Going beyond the question list

Dave’s wife* pulled out a list of questions from her purse. Sitting across from her, I could read her first question upside down, in a shaky cursive script across the top of the page. Her question: “How much longer?” She knew that her husband’s situation sucked. Typically, however, she was more polite. Dave was in the hospital with a bowel obstruction due to carcinomatosis; we were sitting down for a serious conversation, and the real topic was dying.

I didn’t let on that I knew her first question. But when I asked her to read me the whole list, she didn’t include “how much longer?” I got Dave to talk about what was important now (time with grandkids was at the top of his list). We talked through her other questions, about carcinomatosis (bad), more chemo (no), IV nutrition (not helpful). She was trying not to cry.

We had covered a lot, I thought, and from the way she was staring down at her notebook, I judged that she probably had heard as much as she could manage. She seemed determined to get through this without crying, and I didn’t want to push her over the edge—she’d be so embarrassed, it would interfere with our next conversation.

But then she put her notebook aside, looked right at me, and said “Okay, how much time do we have?” Her husband nodded. I said that the time frame was weeks, with a worst-case scenario being two to three weeks, and a best case scenario being 10 to 12 weeks. She looked down again at her notebook, her hands shaking. “Ten weeks from now is winter,” she said, shaking her head. “That’s a terrible time to die.”

This kind of moment happens in cancer care all the time. The communication researchers call it an “emotion cue.” But what’s misleading about that label is that the cue is often masked with a statement (e.g., winter is a terrible time to die). And often we clinicians feel cued to correct the facts, to say something like, “There’s no good time to die.” When you hear an emotion and feel compelled to respond with a fact, hit your pause button.

I waited until she had finished shaking her head. She slumped over in her chair. Then I said: “That wasn’t what you were hoping to hear, I know. This is a very tough situation.” Her face crumpled. “No,” she said. She was holding her breath so she didn’t cry.

When I saw her shoulders relax a little, I said, “What you just heard is a very hard thing to hear.” She sighed, and said. “Well, yes, but that’s how it is.” In another few moments, I knew, she would be ready to make some real plans. Dave’s daughter described it later: “She needed to process, but Dad was dry-eyed. He was expecting this.”

[Originally posted as a guest commentary for ASCO connection. *A few details altered for confidentiality. I'll be sharing more skills at the ASCO Palliative Care Symposium later this month.]

Liftoff!

 
We've launched a new website: www.vitaltalk.org
If you've ever had trouble finding an oncotalk, intensivetalk, or toughtalk resource--your problems are over. We've reorganized our site, consolidated all our old stuff, and wrapped in a new user interface. As one physician told us yesterday: 'it's awesome'. 

What you'll find
You can stop by on your way into a patient's room for a 1-page talking map. When you have more time, dive in and scale up your skills for the next visit: we've got video, chapters, articles, and powerpoint talks, all ready for downloading. 

There's more: you can ask us a question through our curated Q&A hotline, or find our iOS app, or peruse a spellbinding set of video reflections by some of the most fantastic thinkers on serious illness that we know.

You'll see these resources evolve too as we continue to innovate--and we have a lot planned.

Stay ahead of the curve: sign up on the website for our new monthly newsletter, or send us an email at hello@vitaltalk.org. And since we're a nonprofit in the social enterprise space--we won't give your email to anybody. Go to our site--then go talk to a patient in a way that makes a difference.

Vitaltalk goes to AAHPM San Diego!

We're in San Diego, and i'm still blinking from the sunlight. Vitaltalk rolled a new curriculum for palliative care clinicians, in a special day-long preconference collaboration with the American Academy of Hospice & Palliative Medicine: Advanced Communication Skills for Difficult Situations. 

For Bob, James, &; me, it was a special treat to work with a talented group of Vitaltalk faculty facilitators--Renee Boss, Lynn Bunch, Mary Buss, Kristen Chasteen, Elise Carey, Gordon Wood--with their help we did the largest small group course with simulated patients we've ever done. And we need to give a special shout-out to Julie Bruno, AAHPM Director of Education, whose vision made this collaboration happen!

The heart of our 1-day course for palliative care clinicians are two new talking maps: PAUSE for 'early' goals of care conversations; and REMAP for 'late' goals of care conversations. As Palliative Care moves upstream, it's critical for this level of communication expertise to become the standard--and while we have learned that this level of quality entails some complexity, we've also learned that we can do it--and now we're scaling it up. The participants had some great ideas for the future; one said 'i'd love for our oncology colleagues to have something like this!'.

