because that would send a message that, you know, that's kind of Kind of your problem and I'm going to come back in when you're calm. Being there riding the road with the patient, just riding the rough road with patient is very useful being present, physically present for the patient, okay? So what I want to do, we have maybe 5 minutes, if that. And what I want to do is thank you Jane. I'm going to look at a couple of points here and then we'll wrap up and I think what we'll do is--so these are the foundational skills that we talked about. I'm not going to belabor this because, you know, we know this. The intermediate skills that we talked about we're asking before telling, open ended questions, avoid jargon, clarity and then higher order skills at the end we're acknowledging emotions and responding to emotion with empathic responses. Empathy is getting in the patient's shoes. I realize this is a lot for you to take in all at once. I cannot imagine how difficult it is for you. Yes that's a scary thought, this is me or Ben saying, "Yeah, I understand, this is really hard and we're here for you." Creating space in the conversations, you said silence. So we have just a couple of minutes and maybe we can reflect on a couple of powerful points from the peanut gallery back here. You said that number one was, that you get in--we all get in a predicament of, you know, where the expectation is to cure cancer and these expectations are unrealistic. The other thing you said was that we have to--as providers, we have to be in touch with our emotions. And they're both really powerful great points. They're not things that we can easily cover, you know, in 2 minutes, but I think it is important to acknowledge that is very true. You know the curing part, I think when people come to us with these expectations, I think it's very useful to take a very exploratory approach. And say, tell me more about what you're expectations and goals are. Often times if somebody has an unrealistic expectation, I'll simply say and under worst case, if we can't achieve that goal, what other goals would you have? By doing that I send a message that first of all, I want them to think about goals, realistic goals and it's also an empathic way of saying we may not be able to achieve your primary goal with cure. So that's kind of a quick response to your really excellent point and question. So I'm afraid we're out of time. And I want to acknowledge our actors here

[ Applause ]

Chris and Raghav, thank you very much. And thank you very much, okay.