I*CARE Roundtable with Dr. Terrance Albrecht Video Transcript

Interpersonal Communication And Relationship Enhancement (I*CARE)
Roundtable with Dr. Terrance Albrecht
A Conversation with Walter Baile, M.D. and Terrance Albrecht, M.D.
Date: April 30, 2009
Time: 31:58

Terrance Albrecht, M.D.
Director of the new Behavioral and Field Research Core
    Barbara Ann Karmanos Cancer Institute; Detroit, Michigan
Professor in the Department of Family Medicine
    Wayne State University School of Medicine


Dr. Baile: Welcome to I*Care Roundtable, a forum where we discuss important issues in patient communication with notable experts in the field. I am Dr. Walter Baile, Director of the M. D. Anderson Program on Interpersonal Communication and Relationship Enhancement. Today, we're very pleased to have with us Dr. Terrance Albrecht. Dr. Albrecht is Interim Associate Center Director for Population Sciences. She is program leader of the Communication and Behavioral Oncology Research Program at the Barbara Ann Karmanos Cancer Institute in Detroit, Michigan. Dr. Albrecht is appointed as professor in the Department of Family Medicine and also Public Health Sciences at the Wayne State University School of Medicine. She has more than 130 publications in Health Communication and Behavioral Oncology with current funding from the NIH in the areas of patient-physician communication, treatment decision making, and very importantly clinical trial accrual. Dr. Albrecht is also funded for research on parental influence on pediatric patients coping with painful procedures as well as education and intervention mechanisms to reduce cancer disparities among older, underserved African-American men and women. Welcome Terry. Thank you so much for coming today.

Dr. Albrecht: Thank you.

Dr. Baile: It's good to have you here. So I wonder if you can tell us a little bit about how you got started in communication research in oncology. I remember when we were at the Moffitt Cancer Center together; you were just sort of beginning to sort of forge ahead in that field.

Dr. Albrecht: Well, it was really quite serendipitous. The dean that I was working for at the time, the Dean of Arts and Sciences had become acquainted with Jack Ruckdeschel, Dr. Jack Ruckdeschel who was the new President and CEO of the Moffitt Cancer Center and my dean knew that I was interested in studying medical communication, communication in context--in the context of medical centers. We've been doing some work down at Tampa General Hospital in Tampa and he suggested that we have a breakfast, the three of us and we sat down and started talking and one of things that Dr. Ruckdeschel said to me across the breakfast table was, "You know, I don't know why people who are interested in communication aren't all over this place, this hospital. We're a natural laboratory." I remember him saying that and I remember looking at him and saying, "That's exactly what we do." We study mutual influence. We study the ways in which communication affects who we are and is a function of what we want to have happen. In many ways communication under extraordinary circumstances as with a cancer diagnosis is one of the most important--it's a centerpiece of care and the opportunity to study that up close, front row seat was an extraordinary one for me.

Dr. Baile: Of course, your training was in communication at Michigan State University.

Dr. Albrecht: That's right.

Dr. Baile: And what I'm fascinated by is how you brought that expertise to study communication between or among cancer clinicians and patients and their families, and how you developed this new technology to really get a bird's eye view of that. Now I wonder if you could tell us about how that happened.

Dr. Albrecht: Well, I met Jack Ruckdeschel and I remember you as well early on. At that time you said, "Terry, you need to put on a white coat and walk these halls and you need to shadow our physicians and you need to see the kind of discourse, the kind of interactions that we engage in everyday with a wide variety of patients and their families," which I did. I went on rounds and we spent months and for the longest time, Dr. Ruckdeschel, Jack and myself would meet weekly and I would teach him social and behavioral science theories of human interaction, human behavior, human communication and he would teach me oncology. He taught me about cancer. He taught me about phase 1, 2, and 3 trials. He taught me about diagnoses. He taught me about the treatment, the medical side of that which was primarily around lung cancer. But the power--what really brought all of our research program to bear was I think the power of interdisciplinary science. No one of us could dream up and design the kind of technology and the kind of video capture, the kind of data capture that we came up with. But all of us coming together, to me, to study communication, you have to be there and you have to see it as it's occurring. Prior to the time that we did that, for the most part the only way that scientists could really get into that room and see what's going on in those very privileged encounters was with an audio tape machine.

Dr. Baile: Right, right.

