Our view of the JAMA article

We’ve gotten a few quizzical emails about the JAMA article showing that a communication skills clinic elective didn’t improve how patients rated quality of communication. What do we make of it?

Don't forget...

The residents and nurse practitioners acquired new skills. For those who are skeptical that physicians change, this is evidence to the contrary. Lectures don’t work; carefully facilitated small groups can enable learners to acquire skills.


This skill acquisition happened with facilitators who were trained for this project. They didn’t have much small group experience. Our facilitation model doesn’t require years of experience.

Then why didn’t it work? Some hypotheses:

Our measurement tools don’t capture the full patient experience. We used the Quality of Communication and Quality of Dying measures, the best of what’s out there. But there may be a basic conceptual flaw – we are asking patients to say that they are “highly satisfied” with a conversation that may be the most disruptive and difficult they’ve had in their life, even when done well from the clinicians’ perspective. We don’t have direct empirical data on this, but this hypothesis might also explain the recent NEJM study by Weeks et al showing a negative correlation between communication (as measured by 5 generic questions) and accuracy of prognostic understanding. Perhaps we need to be asking patients what the conversation covered rather than whether the doctor did a ‘good’ job.


Measurement needs to occur sooner after conversations are held. The number of questionnaires returned by patients indicating that they couldn’t rate the clinician because they had not had a significant conversation, or couldn’t remember the clinician well enough was sobering. Add that many patients were receiving questionnaires months after they had met the clinician—and we wonder how well the patients could really remember what happened.


Intervention needs to occur when the clinicians really need it. The clinic elective was designed to fit in to the residents’ schedule rather than designed to target times when these conversations were most likely to happen. We used a clinic block slot because it was feasible. But in retrospect, figuring out how to embed the intervention in a clinical experience where these conversations happen a lot would have made the intervention more powerful as ‘just-in-time’ learning.

We should build on individual baseline skill levels. The baseline self-assessment from the study showed that resident assessments were all over the place—from quite accurate, to massive self-overrating, to massive self-underrating. We ought to feed that back and start the learners there.


Findings that made us think...

Discussing serious stuff might make people sad and upset. This seems almost ridiculous to state, but I think we’ve been hoping that great communication skills mean that we can skip the sad step—that might not be true. And maybe the study intervention gave learners the ability to start the conversation—but not enough skill to deal with the sadness?


Sick people might view these conversations differently. Note the subset analysis that showed that the patients who rated their own health poorly rated trained clinicians as significantly better. It’s a subset—but we wonder if experiencing the reality of one’s own illness prepares you in some way.


Are randomized trials really the best way to test an educational intervention? In this study, we treated the communication skills intervention like a drug—give it to all the residents, regardless of their skill level, and see if it changes them (which it did), and if that effect trickles down to the patients (which it did not using these instruments and these methods). But as an educator, I know that learning has to be tailored—and we didn’t do that. Maybe we need to target interventions to performance level? 

What's next?

Seth Godin defines failure as ‘a project that doesn't work, an initiative that teaches you something’, and (borrowing from Nietzsche) declares that ‘failures that don't kill us make us bolder’. We’re with Seth—and our north star is still culture change. The way clinicians talk to patients still isn’t good enough, and it’s still central. We’re sticking to a strategy of innovation and empirical testing, and we’ll seek collaborators who can think big and deal with reality. 

Our next steps are courses for learners at different levels, expanding learning into the peer social space, and using technology to extend feedback and community, and looking at how communication is distributed across teams. If you’re interested—let’s keep talking.

(this post is under construction--hyperlinks coming!)

3 comments:

  1. Thank You for the information.

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  2. I am a terminal patient/participant in a PCORI funded trial aiming to improve the timing and quality of Goals of Care discussions between oncologists and patients. I read your discussion on how GOC discussions received "no improvement" ratings by patients on the quality of communication skills and wanted to raise several questions. I have some training in communications around dealing with trauma, which I believe may be a good model for communicating dire prognostic information. I did not think that patients feeling "sad" was in any way a negative outcome. When people are traumatized by an event (in this case the discussion) they do not feel sad, they go numb and lose access to feeling. If the patient is feeling sad, my interpretation is that they felt safe enough, and cared for enough with the clinician that they retained access to feelings of upset and sadness, a positive sign. The information the patient needs most is not just the externalities of outcomes and clinical best guesses, we need the inner information provided by emotions, values, urgency, and life priorities which is just as important as any clinical predictions for us to fashion plans for our future. If we feel safe and supported enough to have those feelings in your presence, that is a success, not a failure.

    When dealing with trauma in a psychotherapy session there are techniques we can teach and use to help the person reorient ourselves to place and time, feel complete, grounded, and safer at the end, so we can negotiate a safe trip home, not flooded by unconfined emotions. Simple techniques like having us wiggle our fingers and toes, deep breathing, and other physical movement helps restore us to feeling grounded, especially important if we have to drive, navigate traffic, or otherwise safely negotiate travel to where ro can recuperate form the discussion. Bringing us back to current time can be as simple as gently asking what plans we have for the evening, perhaps "prescribing" a special dinner out, or some alternate act of self care, emphasizing that these GOC discussions really are a huge event, deserving of some special comfort. Even a cup of warm tea offered, or brought by staff, helps reorient patients and indicate care. When we may be in shock from a discussion of this nature it is very important to bring us back to the here and now.

    That is the purpose of these small tokens of regard for our well being, which also erect a boundary around the traumatic discussion. There are many additional interventions in the trauma literature that might be very helpful in this situation, and since cancer patients exhibit post traumatic stress syndrome at rates as high as 70% by the conclusion of treatment the trauma model might be very appropriate for this situation.

    I personally had a prior diagnosis of PTSD, had a great deal of psychotherapy to relieve it, and feel my earlier treatment has provided me with incredibly valuable skills with which to face my current diagnosis, allowing me to make the most of my remaining time, remain emotionally present, make the best possible decisions in a bad situation, and have the most deeply satisfying experience I am capable of given my physical limitations. I am hoping some of these interventions from the treatment of trauma might help clinicians and patients navigate these treacherous waters, and have a more satisfying relationship and journey together.

    This can be traumatizing for clinicians, as well. You might decide to join us in the deep breathing, mindful emotional presence, and self care. :)

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  3. nice post, very informative for readers. Thanks !

    pankaj

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