We all communicate. We cannot help it. Whenever we are in contact with other people, we send and receive messages. Because we all can communicate, we take communication for granted. We tend to assume that our natural abilities are sufficient. In palliative care this often is not the case; good intentions and personal experience are usually inadequate to rise to the great challenges inherit in this work. Especially at the end of life, the stakes are high. Agonizing decisions must be made. Misunderstandings can easily occur. We encounter taboos and assumptions that obscure communication and comprehension. Communication is dangerous, emotionally charged, and absolutely critical to good palliative care. Advising clinicians to start this drug or that is fairly easy. Working with clinicians, patients, and their families to enhance understanding and facilitate collaborative problem solving through communication is difficult and requires greater skill than does practically anything else we do.
The evidence is overwhelming that clinicians have difficulty communicating well with patients and families in general.1 For example, Beckman and Frankel analyzed 74 audiotapes of physicians in a general medical clinic talking with patients and found that in only 23% of cases did physicians give patients a chance to fully describe their concerns. On average, patients were interrupted 18 seconds after beginning to talk.2 In a similar study Waitzkin found that in clinical encounters that lasted on average 16.5 minutes, patients spent an average of 8 seconds asking questions of their physicians. Although physicians believed they spent on average 9 minutes providing information to patients, in fact, they spent less than 40 seconds.3 This data is striking in the presence of evidence that "information seeking is a foremost goal of patients in primary care."1,4
Recently, palliative care literature similarly has documented poor communication by clinicians.5-8 For example, Tulsky, in reviewing audiotapes of resident physicians discussing resuscitation statuses with patients, found that they often did not relay critical information that was needed for decision making, such as what resuscitation entailed or the probability of successful resuscitation. Even so, physicians dominated the average 10 minutes of speaking time. In only 10% of cases were patient values or goals discussed.5 Fortunately, studies have also demonstrated that good (or at least better) communication is possible. Roter and colleagues compared audiotaped physician-patient discussions that involved 18 purported expert physicians (as evidenced by publications in bioethics or communication) with 56 academic general internists. As measured by a communication rating scale, the experts were significantly better than were the nonexperts. They were less dominant in conversations, were more likely to engage in partnership building, and paid more attention to psychosocial and lifestyle concerns of patients.9 Although these studies all relate to physicians, I suspect other health care disciplines share difficulties in communication. It makes sense that if we have trouble communicating effectively even in routine office visits, it will be much more difficult to communicate about the critical issues that routinely arise in the provision of palliative care.
The importance of good communication in palliative care has not been lost on the leaders of palliative care education. Numerous calls have been made for better training in this area.10-15 The good news is that major educational initiatives to improve the quality of palliative care, such as EPEC (Educating Physicians about End-of-Life Care), End of Life Nursing Education Consortium (ELNEC), Improving Residency Training in End-of-Life Care directed by Dr. David Weissman, faculty development programs in end-of-life care at Harvard, the Program in Palliative Care Education and Practice, and our own End-of-Life (ELC) program at the Stanford Faculty Development Center, [available for download at www.growthhouse.org/stanford/] devote a great deal of time and effort to improving communication skills. The bad news is that improving communication skills and demonstrating a lasting effect on clinician behavior is very difficult. Shorr recently published a study that demonstrated no significant difference in the frequency of documentation of end-of-life care issues following an administrative and educational effort to improve both the quality of discussions and their documentation.16 Although of limited scope and focused on documentation rather than qualitative aspects of communication, this report serves as a warning to those who think that clinicians will necessarily change their ways following brief educational interventions aimed at skill training.
Skill training in communication is important, and certain core skills will be reviewed later in this chapter. However, it is not enough simply to learn how to do something, such as share bad news, as we might learn a technical skill such as catheter insertion. Communication involves dynamic interactions among individuals. We clinicians are not entirely in charge of what happens. How participants understand and view the world and their communication styles will have a profound effect on any given interaction. As Shaw suggested in the epigraph to this chapter, understandings of communication may differ so much that any perception that communication has occurred may be an illusion. Thus, if we are to improve our abilities to communicate with patients and families, who may have very different communication styles from us, we need first to reflect on our own communication styles.
Clinicians are at least "bi-cultural" in communication styles. That is, we learn from childhood certain ways of communicating that are shaped largely by our cultural experience - a blend of ethnicity, national origin, generation, and sex, among other things. In becoming clinicians we are "acculturated" into a new "subculture" of medicine, with its own peculiar communication styles. We learn to pay attention to some things and to ignore others.17 For example, in learning how to "take a medical history," we learn to ask certain questions to the exclusion of others. We learn to take a "social history" that stresses documentation of risky lifestyle behaviors, such as smoking, drinking, and sex, over understanding the patient's social network. We do not even have a personal history section in the history and physical to reflect how that patient understands his or her illness or how that patient might characterize himself or herself as a person, helpful though such information might be. In learning how to do an history and physical that stresses the importance of objective data, we also quietly learn that what the patient thinks of his or her condition is largely irrelevant.
Of the various skills needed in palliative care, none is more important than the ability to communicate effectively. Without such skill, little else is possible. Unfortunately, no skill tends to be so taken for granted. I have also found no area to be more challenging educationally. Our fast-paced medical world demands that things be neat and tidy-crisp, bulleted presentations at noon conferences over pizza. Such approaches work poorly for subjects better learned through apprenticeship and informal learning. However, I have also found no area more fascinating, challenging, and rewarding. Nothing is more delightful than to connect with a patient or family member and, often suddenly, come into mutual view. Having found each other, we can share a cup of tea and tell some stories.
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Palliative Care Perspectives
James L. Hallenbeck, M.D.
Copyright © 2003 by Oxford University Press, Inc.
The online version of this book is used with permission of the publisher and author on web sites affiliated with the Inter-Institutional Collaborating Network on End-of-life Care (IICN), sponsored by Growth House, Inc.