Dr. Albrecht: And what you see with the video was the visual of what's going on between people when they interact, particularly around something as emotion-charged as the disease of cancer. You miss so much there. And so we, through some grant funding and some pilot studies, very carefully orchestrated first of all the question of whether we could even get the cameras in the room, how obtrusive would they be, would people agree to have their encounters with their physicians video recorded, would the physicians agree to this, what would we learn. And indeed, we learned a great deal. People forget about the cameras. They helped us design how to make them unobtrusive yet fully functioning and not something that's hidden. And so, over a course of about 4 to 5 years we developed a state of the art customized system.

Dr. Baile: So tell us how that works.

Dr. Albrecht: Well, the system actually is--it had to meet three kinds of criteria. One, it had to be completely unobtrusive and it had to be something that people would forget about and had to blend into the background. It also had to blend into the background of the clinic flow. So it wasn't just a room that was equipped with cameras and you know, it was sort of the, you know, the place where they do the video recording. These cameras had to follow patients as they went in and out of--

Dr. Baile: So they're portable?

Dr. Albrecht: They're portable. They had to be portable. They had to be mobile and they--and then what they--they had to be set up in such a way that we could monitor those but not have a live person in the room monitoring that because that would be too obtrusive. So they had to plug into a wall into something that would be digitally wired. So that--but there would be a person sitting in a remote site who would then be managing and could see the cameras and could move, remotely move and pan and tilt and zoom.

[Simultaneous Talking]

Dr. Baile: So let me see if I understand. So you have a portable system.

Dr. Albrecht: Right.

Dr. Baile: You can go into the clinic room.

Dr. Albrecht: That's right.

Dr. Baile: Plug it into the wall.

Dr. Albrecht: Right.

Dr. Baile: Okay, set up the cameras--

Dr. Albrecht: Right.

Dr. Baile: --which are part of the system and then have someone sit outside for example or in a more remote location--

Dr. Albrecht: That's right.

Dr. Baile: --and actually see what's going on in the interaction between the clinician, the patient, the family and capture detail of, for example, facial expressions and silences and dialogue. That is really, really incredible.

Dr. Albrecht: Exactly. And can follow people as they move around the room.

Dr. Baile: Yeah.

Dr. Albrecht: The cameras need to be able to swivel, they need to pan--to move up and down and you need to be able to zoom in and out, and monitor what's going on. The other thing that needs to happen is that if there is some sort of exam, for example, where the patient is disrobed, the cameras can--we can turn the cameras so that the patient's privacy is protected. And also, if anyone in the room decides that this isn't something they want to have happen, that they want us to end, they can simply say that and we turn--we remotely turn off--can turn off the cameras. Interestingly, no one has ever asked us to do that.

Dr. Baile: That's incredible.

Dr. Albrecht: But we've made it so that it--while it's obtrusive, it's also something where all the participants have control over it.

Dr. Baile: Right.

Dr. Albrecht: And we tell them you can throw a sweater over this if you decide this isn't something you want to happen.

Dr. Baile: You know, but people get used to it after a while.

Dr. Albrecht: We've done all of these studies to determine that.

Dr. Baile: Yeah.

Dr. Albrecht: And how reactive are they to having this session video recorded and we published quite a bit on the fact that those effects seem to really not be there.

Dr. Baile: And after you've captured the video, I supposed you have it down on a hard drive on the computer. You have a coding system where you can actually sort of look at the dialogue and break it down into meaningful categories. Could you tell us a little bit about that?

Dr. Albrecht: Yes, we can. We create a DVD and our coders put that in there and our computer systems are set up in our lab where we have multiple systems set up in, you know, various coding stations and then we've developed a coding system whereby the system is actually on the screen. We have two monitors so that the video is going on in one screen of the interaction and then the coding is in the second screen and it's a point-and-click kind of operation so that the coder, as they're seeing behaviors that appear and--that we're coding for what we're looking for, they can actually mark those on the tape and those automatically summarize and are then transferred to an Excel spreadsheet.

Dr. Baile: So what kind of behaviors do you code for?

Dr. Albrecht: In our work, we code for two kinds of communication behaviors. Communication theory is such that we know that messages occur at a content level, that's what we say, and they occur at a relational level, how we say that. And so our coding system tracks that kind of principle. We've been interested very much in how patients and their family members talk to doctors about clinical trials. So we focus on a specific kind of interaction, specific types of strategic communication and in our case it's been the discussion of clinical trials as a treatment option. There's lots of information about clinical trials that patients should be told for informed consent and for informed refusal. So we have a system where we--we lay out the content of communication and that's a checklist. We simply are able if the physician utters talks about for example the side effects associated with the treatment. We can note those, what those are and we note what they, you know, where they've said that and you know, how much has been said about it. We can capture all of that. But then we also have a series, a part of the coding, is a very general coding system. It's called the global judgments portion where at the end of the interaction, our coders judge on a 7 to 10 point scale depending on which study it is the extent of the relational dimension such as hierarchal rapport, trust.

