Friday, 20 February 2009

Teaching Communication Skills

It's a month since I've last posted on my blog and I am not quite sure why. I've thought about many things and wanted to write about them but I kept thinking that I had to look something more up before I could put fingers to keyboard. And while I do think it would be wonderful if I did have the time to research everything I write and place it within a context, I also think it is good to just get on with sharing reflections on work.

So, I spent this afternoon teaching a 'breaking bad news' session to 3rd year medical students. Our course is undergarduate so these students are in their early 20s. The session is 3 hours long, with 5 students, me and 5 standardized patients(actors) who cycle through the rooms and are with us for about 15-20 minutes.

This is the third of 3 communication skills in 3rd year. I was stepping in for another tutor so had not met the students before and they had bonded quite a lot together as they had been on many placements together not just this class. They were even going out to a pub quiz together.

I want to tell about two of the scenarios we discussed. No. 2 patient/actor has to be told that his long-waited for operation had been cancelled due to emergency admissions. The student psyched herself up because she and the other students had heard on the grapevine that this scenario was particularly confrontational. The others joked that if any of them could cope with this angry man then she could. And so the metaphor of battle for this consultation was set, and it continued throughout. It really did feel that they were on two opposing sides rather than her being there to support the patient. I know from talking to these students that they care deeply about patients, but in this scenario the 'game' of sparring with this actor was too strong. It had been mythologised by previous students and there was little chance for this student to come to it with her own angle. It made me think (again) about who un-natural communication skills teaching can be. I was a bit shocked when I came across this book chapter yesterday.... our exams deconstructed! And I realised that our teaching sessions can be too predictable for students as well. When he had finished acting our actor told how his real-life wife has had an operation cancelled three times in the last month. On the second occasion she had got as far as changing into her gown when she got news it was off. But the news came from the surgeon who left the theatre and came down to sit beside her bed and apologise. It was this story which made the scenario seem real for the students and they thought that perhaps the wrong approach had been taken by their colleague initially. The example of the surgeon who sat alongside his patient, rather than on the other side of the battle lines made sense to them.

We were recovering from this encounter when our next actor/patient arrived. This involved a patient returning for the results of her chest x-ray. It showed an opacity and she was to be referred urgently for a CT scan and to a chest clinic for assessment. She had a high chance of having a lung cancer. I quickly checked with the student if she was prepared as she thought she was going to have another scenario. She made an aside comment about the patient probably going to start crying and I wondered if she was in the right place. I asked her again if she knew what she was going to say and she said yes. The actor/patient was rapping on the door so we moved on. It quickly emerged, to me,that the student after talking about 'shadows' on the scan and the fact that this could mean many things.... but possibly something 'serious', was not going to discuss the possibility of cancer with the patient.

I called time out and asked the student if this was the case. She said it was and said that if the patient asked she would tell them but not otherwise. I said that I didn't think this was the best approach, but the other students said that they thought she was right. It wasn't fair to burden the patient with the possible cancer diagnosis if she didn't want to know. And we had to presume that she didn't want to know if she didn't ask. So they resumed the consultation, and it finished without the patient ever knowing that she was being referred because she might have cancer.

Afterwards the student said that she thought it was the job of the chest clinic to inform her about the possible cancer diagnosis or the actual cancer diagnosis. At the time I was quite strident in my opinion that the patient should have been informed but the students were still not coming round. One did, but just the one.

The next scenario helped us as it was about a young woman presenting with a breast lump. This student mentioned the possibility of breast cancer within her first few sentences. The consultation ran smoothly. The actor shared in the feedback that she felt it was unfair to expect the patient to raise the possibility of cancer and that it was good to get it out in the open. She called it the elephant in the room. We all laughed and told her about our debate with the previous scenario. Some of the others now also started to agree that if the patient was being referred because of the risk of cancer then it was important that they should know and that it was not fair to leave the responsibility of asking to the patients. By the end of the afternoon they all seemed to agree on this.

I framed it in the context of 'informed consent'. Could the patient really give consent to the tests they were to undergo if they didn't know what they were actually checking for?

But I recieved today "The Logic of Care" by Annemarie Mols. I haven't read it yet but I wonder if I will be so sure that I am right when I finish. She compares the logic of choice, which she says is becoming dominant in western healthcare, with the logic of care. Were the students being more caring in wanting to give a woman who has a probable cancer diagnosis her last two weeks without having had cancer overtly referred to, than I with my thoughts of empowering the patient through information? I don't know.


  1. Great thoughtful post! This is a wonderful example of role modeling the need to constantly be reflecting on practice. A great deal of medicine isn't cut and dried and asking students to reflect on their assumptions is important aspect of communication.

