Clinician Talk Training Is 'Game-Changing Experience'

Fran Lowry

June 27, 2019

One morning during rounds, Anthony L. Back, MD, then an oncology resident at Harvard Medical School, heard a conversation that shocked him.

Dr Anthony Back

"We were following the attending on our way to somebody's room, and the attending asked, 'How is Mrs So-and-so,' and the Fellow said, 'Well, she died.' And we all just turned the corner, like...no comment, no nothing. We turned the corner, and we all followed like a school of fish, and the attending doctor said, 'Well, she was kind of an old trout,' and I was like, oh my God, what is this?

"In retrospect, I think it was just awkward and he didn't know how to handle it, but I remember I felt uncomfortable," Back said.

Now a professor at the University of Washington, Seattle, Back is on a mission: to educate every physician who treats people with serious illness how to communicate with their patients in a meaningful, fruitful, and compassionate way.

"This set of communication skills during serious illness requires expertise and should be regarded as a procedure requiring special training and demonstration of competence," he said.

There is a great need for such training.

In a special article published online in the Journal of the American Geriatrics Society, Back and his team estimate that some 220,000 physicians and advance practice providers could benefit from training.

It's important for clinicians to understand that communication skills are different from doctoring skills and that they can be learned, Back emphasized.

With the proper training, these are skills doctors can learn...and this is a game-changing experience. Dr Anthony Back

"This really is good news, that with the proper training, these are skills doctors can learn and practice and get better at, and for many of them, this is a game-changing experience, when they realize they can actually change their behavior and patients will respond differently to them," he said.

Back is a cofounder of VitalTalk, a 501(C)3 organization for the dissemination of communication skills training.

It is one of six established communication training models. The others are the Center to Advance Palliative Care CME modules; Respecting Choices; the Serious Illness Care Program at Ariadne Labs; the End of Life Nursing Education Consortium; and the Education and Palliative and End-of-Life Care.

Good News! You CAN Learn

According to Back, the main reasons why many physicians have poor communication skills are lack of time and a false belief that they are born knowing how to communicate.

"There is an onslaught of stuff coming at doctors. Technology is getting more and more complicated. More and different drugs are always coming on the market," he said. "For example, for oncologists, there have been 15 new drugs approved by the FDA every year for the past 3 or 4 years. This means that oncologists have to become experienced with them, learn how to get them approved by insurance, and that's on top of all of the constantly changing documentation requirements that they have for different payors. So, honestly, clinicians are being barraged with things, and with all of this going on, it's very easy for the issue of how you connect with your patient to get pushed aside.

"All of these other issues, the administrative and the scientific, present with urgency. You have to do this right now in order to get the patient on the right medicine, things like that," he said.

"Most doctors, except for the ones who were trained very recently, were raised with the idea that you get better as you go and that experience will help you and you're pretty good at this anyway," Back said.

"So what that means is that doctors not only have all these other demands on their time, many of them are not trained to see good communication as a skill that you learn and perfect and need to work on. They think they were either born with good communication skills or not and that they will automatically get better with a lot of experience. But we've learned that experience, while good for a lot of things in medicine, is not good for improving communication skills," he said.

"People get into habits and keep doing the same thing, and when that strategy doesn't work, instead of saying, 'I need to change,' they say, 'That patient doesn't get it, the patient is the problem,' and tend to blame patients.

"There is a body of research that shows communication training is effective, but most of this training has only been available through research studies, because nobody has created a business model to make it happen, and such training is quite expensive compared to most continuing education," he said.

"Doctors get to role play in small groups, we use actors, we have clinician facilitators, and all of those things add up to a very experiential process," Back said.

He explained that VitalTalk began as a start-up company with fellow cofounders Robert Arnold, MD, the University of Pittsburgh; Kelly Edwards, PhD, the University of Washington; and James Tulsky, MD, the Dana Farber Cancer Institute. They realized that they could either apply for another grant to fund yet more research, or else try to set up something more durable that would actually have an impact.

"If we just wrote more research grants, we realized our goal of educating physicians was not going to happen. We could write another big research grant and maybe train 80 oncologists, half of which would be in the control group, and yet we need to educate 20,000 oncologists in the US. So obviously, we would not have any impact. Even if we made the science better, it was not going to have any impact, because there was no channel to provide training," he said.

VitalTalk workshops typically last a half day to a full day, which means participation is feasible for most clinicians, Back said. During the past 5 years, VitalTalk has trained more than 500 clinicians. In the past 3 years, more than 650 workshops have been conducted throughout the United States. Clinicians wishing to learn more can visit the website at https://www.vitaltalk.org/about-us/.

Back and colleagues conclude their article with a list of "shoulds" or recommendations for advancing progress in the field in the next 2 to 5 years.

They would like to see evidence-based communication training programs become more available. They recommend that a national cadre of skilled communication teachers be developed and that communication teachers or experts, such as geriatricians or palliative care clinicians, be included in health systems to act as resources for frontline clinicians.

Redesigning the workflow at the office to give added support to time-burdened physicians would maximize the impact of this training, Back said.

The work was supported by the Gordon and Betty Moore Foundation. Back reports no relevant financial relationships.

J Am Geriatr Soc. Published online May 10, 2019. Full text

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