Dr. Baile: Say for example, could--would you code something like smiling or physician moving closer or making eye contact? Is that sort of kind of relational--

[Simultaneous Talking]

Dr. Albrecht: We could do that and yes, we have done that. We have asked--we've coded the number of questions that patients ask. We've coded for the types of questions that patients ask. We've coded for the kinds of behaviors that family members engage in the interaction, and how much floor time they take up in the overall encounter, what kinds of questions they are asking, whether or not their behavior is supportive of the patient and the physician or are they somewhat contentious and reserved and contrary to the kinds of recommendations being made, all of these kinds of things we can capture.

Dr. Baile: So could you maybe summarize for us a little bit about what sort of notable findings that have come out of the research.

Dr. Albrecht: Well, what we found has been quite remarkable and the most recent, for example, with clinical trials, there is an adage in the oncology literature that we have a very low accrual rate of patients to clinical trials, very low between 2 and 20 percent. We find that when we're actually there with a front row seat of what's going on in the encounter, that actually the problem is with that low accrual rate is really not with the patients. For the most part, when patients are advised to go on a clinical trial, they do that. They're quite, in fact, compliant and you know, do everything they can to seek what they believe will be the best possible treatments and in many patients' minds that's a clinical trial option. Unfortunately, what we're finding is that how clinical trials are communicated to patients sometimes vary, and when patients say no or when the patient is not enrolled on a trial for which he or she is eligible and there is one available, it's sometimes because an offer was not clear. We find that in discourse. We had to separate out those encounters where a trial was discussed but at the end of the encounter the patient wasn't quite sure what they were being asked to do.

Dr. Baile: They weren't even being sure if it was recommended that they consider enrolling in the trial.

Dr. Albrecht: Exactly and you know, versus those situations where we could actually code reliably that indeed an offer was made to the patient that they could accept or refuse.

Dr. Baile: Do you think that that's an issue of training doctors to be more effective in communicating about clinical trials or is this ambivalence on the part of the person who's explaining the trial? Do you have any kind insight into that?

Dr. Albrecht: Oh, I think it's absolutely a cause for an essential need for training for physicians and also for physician extenders, for their primary nurses, for everyone involved in the team. In fact, the article that we had published in the Journal of Clinical Oncology was published with an editorial that said just that. The point of the editorial was based on these findings. We need to train physicians because in the presentation of the trial, in the discussion of the trial, because in doing so we can actually, we believe, make these discussions more efficient, more relationally sensitive to the needs of the patient. Our related finding that was very important was that when we interviewed patients later about their reasons for why they elected to go on the trial, many of them said, "Because my physician was so helpful to me, because I trust my physician." And you know, they really didn't talk a lot about the content side. They talked a lot about the relationship that they felt that they had developed with their physician which led to a sense of trust and confidence, and which also then led to a greater sense of confidence in themselves for the decision that they've made now to enter what may well be a fairly toxic treatment process.

Dr. Baile: Those are very important findings. Let me ask you if you also turn your cameras, so to speak, on the relationship between physician or physician extenders who are taking care of patients who might fall into the category of minorities.

Dr. Albrecht: Yes.

Dr. Baile: And that is a more recent interest of yours as I understand it. Could you tell us a little bit about what kind of work you’re doing there and what sort of outcomes that you've seen around communication with minority patients?

Dr. Albrecht: 0h. It's quite profound. I work in the heart of Detroit. We are the cancer center, is the safety net for the underserved population in the city and in the southeast region of Michigan. And we're learning a lot about the very specialized needs of patients whose healthcare, they've a lifetime of poverty and deprivation and now suddenly there's a diagnosis of cancer and the needs that they have are great.

