Teaching Physicians Communications Skills

Timothy Gilligan, MD, MS
Co-director of the Center for Excellence in Healthcare Communication, Cleveland Clinic, Cleveland, Ohio

Here’s a patient scenario you might have encountered: One day, a patient with a highly curable cancer is admitted to our hospital, but he will not consent to the chemotherapy needed to be cured. The health-care team has been discussing his treatment options with him for days, but the team is not making any progress. Arguing and medical facts haven’t been working, so what can we try next?

The following day, I meet with the patient and change the approach: Instead of arguing, I ask him what his story is. It turns out, it’s an incredibly complicated one: His dad was dying of lung cancer, his mother had tried to prevent his dad’s medical treatment, his girlfriend had gotten pregnant and thrown him out, and he had this new girlfriend … . Many physicians would feel that this history, and his social situation, are not as important as his cancer. But for him, they were.

On that first day, all I did was to listen and forge a relationship. The next day, we talked more about his cancer. The day after that, he started chemotherapy. If my only goal had been to start chemotherapy – and I hadn’t focused on building a successful relationship with him – I doubt I would have been successful.

Communicating with patients is one of the hardest tasks that physicians have to take on. Until recently, it hasn’t been considered a serious subject of physician training in the same way that procedural skills have been taught. We believe that communication and relationships are critical tools for us to succeed in the medical part of our work.

What We Teach

In my opinion, the standards for communication in medical education have been pathetic. The general expectation is that health-care providers will simply learn by watching our role models or senior physicians do it. In my mind, that’s like telling someone, “Watch Roger Federer play tennis, and then go play like him.” It doesn’t work.

Lecturing physicians about the principles of communicating similarly misses the target. Keeping with the same analogy, it would be as effective as giving a PowerPoint presentation on how to play tennis, and then expecting that person to go out and hit a moving tennis ball – or a still one, for that matter.

For our physicians, we started making communication a priority about four years ago. Communications training is now mandatory for all attending physicians, residents, and fellows, and, since 2011, we have trained more than 4,000 clinicians.

Trainees and physicians in our communications clinic attend a full-day, eight-hour course in which we present fundamental ideas about how to build a relationship and how to engage in it. Our theory, which is built upon several other learning principles, is that relationships are at the center of medical care. If you don’t pay attention to your relationship with your patients, the human work that takes place in the context of those relationships becomes much harder.

Our training is built on two guiding principles: 1) communicating is a motor skill and needs to be practiced, and 2) the relationship is more important than anything else, especially when you consider it to be long-term.

Model the Behavior You Want to See

Our approach is very learner-centered. Instead of telling people what we think they should work on, we ask what our participants – often a fellow or attending – want to work on; what frustrates them in their daily patient encounters; and where they think they need improvement. Then, we practice those through role-playing scenarios.

Let’s face it: If you put a group of doctors in a room, and tell them, “Today is communication training day; we’re going to role-play some scenarios,” the groans are audible. However, when we start by inviting physicians to share some of the hard conversations and challenging patient situations they’ve had, the stories start flowing. From there, we start practicing by building cases from their past experiences – opening it up to feedback from the other attendees.

Similarly, it’s important for physicians to practice these skills in a “safe” environment, in which we reinforce all of the things they are doing well – and not just criticize the areas where they need to do better. In medicine, we tend to look for people to make a mistake and then pounce; if that person does 10 things well, though, we just assume that’s normal because we expect that person to be competent. We’re trying to reverse that.

To create a safe space for learners, we aim for a four-to-one ratio of positive-to-negative feedback. And people learn better that way; they become much more open to identifying areas where they would like to improve. Again, similar to our patient encounters, if we start naming all of the things people are doing incorrectly, they are going to enter a closed-off, defensive mode. That’s not the optimal learning stance.

We actually don’t use words like “well” or “badly.” Instead, we use terminology around specific behaviors and the impact of those behaviors.

For instance, “What did you do that was effective in achieving your goals, and what could you have done differently?” The process is not about evaluating or ranking the communicator; we are trying to define what types of behavior work and what types of behavior don’t work.

Stuck in a Lack-of-Feedback Loop

Placing an intravenous catheter, suturing, doing a physical examination – these are all skills that physicians are given the opportunity to practice and skills that they must demonstrate competency in before they graduate from medical school. There simply hasn’t been the same structured approach to measuring whether or not medical students, residents, fellows, and attending physicians are competent in patient communication.

