The doctor-patient relationship can be fraught with sensitive issues. For doctors, delivering bad news (or even good news) delicately, discussing treatment options, even handling anger or sadness can define whether communication is successful, and whether the dynamic is a positive one.
A recent segment on the Brian Lehrer Show that dealt with this topic featured Philip Bialer, Interim Director of Memorial Sloan Kettering’s Communication Skills Research and Training program, or Comskil, an innovative program that’s been teaching doctors how to improve communication with their patients since 2005.
About 100 fellows and residents at MSK are required to participate in a Comskil course every year as part of their oncology training. Subjects covered include how to break bad news; discuss prognoses and treatment options; respond to patients’ anger; help the transition to palliative care; and handle end-of-life care, death, and dying.
“A lot of the focus is on making things patient centered and trying to encourage our physicians to check in with our patients,” says Dr. Bialer. “We devised this course to make us more empathetic and to better understand our patients’ needs.”
“For instance, when talking about prognosis, sometimes patients don’t want a lot of specific information,” he says. “They might want more general information. It depends on the patients. Our focus is on emphasizing that not all patients are the same.”
Empathy and sensitivity may be tough skills to teach, but Dr. Bialer says there’s evidence that the course is helping physicians — and that most doctors have an innate sense of kindness. “There are certainly improvements with some of the fellows, but many are already starting from a very high place. I think that says something about the kind of person who chooses to go into this field. They already come with a high level of compassion.”
To evaluate its effectiveness when the program first began, Comskil staff would record an in-person meeting between physician-trainees and first-time patients who agreed in advance to participate. Today, doctors interact with actors playing patients, so they can by evaluated on the complete spectrum of skills. Before each scenario, facilitators give the actors instructions — for example, asking them to weep or to react with anger, or to show any of the range of emotions a patient might experience.
At the conclusion of a scenario, doctors are able to view a video to see exactly what they were doing and learn where they can make improvements. Doctors also receive feedback from the facilitators, and even from the actors, who often remain in character to deliver their assessments.
One of the first physicians to take the course was medical oncologist Maura Dickler, a breast cancer specialist.
“You’re always finessing your communication,” Dr. Dickler says. “When I tell women about early-stage breast cancer, for example, and I tell them their diagnosis and options for treatments, I’m always checking in with them, taking stock of what they heard and having them repeat it back to me. I give them time to answer.”
She is among a number of physicians who went from being a student of the program to then becoming a facilitator. She says she continues to use skills she learned in Comskil day after day. “To be honest, many of those skills are very useful in my own life. Communicating with our children and spouses, we sometimes forget that these are life skills.”