Any doctor who sees patients should be able to communicate with them effectively and sensitively, however, good communication skills may be of particular importance for oncologists, who need to be able to discuss complex disease states and complicated treatment options, and frequently have to deliver distressing news.1,2

“Starting out in the field, you realize early on how crucial every conversation you have is,” said Lanie K. Francis, MD, hematologist/oncologist at the UPMC Cancer Centers at UPMC Mercy Hospital, and clinical assistant professor, department of medicine, at the University of Pittsburgh School of Medicine in Pittsburgh, Pennsylvania. “People are hanging on every word you say. I’ve learned from my training, from additional coursework, and even more so just being in practice the past 4 years, how carefully you have to choose your words.”1

Good communication skills are critical at every point of the oncologist–patient relationship, from the initial visit to the last.2 “The first visit is often very complicated [and it may] involve bad or serious news. Often, patients with cancer have not gotten a sense of the full extent of their disease before they see the oncologist,” said Anthony Back, MD, professor, Department of Medicine, Division of Oncology, University of Washington Fred Hutchinson Cancer Research Center in Seattle, Washington.

The first patient visit also usually entails discussing the pros and cons of different treatment options and a discussion of how a course of action will be decided on. In subsequent visits, there comes a conversation about the patient’s prognosis. According to Dr. Back, this conversation might include patient questions such as, “What do the statistics mean to me?” “How is my family going to handle this?” “How do I talk about it with my friends?”

When a course of treatment ends successfully, patients may experience anxiety as they move away from the intensive support of a cancer care team and onto survivorship. If treatment fails, there needs to be a discussion about what that failure means to the course of the patient’s disease, and about the possibility of trying a different type of chemotherapy. End-of-life issues also may arise at this point.

“Through the whole trajectory of illness there is a sequence of difficult, often awkward, often emotionally charged conversations,” Dr. Back explained.

Despite the importance of good communication skills, many oncologists never receive specific training in this area.2 Accredited fellowship programs now are required to provide some sort of communication training, but that can vary from one-on-one coaching, which can be quite effective, to a didactic lecture, which can be informative but may not have the power to influence change.

“Knowing the right first, second, and third line of chemotherapy for a particular cancer is something that you can get from lectures, but communication is a skill you need to practice,” Dr. Back said.

In order to augment the communication skills training offered by their fellowship program, fellows can help themselves to identify their own strengths and weaknesses and to improve in the areas where they need further training (Table 3).

Table 3. Tips To Improve Communication Skills
Identify a good communicator and observe (take notes!).
Listen instead of talk.
Assess what the patient understands and what knowledge he/she seeks.
Obtain overall expectations of the patient and family members.
Based on conversations with Anthony Back, MD, and Lanie K. Francis, MD.

One approach is to identify a good communicator and ask how he or she prepares for difficult conversations with patients. “Good communicators don’t just go in and wing it,” Dr. Back said. “They will have given it a lot of thought and have very specific strategies.”

Fellows also can learn by paying close attention to a good communicator; it helps to take notes. “A lot of doctors don’t remember what happened in a patient conversation because they are not used to paying attention at that level,” Dr. Back said. Doctors often gloss over the patient’s response to something the physician said. “The key to becoming better at this is to look at the relationship between what you said and how they [the patients] responded.”

Along with observing others, fellows can ask someone to observe their interactions with a patient and then provide some critical feedback. Fellows who work in a cancer center or clinic should consider asking a nurse or social worker to observe them during a patient visit, but they should keep their request limited. “Ask for specific feedback, for example, 1 or 2 points on how you talk about prognosis,” Dr. Back suggested. “The feedback you want is: What did I do well? What should I change? Is there something I can work on? Someone can give you that feedback in less than 5 minutes, and it’s very useful if you get it from someone you trust.”

Finally, more written resources have appeared as the importance of communication skills has gained recognition. “There are a lot of papers in the medical literature that describe specific strategies that can give you an idea of how to deal with a particular problem,” Dr. Back said.

As Dr. Francis transitioned from fellowship to attending, she found herself reaching for strategies that she had learned that can help oncologists move forward with patients when they’ve reached a stumbling block in a difficult conversation. These strategies include, for example, listening instead of talking, assessing what the patient understands and wants to know, and trying to get a sense of the overall expectations of the patient and his or her family members.

“Ask them what they know so far about their diagnosis. Listen to how and what they are ready to hear before beginning the conversation,” Dr. Francis said. “I’ve found it very useful to take a step back, take a deep breath, focus inward, look the patient in the eye, and think about how I would feel in their shoes. Put yourself in that place and then proceed with caution.”

As with all skills, communication gets better with practice. “But you have to remind yourself every time you walk into the room that what you say has such an impact on your patients,” Dr. Francis said. In sum, think before you speak.

Oncology fellows interested in learning more about communication skills can read Dr. Back’s book entitled, “Managing Communications With Seriously Ill Patients: Balancing Honesty With Empathy and Hope.”

References

     

  1. Francis L. Learning to listen: a fellow’s experience. J Clin Onc 2006;24(19):3209-3210.
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  3. Back A, Arnold RM, Tulsky JA, Baile WF, Fryer-Edwards, KA. Teaching communication skills to oncology fellows. J Clin Onc. 2003;21(12):2433-2436.
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