For instance, we all have to get consent from patients in order to administer chemotherapy, but do we ever measure how well our physicians do that? After they get consent from the patient, is the patient able to say what he or she was consented for, what the risks and benefits are, what treatment alternatives there are, or who will be involved in his or her care? Physicians are required to educate patients of those four things, yet we never test patients, and we never know whether or not we have successfully educated them. I only have to document that I told them something; I don’t have to document that they understood it or remembered it.

Following on our belief that communication is a learned motor skill, honed through practice and feedback, in our program, we don’t ask learners to take a multiple-choice test on how to communicate with patients; we ask them to actually do it. Most physicians are comfortable in the cognitive realm, so they may understand what skills are necessary to communicate effectively with patients, but can they actually put those skills into practice? They may be able to tell me what empathy is, but can they express empathy effectively to another person?

The lack of feedback is one of the major obstacles to effective physician communication education. When I have to deliver a cancer diagnosis to a patient or his or her family, I get little feedback as to whether I did that well. I’m getting no information back other than the look on the patient’s face. Obviously, I cannot expect that person to be happy after receiving that diagnosis. If the patient is upset, that does not necessarily mean I did a bad job; it may mean that he or she understood the upsetting news I was sharing, and, therefore, had a normal reaction to upsetting news.

Embracing Conflict

The issues we face in communicating in medicine are not too distinct from those of communicating in all aspects of our adult lives. Most of us haven’t thought seriously about how to have difficult conversations, and, consequently, most of us haven’t thought about what it means to engage in those conversations successfully. Think back to the first time you had to give someone bad news. It was probably when you broke up with a boyfriend or a girlfriend, right? You tried to deliver the news in such a way that he or she did not get upset. But, does that work with patients?

The normal, human response to upsetting news is to get upset. And, as hematologists and oncologists, the bad news we have to deliver is often very bad. Most people would rather avoid conflict than resolve it but, as physicians, our strategy should not be to try to block the natural human response.

We actually see conflict as an opportunity for a stronger, more honest connection and try to emphasize that to our learners. If done skillfully, conflict conversations tend to be very honest. People, once they get mad, will start to tell you what they really think. If you can have that conversation in a way that isn’t damaging to the relationship, it can actually deepen it.

What Patients Do (And Don’t) Need to Hear

Too often, clinicians walk into a patient’s room with an agenda – making the conversation fundamentally dishonest in the sense that there is no mutual commitment to it. For example, if my primary goal in a patient interaction is to get him or her to quit smoking or take his or her medication, I am trying to control that person. The message, “Smoking causes cancer, so you should quit” is very different from the message, “I don’t want to see you get lung cancer – is there some way we can work together to make that happen?” Convey to the patient that you are committed to him or her and not his or her medical outcome; let the patient play a more active role in setting the “agenda.”

These are some of the reasons we propose that doctors focus on building an effective relationship with the patient as their first priority. If you forge a strong connection with the patient and build a trusting relationship, everything you want to do medically thereafter will be much easier.

When patients come into the hospital or clinic, they are in a foreign environment – our environment. It is in our best interest to make them feel welcome. This can be done by asking about what has happened in their lives since we last saw them and showing them that we are interested in more than just their medical problems. We want physicians to enter the room with a sense of curiosity and interest about their patients.

Studies have shown that patients accurately remember less than 25 percent of what doctors tell them. We need to be really thoughtful about what information is the most important to them. How do we figure out what that information is? By listening. Patients do not need a detailed understanding of the pathophysiology of their diseases. Some may want that, and we can try to provide that, but most patients are probably never going to have to take their board exams in oncology.

When a human being is upset, he or she needs empathy. Acknowledging his or her distress or suffering is much more important than rushing to reassure the patient about his or her prognosis or making promises we cannot keep. If I had a heart attack, my doctor might say, “The good news is it was just a single vessel and you are at a very low risk of ever having a recurrent heart attack. There is no damage to your heart, so you will be totally fine.” But, do I, the patient, feel fine? Of course not – I’ve just had a heart attack and have been reminded that I am mortal.

Building a relationship is akin to making deposits to the bank. The physician is building up trust, and, when it comes to making a plan, the patient will be more likely to “buy into it.”