Let me give you a couple of examples of the characteristics of our and particularly our older, underserved African-American men and women who've come into our clinics. We have a very high illiteracy rate in Detroit, 47 percent. We have one in four people living below the poverty line. Our older, underserved African-American minority patients are often treated-are often diagnosed with cancer in a much later stage than white patients in the city. And as well, the mortality rates from cancer are much, much greater. They're much higher. And indeed, the mortality rates for our African-American men and women in the city of Detroit are higher than they are for those--the average rates nationally for African-Americans. So we have a very serious problem with health disparities. And what we're learning is a number of ways in which we need to not only help our patients in the clinic setting but helping our patients get to the clinic and supporting them when they go home. We have--many of our minority patients come to a significant degree, come to the visit alone, 82 percent of our white patients come with someone and little less than half of our African-American patients come with anyone. So the kinds of questions that they ask are automatically cut in half because they don't have other people in the room asking questions for them. The extent to which people are supported to understand just even what a clinical trial is and the seriousness of the disease and how to take for example oral medication at home, all of these kinds of things are--require additional support, additional services. We have as well our patients are--with--along with a cancer diagnosis are often quite sick with other comorbid conditions.

Dr. Baile: Right.

Dr. Albrecht: And those have to be carefully addressed and discussed with the patient.

Dr. Baile: So have you been finding also that clinicians really need to be tuned into some of the communication aspects of the encounter in a different way with a minority patient who may not have the education or may not have a family member with them to help ask questions or support them? Is this something we could translate, for example, into some guidelines for clinicians in their interactions with minority patients?

Dr. Albrecht: Not only is it something we can do, it's something we must do. We're finding, for example, that our minority patients are less likely to ask a direct question. And so, they will make a statement with a lilt. "So it doesn't look good for me doc." That's what some will say. And that's often something that trails off and we see very little uptake on the part of the physician in responding to that kind of question. We find our white patients, our educated, white patients who have greater income levels and education levels ask their questions directly so that they are getting the answers. They're almost demanding the answers from their doctors. We have--for our minority patients who have to come alone, we find that sometimes when the doctor leaves the room they will make a call to a family member. They'll take out a cell phone and make a call. But the physician isn't in the room at the time to help with that discussion and to help the patient explain to the family member what's going on. And so, we need more technology in our exam rooms so that during patient visits these people can be put on speaker phone and can be called.

Dr. Baile: You know, it's very interesting because I'm very interested, as you know, in training doctors and I was thinking that oncology is a very data based field.

Dr. Albrecht: Yes.

Dr. Baile: An evidence-based.

Dr. Albrecht: Right.

Dr. Baile: And I'm wondering whether or not your ability--but on the other hand, everyone thinks that they're a good communicator.

Dr. Albrecht: Right.

Dr. Baile: And I'm wondering whether or not your technology where you're able to actually show doctors what happened in the encounter think maybe it has some impact on stirring up their interest in getting more training or sort of busting through this notion that anybody can just talk about a clinical trial and it really doesn't matter how you do it.

Dr. Albrecht: You know, that's a very important point, a very important question and I'm finding that as I'm talking with physicians across the country within various talks but particularly just in my own cancer center, the interest of our physicians and the urgency that they feel for training may be not so much for themselves but for physicians coming up, for the residents, the fellows, the students, younger physicians who may be overwhelmed with a new practice because they're learning that there are--that the beauty of training and guidelines is the ability to learn to adapt efficiently and to not be thrown by so many of the unexpected kinds of behaviors that come up in the, you know, extraordinary circumstance of a visit to a cancer center and the treatment of a patient.

Dr. Baile: Right.

Dr. Albrecht: And this can be reassuring for physicians. I even had a physician here at M.D. Anderson in another context say to me that he appreciated the work that we were doing because it gave him a new appreciation for the idea of informed consent and informed refusal.

Dr. Baile: So maybe starting with our fellows and incorporating some of this training into the oncology fellowship curriculum would be a great idea and--

Dr. Albrecht: Oh, absolutely.

Dr. Baile: And you know, in helping the senior clinicians --teaching them how to mentor some of these conversations as they interact with the fellows that would--

Dr. Albrecht: They have a huge amount of experience and wisdom gained through the years. We bring a way to organize all of that experience and that wisdom through the kinds of theoretical models that we have that put terms and labels--

Dr. Baile: Right.

Dr. Albrecht: --on the kinds of behaviors and practices that they see as second nature and we think that by organizing this in a way, that it's a very rich and very important set of skills to teach young doctors.

Dr. Baile: I think that the--really a centerpiece word is skills because oncologists very often don't believe or really aren't familiar with the concept that communication is really a skill that can be observed --

Dr. Albrecht: Absolutely.