You can find the talking maps now on our new Vitaltalk website. 

But in meantime, if you're here in san diego feeling a little smaller because of the great work everyone ELSE is doing....

Or if you're thinking 'does EVERYONE in this city jog?'...

Or if you're not in san diego feeling oppressed by all the perfect physiques (do we have to share the convention center with a conference of fitness professionals?) and are ready for a little wisdom to POWER up your communication skills...

Enjoy!

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!)

New talking maps for discussing prognosis, & goals of care

What's a talking map?
In our recent courses for the American Cancer Society, we used cognitive maps as learning tools for communication. We're giving them away here, because we hope you'll use them. A good cognitive map, or talking map, can point the way through a tough conversation, and keep the clinician on track.

Pointing a way through the evidence.
The talking maps we used are new--we've been tweaking them for some time--and they incorporate some new features. They represent a synthesis of evidence-based practice, and they're short--just 5 letters each. For each task (discussing prognosis, and discussing goals of care), the 5 letters form a word that represents a critical meta-theme about that communication task. We're posting the talking maps in a one-page user-friendly form:

• The "ADAPT" talking map for discussing prognosis.

• The "REMAP" talking map for goals of care. 

There's more: here are pdfs adapted from the brief presentations we did in our ACS courses--these are intentionally short, because our goal here is to get to a modeling demo, and then to deliberate practice. (As you know, lectures don't work!)

• Using "ADAPT" for discussing prognosis.

• Using "REMAP" for reevaluating goals of care.

We make these available with a Creative Commons license--use them freely, with attribution, edit as you need, in noncommercial settings--because we see this work as social entrepreneurship. We'd love to hear your feedback.

What talking maps don't do.
Talking maps form an important scaffold, but not the only one you will need. A talking map is akin to a a road map that gives you the freeway exits and road names; it won't show you the flowers at the side of the road. And with medical conversations, ignoring the small details to push forward can give patients & families the sense that you only want to talk about what's on your agenda. The great medical communicators balance guiding with responsiveness (you can read the study here)--it's a back-and-forth balancing act that blends medical information with empathy. We'll have more about this here and on our brand-new website--but while you're waiting, check out Bryan Vartabedian's terrific blog post on communication as the primary skill set of the doctor in the era of social media. 

Inflight with the American Cancer Society

We're doing a new gig in collaboration with the American Cancer Society--a series of one-day workshops in Los Angeles, Minneapolis, Miami, Boston. (And we're in the air right now!) This is not CME as usual--it's culture change--we attract clinical role models from top cancer centers, equip them with new tools for talking about prognosis, and goals of care, and send them out to be changemakers. And we're drawing on the talents of an extraordinary group of faculty who are teaching with us: Holly Yang (Scripps), Toby Campbell (University of Wisconsin-Madison), Wendy Anderson (University of California San Francisco), Gordon Wood (Northwestern), and Vicki Jackson (Massachusetts General Hospital).

What are we learning? These clinicians are the opposite of resistant--they're eager. They're not burned out--but they're worried about it. They're working in balky systems--and they're holding their own. In our view, they need resilience--and a first step towards that are a set of communication tools that are practical, actionable, and valuable. (In our first workshop, 100% of the clinicians said they would recommend this to a colleague.)

We're always working on two levels--sometimes called 'parallel process'. I've never liked this term--it's always struck me as inside baseball--but the idea is powerful: treat your learners the way you want them to treat patients. So you engage them, activate them, equip them. This is teaching as awakening, feedback as positive change, and metacognition as a pause in everyday practice. I think of these as small acts of courage. I'll add the video player here later, but for now you can watch it here on facebook (& tell me what you think of this experiment).

Hey Miami, how about a little bling?

What more expertise looks like

Our first Pallitalk course is next week--and as we get ready for Aspen, i've been thinking about how we talk about improving our own skills. How could explain better the journey of acquiring expertise? It's central to learning skills--either communication skills, or teaching skills--but hard to explain. Then i found this video--and amazingly, it's all there, in less than 2 minutes. The increasing fluidity, the improvement that is excruciatingly slow--then blindingly fast, the sense at the end that she was born to dance this way. Thanks Karen!