Surveys conducted between 1950 and 1970 show that most physicians considered it inhumane to give patients with a poor cancer prognosis the bad news.1,2 Since then, it has been well established that open communication between physician and patient is an essential part of effective cancer care and can even improve patient adherence to treatment regimens and help oncologists and palliative care specialists experience greater professional fulfillment and avoid burnout, according to James A. Tulsky, MD. Dr. Tulsky, Chair, Department of Psychosocial Oncology and Palliative Care at Dana-Farber Cancer Institute, and Chief of the Division of Palliative Medicine at Brigham and Women’s Hospital, has been studying effective physician/patient communication for over 20 years and cofounded VitalTalk (vitaltalk.org), a nonprofit company that teaches advanced communication skills courses and faculty development courses to help clinicians deliver bad news and discuss goals of care in an empathic manner.
Delivering bad news to patients, said Dr. Tulsky, is something oncologists do thousands of times over their career and yet is a source of great stress that can linger for days after the initial conversation with patients and lead to physician burnout. However, when bad news is communicated in an empathic way it can reduce not only the patient’s feelings of anxiety and depression, but can alleviate the physician’s feelings of stress and sadness as well, he said. To build a coherent strategy for delivering bad news, Dr. Tulsky recommends using a series of six communication steps described in the mnemonic SPIKES. They include:
- Setup—The physician is prepared with the patient’s medical facts and has a plan for delivering the news.
- Perception—Find out what the patient’s understanding is of the medical situation and how much information the patient wants.
- Invitation—Ask permission about whether now is a good time to discuss the news.
- Knowledge—Be direct in explaining the medical situation and use language that matches the patient’s level of education.
- Empathize—Use empathic statements to respond to a patient’s emotions. For example, “I know this must be disappointing for you.”
- Summarize and Strategize—Summarize the clinical information and make a plan for the next step, which may include further testing or a discussion about treatment options.
To improve communication between oncologists and their patients, Dr. Tulsky has teamed up with the American Board of Internal Medicine (ABIM) to study a computerized program called SCOPE in which oncologists audio record conversations with patients and then receive feedback on what went well and how they can improve in the future.3 Oncologists participating in the 3-year study will use the program as part of their ABIM Maintenance of Certification Program recertification process, and the researchers will test whether SCOPE improves oncologists’ communication skills and increases patients’ satisfaction.
The ASCO Post talked with Dr. Tulsky about how developing effective communication skills improves patients’ understanding of their illness, increases patients’ adherence to treatment, and helps oncologists avoid professional burnout.
Improving Adherence and Patient Care
How can good communication between patient and oncologist result in greater adherence to therapy and improve overall patient care?
When oncologists communicate effectively with their patients, patients have greater feelings of trust and satisfaction. And if patients feel more trusting, they are more likely to adhere to the therapies being prescribed because they will believe in their effectiveness. The other piece is that patients frequently have concerns or questions about therapy, and better communication will lead them to a greater understanding of what the issues are with their treatment and allow them to express their concerns and to have those concerns addressed by the oncologist.
All of this leads to greater treatment adherence, and greater adherence to treatment ought to lead to better outcomes.
Empathic Opportunities
How can effective communication promote professional fulfillment and help oncologists avoid burnout?
One of the major causes of burnout is the stress of dealing with patients who are very sick and ultimately die, which is exacerbated when it is also hard to communicate effectively with patients about their medical situation. There is a tremendous amount of emotional energy that goes into avoiding directly confronting patients with bad news, which then makes us feel less effective and more stressed.
Also, patients living with advanced cancers have a lot of emotions, including anger, fear, and sadness, and those emotions enter into the clinical space, and we as health-care providers are the recipients of those emotions, which can be difficult to experience. When oncologists are better trained to manage these feelings and have the skills to respond to patients in a way that is effective and makes patients feel supported, then clinicians also feel better because their own stress level is reduced. Engaging in these conversations can also make clinicians feel fulfilled because they allow physicians to feel helpful and get closer to their patients.
What are the skills oncologists need to communicate more effectively with their patients?
First of all, oncologists need to be able to elicit their patients’ concerns and correctly identify the emotional responses from patients. Some physicians have a hard time seeing the emotion a patient may be experiencing or interpreting it accurately, and then they need the skills to know what to do with that information (for example, how to make an empathic statement in response to a patient’s emotional concern).