Dr. Baile: --encoded and analyzed and taught and learned and so, I think that's an incredibly important concept to get across that, you know, it's like any other skill. For example doing a bone marrow biopsy, there are steps that are involved and there are techniques and that communication can be broken down into specific skills such as, for example, keeping eye contact with the patient and talk.

Dr. Albrecht: The skills are related to the behaviors. You know, at any given turn in an encounter, we have a choice of behaviors that we can, you know, that we can project and what we are able to do is to give physicians through what we've learned from an extensive kind of observational work that we've been doing. This is very close descriptive research. We're able to see an array of different kinds of choices that we believe will make for some better outcomes. We have confidence in the work that we're doing and believe that practice can be improved through research so that we have--we're teaching skills that are based on evidence-based skills.

Dr. Baile: Evidence-based skills, yeah.

Dr. Albrecht: And we're doing that because we're seeing that there--while there isn't one right way to script a dialogue with the patient, there are a set of behaviors and a set of patterns that we've been able to cultivate that we think that we can help physicians feel that they have more flexibility and a little bit--some better ideas for how they can handle challenging patients, how they can handle older patients with a variety of infirmities, a way that they can handle minority patients that they don't have a history of interacting with.

Dr. Baile: And I think it's very powerful to be able to bring a clinician to a room and see their video and review it with them and that's a method which I hope can find its way into more oncology programs. The last thing I just wanted to sort of bring up was yesterday you had mentioned you just got funded for a new project. Congratulations.

Dr. Albrecht: Yes, thank you.

Dr. Baile: And I wonder if you can tell us what direction that's going into and what that project is about.

Dr. Albrecht: Well, one of the things we've learned is that the encounter with the patient in the exam room, the out-patient visit is--does not occur, of course, in a vacuum as everyone knows. But to be able to develop a research program where we look at this encounter not in a vacuum but as part of a process that can better support the physician coming into the room to talk with the patient is something that has been a missing piece. And so, what we--the second aspect of our clinical trial research is that we're learning, for example, that most patients that we're seeing when directly invited to enroll in a clinical trial do so, accept that. But what we need to do is increase the number of offers then that are available. We have a real problem with the number of available trials, the pressure of our--on our physicians in the clinic, in these busy clinics. It's 5 o'clock and it's, you know, it's been a long day with many difficult cases and suddenly there's a patient who has a low literacy perhaps and is--and the physician walks in and thinks, "Oh my gosh, you know, they can't even remember necessarily all the trials that may or may not be available." That's where we're learning that an enhanced program that starts with the multidisciplinary team that looks at the patients, the new patients coming in together, looks at the available trials and begins to match up these appropriate patients with appropriate trials moving backwards in the system upstream.

Dr. Baile: Right. So how do you plan and how do you really capture the possibility that a patient maybe able eligible right from the start and communicate that amongst team members?

Dr. Albrecht: Precisely. And we're finding that while we've spent a lot of time focusing on good communication between the physician and the patient and the family member, that sort of convergence of accuracy and agreement about what's been said and the decisions that are going to be made are really contingent on a host of interactions that have occurred prior to that encounter. And it's achieving the kind of convergence and the kind of quality communication in the team that then supports the physician when he or she goes in to accomplish all of the things that he or she has to do in that room with that patient.

Dr. Baile: Which may even involve prompting the doctor to sort of be positive [laughter] then to offer a trial?

Dr. Albrecht: It's easier to be that way if you have support going into the room as a physician, with all of that information with the people around you who can help you with that. So what we're doing is extending that visit outward and so that that will be--that's the second piece that we're going to examine in order to increase the number of offers that are made. And then finally, our last--the last piece that we want to study will be not just compliance with the patient agreeing to go on the study, but one of the things that we're learning is that patients aren't always confident in that decision. They're not always sure that this is necessarily the right thing to do and that lack of confidence in them selves and that lack of confidence in the decision that they've made certainly we think is going to have an impact on adherence to the trial regimen. And they--so what we want to be able to do then is look at how the effects of that encounter play out longitudinally through the course of the patient's experience on that trial.

Dr. Baile: Well, that's very exciting.

Dr. Albrecht: Thank you.

Dr. Baile: So thank you so much for chatting with us about your research and good luck with your new project. That sounds wonderful and we'll be looking forward to hearing more about it and reading about it in journals. So thank you.

Dr. Albrecht: Thank you.

Dr. Baile: We've been meeting today with Dr. Terrance Albrecht and discussing her communication research, a very exciting work with patients being enrolled to clinical trials and minority patients. So thank you again, Terry.

Dr. Albrecht: Thank you.