Timothy Gilligan, MD, FASCO

Timothy Gilligan, MD, FASCO, Co-Chair of ASCO’s Expert Panel on Patient-Physician Communications Guideline and Vice-Chair for Education and Associate Professor of Medicine at the Cleveland Clinic Taussig Cancer Institute, spends half of his professional time treating patients with urologic malignancies and the other half teaching clinicians and clinicians-in-training how to improve their communication skills. He also teaches team-building strategies, coaching, and conflict engagement and resolution courses.

The ASCO Post talked with Dr. Gilligan about applying the recommendations in the ASCO Patient-Clinician Communication Guideline (see more in JCO Spotlight on page 90) in the clinic and asked his advice on how oncologists can become more effective communicators with their patients.

Defining Effective Communication

What constitutes good or successful communication between physicians and patients?

At a very fundamental level, you can say it’s when we accurately understand each other. There is research showing that patients accurately remember about 25% of what they are told at a medical visit. So, if we just look at that simple definition of effective communication, we are leaving ourselves substantial room for improvement. But we can be more ambitious than that. Obviously, we want to understand each other.

Another measure of it is to ask a few questions. Do we have an effective relationship? Do we trust each other? Do we feel that we understand each other? Certainly, the ASCO guideline is trying to reach that element of communication. Do patients feel like they are being seen and heard, and do clinicians understand what patients are going through? The flip side is to ask, Do patients feel like they can trust the medical team taking care of them?

We want patients to feel cared for and supported, and that’s another benefit of listening, so we can understand what their experience is. They will feel more cared for if we treat them in a way that suggests they matter and their experience is important to us.

When to Start End-of-Life Care Discussions

The ASCO guideline recommends physicians take the lead on asking patients about their end-of-life preferences. Oncologists are often hesitant to broach that topic with patients, especially now when there are so many therapies extending life. What is the right timing for these conversations?

You bring up an important point. In some ways, it was easier when we could say in black and white terms, “We have run out of treatment options, and there is nothing more we can do to control the cancer.” Now there are situations that are more ambiguous. However, the real push in end-of-life communication is not to wait until patients are at that point and to have these conversations earlier in the process.

Death and mortality are exactly what they worry about, so giving patients an opportunity to talk about the topic is not introducing something new.

— Timothy Gilligan, MD, FASCO

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Part of the hesitancy in initiating these conversations is that death and mortality are scary subjects, and it’s more comfortable for us not to discuss them with patients and to put them off for as long as possible. But as soon as you tell a patient he has cancer, one of the first things he thinks is, “Am I going to die of it?” So, in some ways, we are playing a silly game of thinking that if we don’t mention the word death or mortality to patients, they won’t think of it themselves. In reality, patients think about those things long before they come into our office. Death and mortality are exactly what they worry about, so giving patients an opportunity to talk about the topic is not introducing something new. It is acknowledging that death is something patients are already thinking about.

Often it is a relief for terminally ill patients to have the opportunity to talk openly about what they are scared of. It can be helpful to talk about death before it becomes imminent and say something like, “Treatment can control the cancer for a period, but ultimately, the disease will most likely become resistant and uncontrollable. Would it be helpful to you to talk about what that means and what you would want at that point?”

There is a lot of talk about the promise of immunotherapies and their ability to produce durable remissions in patients, but most patients will not experience durable remissions. So, again, we can have a conversation with patients about the best-case scenario of perhaps having a durable remission from these drugs and also ask what they would want to do if that doesn’t happen.

Having these conversations early on after an incurable diagnosis gives physicians a chance to learn what is most import to their patients so they can then make decisions based on their values and priorities. The goal is not to put everyone in hospice. The goal is to make sure that a treatment plan matches what the patient actually wants based on an accurate understanding of his or her prognosis and the effectiveness of treatment.

Getting an Early Start

When is the optimal time to begin communication skills training? In medical school?

Yes, and more medical schools are offering this type of training. I’m very hopeful about the future because many medical schools are taking skills-based communication training seriously. Many medical schools and residency programs now have simulation centers, where trainees can practice their communication skills using role-play scenarios conducted by trained facilitators to enhance their empathy for patients and families or can be videotaped interviewing real patients; this way, they can watch themselves and see what areas need improvement. The skills-practice exercises should also include structured feedback, so participants can learn which of their behaviors are effective and which ones would benefit from modification.

I would love to see a requirement that 10% of CME hours focus on interpersonal and communication skills.

— Timothy Gilligan, MD, FASCO

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But the key element in communication skills training is to recognize that being a strong communicator is a learned motor skill and to be successful at it takes structured practice and feedback for most people. It’s difficult to learn this on your own through trial and error. For example, practicing telling a patient he or she is terminally ill in a learning environment allows clinicians to develop the expertise and confidence to be comfortable in those difficult situations.

If a physician goes into a room to have a difficult conversation with a patient and feels incompetent, the patient will be able to tell, and that makes it difficult to have the conversation effectively. On the other hand, if we clinicians exude a sense of compassion and confidence, patients will be more comfortable, and it will be easier for them to trust us. The only reliable way to get there is through practice.

Making Communication Skills Training Part of Continuing Medical Education

Is communication-skills training becoming part of continuing medical education?

I wish it were. Our team at the Cleveland Clinic is pushing to make that happen, and I’m hopeful we will get more traction as time goes by. Every 2 years, physicians in most states are required to obtain 100 hours of continuing medical education (CME). Other clinicians also have CME requirements. I would love to see a requirement that 10% of CME hours focus on interpersonal and communication skills. Communication is far more than 10% of our work. To learn a skill takes some time, and we have to decide as a profession if becoming adept at effective patient communication is important enough to justify dedicating time to work on it.

In addition to becoming more effective communicators with our patients and improving their well-being, good communicators are more efficient in the clinic and work more effectively, so physicians benefit, too, by experiencing less burnout and greater work satisfaction. The training is labor-intensive and takes a time commitment, but the benefits to patients, family members, and clinicians are worth it. ■

DISCLOSURE: Dr. Gilligan reported no conflicts of interest.