Refining the patient-doctor relationship became a focus early on in my career. Unlike many of my colleagues in academic hematology and oncology, I also practiced internal medicine for the first 12 years post-fellowship. I quickly realized that I was drawn to caring for patients who had serious, life-threatening illnesses like cancer, so I came to oncology with a passion for both the science of disease and the opportunity to develop strong relationships with my patients.
Even as a fellow, I appreciated the importance of the relationship that grew between patients living with serious illnesses and their doctors. In many instances, those relationships can be therapeutic and sustaining. A strong patient-doctor relationship is an important part of treatment; it has the potential to provide patients with solace and comfort, even after treatments fail to control their disease.
That led me to ask myself, “What are the skills clinicians need to bring to patient encounters and what do we need to give of ourselves? How can we cultivate and nurture that in ourselves and our fellows?”
After exploring those questions with fellows and faculty members while I was at Harvard Medical School, we developed a communications retreat for fellows with the help of colleagues in palliative care and psychosocial oncology from Massachusetts General Hospital and Dana-Farber Cancer Institute.
Our work as hematologists and oncologists can be both incredibly rewarding and incredibly difficult. Unfortunately, we often had to give bad news and experience the deaths of our patients. Together, we recognized that fellows needed proper training in patient-centered communication in a safe environment where participants could share their experiences with fellow trainees and with senior faculty members.
So, for one day, fellows signed out their beepers and headed to a beautiful setting outside the hospital where they engaged in a combination of learner-centered exercises, including simulations, role-playing, and small- and large-group discussions.
Compassion is the component that is valued most by our patients and families, but, unfortunately, it is often not recognized in our curricula.
To ensure that we were providing the fellows with relevant skills, we first asked them what types of conversations and situations were the most difficult. From that feedback, we devised scenarios that mimicked real-life patient encounters. Faculty members and actors portrayed doctors and patients, and instructors modeled the skills to use in these situations – everything from conducting a typical patient interview to navigating tough conversations about treatments to delivering bad news to patients and their families.
Over the years, we introduced new sessions to the agenda, like creating a faculty question-and-answer panel in which the younger doctors could ask more senior faculty about their experiences – what shaped their careers and what they found most rewarding or challenging. It was an opportunity for faculty to provide frank feedback and it also had the benefit of opening fellows’ eyes to some different career paths available to them.
In the small-group exercises, we invited fellows to discuss the scenarios we presented and brainstormed potential solutions. Taking this learner-centered approach helped us tailor the training to meet their needs and understand exactly why these situations felt so difficult. We encouraged reflection and, again, set up a safe environment where participants were able to voice their concerns without judgment.
Talking Less, Listening More
It became clear, working with our trainees and fellows, that they are not poor communicators. They did need instruction, though, in the specialized skill of communicating with patients and caregivers. Early-career doctors are trained in how to present research, give lectures, and persuade colleagues; they need more guidance in developing interpersonal skills and interacting with patients and families.
Fellows occupy an interesting position: They know more than they did as medical students and residents, but they have much more to learn before they transition into attending physician or faculty member roles. Because they want to demonstrate the knowledge they’re gaining, they sometimes have a tendency to teach patients or give “mini lectures.” In a rush to prove their expertise, they provide a litany of data instead of developing a relationship and responding to the emotional aspect of the encounter. As you progress through your career, you realize that sometimes, you need to talk less and listen more.
Fellows’ experience level works to their disadvantage in some ways: A medical student with less training may find it easier to respond to a patient who is emotionally distressed because – as I have heard from several fellows – the training experience can be dehumanizing. They have strong instincts and intuition, but often what’s missing is what I call “presence.”
Presence involves listening, conveying deep respect and warmth, and providing the comfort that we all want when we’re sick. It requires the clinician to be an expert in the treatment of the illness and in the psychologic aspects of the patient experience. This means exercising empathy, helping people find sources of inner strength, knowing how to comfort caregivers, and recognizing when it is appropriate to refer someone to a colleague with expertise in mental health.
Presence is a skill we can cultivate, much like we cultivate knowledge about a disease state. We need to learn how to be with someone who is emotionally distressed, like a patient who has been told that his or her leukemia relapsed or that a loved one has aplastic anemia. We have to ask ourselves, “What does it take to simultaneously display competence and provide a comforting presence to patients, caregivers, and families?”
As we help trainees cultivate their compassion and patient communication skills, we also need to ensure that they are caring for themselves. Empathy can be a slippery slope, so to speak. It has taken me a long time to understand this point, but being empathic means that you open yourself to experiencing patients’ distress or even mirroring their suffering. If you live in that, you can burn out quickly.
I believe that compassion is the component that is valued most by our patients and families, but, unfortunately, it is often not recognized in our curricula. So, practicing compassionate communication should be a focus of our training. At the end of the day, it helps us to be more effective and find joy and meaning in our work – without feeling that we’re completely spent emotionally.