There are moments that arise in these conversations, we call them empathic opportunities, in which patients express negative emotion and the physician can respond either with an empathic statement, which identifies that he or she understands the patient’s position, or with what we call a “terminator,” in which the physician changes the topic or distances himself to avoid the emotion all together.
Ask-Tell-Ask
Please explain the principle of “ask-tell-ask” when communicating with patients.
This principle is based on understanding what the patient already knows about his or her situation before giving additional information. Oftentimes, we walk into the examination room armed with a lot of details, such as the status of the patient’s disease and treatment options, and the temptation is to launch into a long monologue. Yet, frequently, patients already know this information. Asking patients to describe their understanding of the issue allows clinicians to learn the patients’ level of knowledge, emotional state, and degree of education and then tailor their message based on their patients’ understanding.
For example, a typical “ask” might be, “What have your doctors told you about your cancer?” or “What is your understanding of your illness right now?”
Another “ask” might be for permission to give additional information. For example, “Would it be okay if we talked about the results of your cancer treatment and what your options might be?” Asking permission before telling a patient more information is a way of putting more control into the patient’s hands.
Delivering Bad News
What is the most compassionate and effective way to give bad news?
Clinicians can follow the SPIKES protocol, which starts by first checking the patient’s perspective about his or her situation and then asking permission to give additional news so the patient doesn’t feel overwhelmed. For example, you might say, “Is now a good time to share your test results?” And to prepare the patient for the bad news, it is a good idea to fire a warning shot first, for example, by saying, “The scan didn’t come back as we were hoping,” or “I wish I had better news to give you.”
Then when the news is delivered it should be in short, clear, concise sentences. For example, “The biopsy showed that you have cancer.” “The scan shows the cancer has come back in your liver.” “Your treatment is no longer working.” Then I advocate being quiet and letting the patient absorb what has just been said.
Often a patient will then say, “What is the next step?” And before I go into the next phase of presenting information, I immediately recognize the emotion the patient is feeling and I might say, “I wonder if you are feeling angry or afraid.” I try to address the emotion before going on with more facts.
During that conversation is it appropriate to schedule another appointment with the patient to detail the next treatment plan rather than giving all the information at once?
Yes, absolutely. If clinicians have the time in their schedule to have the patient come back to discuss options, especially if the options are complex and the likelihood that the patient will be able to absorb them are low, or if a decision has to be made between continuing active treatment or receiving palliative care only, it is best to separate the two conversations.
The most important way to end the initial conversation is to give the patient a plan. The plan might be as simple as, “Let’s make an appointment for next Tuesday to discuss a new course of treatment and other concerns you may have.” The greatest antidote to patient anxiety is having a plan.
Maintaining Hope
How can oncologists help their patients with advanced cancer maintain hope without giving them unrealistic hope?
Being honest in their conversations about the patient’s prognosis is always best. I don’t think we can give or take away a patient’s hope. Hope is something that is a very internal resource. Hope is reliance, it is faith, and it is having trust in what the future holds.
We can support our patients during this difficult time by expressing our concern and assuring them that we will be there for them during the course of their disease, no matter what happens.
By using “I wish” statements, for example, “I wish I had a chemotherapy that could cure your metastatic cancer,” oncologists can acknowledge what patients are hoping for while also acknowledging that their hopes cannot be fulfilled. ■
Disclosure: Dr. Tulsky reported no potential conflicts of interest.
References
1. Oken D: What to tell cancer patients: A study of medical attitudes. JAMA 175:1120-1128, 1961.
2. Friedman HS: Physician management of dying patients: An exploration. Psychiatry Med 1:295-305, 1970.
3. Tulsky J: Improving communication between cancer patients and oncologists using patient feedback on actual conversations and the ABIM Maintenance of Certification program. Patient-Centered Outcomes Research Institute, 2014. Available at pcori.org/research-results/2014/improving-communication-between-cancer-patients-and-oncologists-using-patient. Accessed January 8, 2016.
GUEST EDITOR
Addressing the evolving needs of cancer survivors at various stages of their illness and care, Palliative Care in Oncology is guest edited by Jamie H. Von Roenn, MD. Dr. Von Roenn is ASCO’s Senior Director of Education, Science, and Professional Development Department.