  2. Thank you Deirdre. I'm still thinking about it all and I hope I keep challenging myself...and others.

  3. Hi Anne Marie, I noticed you've been quiet, but wow, this was worth the wait. I really appreciate that you explained each scenario to us and how this unfolded for the class, and for you. I love the fact that you were in class that day (by chance it seems) and that you took the time to be a reflective practitioner with your students :-) Using a set up scene to firstly challenge pre-conceived ideas, then secondly to sit beside your students as they challenged themselves to let the scenario unfold, without pre-conceived ideas and move through the moment with their "patient". I will share this post with my Inter-Disciplinary class :-)
    Thanks, Anita.

  4. Anita
    Thanks for your lovely comment. Anne Marie

  5. Saw your comment over on DB's Med Rants on Breaking Bad News... I like your blog! Med Ed is something that I'm interested in and it's great to see someone speaking openly on this specific subject in medicine. :)

  6. Thanks Clinton! Its tough keeping a blog going and comments like this help.

  7. Reading your posting, specifically the possible chest cancer scenario; I'm reminded of the Schrodinger's cat thought experiment. Where it's the action of opening the box that resolves the question about whether the cat is alive or dead. In your case it would be the CT scan that resolves the paradox rather than the x-ray.

  8. Hello Kenneth

    Yes, it is the CT scan that really moves thngs forwards...not quite as definite as Schrodinger's cat but I think I know what you mean!

    Anne Marie

  9. I'm a med student, and I hope that my faculty includes this type of training at some point in my course. I'll never forget the time a patient asked me "Did I just nearly die?" - it wasn't my place to answer her question, but I knew the answer and it was hard to face even then. I tend to think that our role is, where possible, to help our patients avoid death, and where it's not, to make the dying process as least-difficult for them as we can - and good, early communication is a huge part of that.

  10. Very interesting. The CxR example was good, partly because, wodnering precisely what "She had a high chance of having a lung cancer" meant, I found some pre-test probabilities. An old edition of Evidence-Based Medicine has, on page 119, the pre-test probabilities of lung cancer for a symptomless 50yr old with a solitary pulmonary nodule as 50% (slightly higher, 65%, if >3cm). I am also passingly familiar with a very limited literature on information seeking styles, using tools like the Monitor-Blunter Style Scale (MBSS, Miller 1987) to categorise peoples' preference. Typical extremes are called Monitors (those with Muir's Maladie du Grand Print Out) and Blunters (the ones who don't want to know). There's at least one, very limited trial in post op pain, which shows that, in a factorial design, Monitors who are not specifically told about post op pain don't do well (more pain and analgesia), but neither do Blunters who are told.

    What's the relevance? Well, I've long been concerned we are moving towards telling everyone everything and simply some people don't want that and it makes them feel worse. I'm not convinced that a third party's view that the referral was "for suspected cancer" and not to "find out what is wrong" should have any bearing, particularly if the clinicians' perception of likelihood is inaccurate. hence, my suggestion that you do everything to give someone the opportunity, by perhaps asking "would you like me to tell you more about what might be causing this?". Perhaps we should all have our MBSS on the front of our notes?

    Just some thoughts.

  11. I shared this post again today on Twitter as @grforhire raised the question of whether cancer should be mentioned when making an urgent referral for suspected cancer. I had the following tweet from @IanatPHP
    "What would happen if instead of telling the patient, you ask whether they would like you to outline what it might be?"
    This made me realise that I hadn't perhaps given enough information about the format we follow for 'breaking bad news'. This is treated as a special kind of 'information giving', and students are advised to check how much the patient knows already and how much they want to know. So in these scenarios the patient has probably asked 'What do you think it is?' or 'Do you think it is something bad?' or 'What could it be?'. The discussion was around whether or not the word cancer should be mentioned if the patient does not say 'Could it be cancer?'. So it is quite like @gpforhire's question.

    As I said I explain that I am making an urgent referral (you're going to be seen very quickly- you should get an appointment in less than two weeks. When we find something like this then we need to make sure that it is not cancer.)NOt exactly like that- varies all the time- but I try to be open and honest.

    That might sound a bit of an about face way of describing it, but it makes sense to my (Irish) mind. But I keep this blog because I want to learn so I am always happy to get more feedback and ideas.

    I'm not sure it is realistic to ask, if there was a possibility that I thought you might have cancer at this stage would you want to know, because that automatically suggests that there is a possibility that there is cancer! And it wouldn't make sense to ask someone at 20 say,, would you like to be told at 70 if there was a chance that your doctor suspected cancer. I don't think it is possible at least. I hope this explains more.

  12. Hi Ian,
    I can't remember all of scenario but I'm sure those probabilities are about right. How do you think they affect whether or not cancer is mentioned as a possibility? Do you think that most people who want to know if cancer is a possibility will ask? I think that nowadays everyone knows= or will know someone who does know- that if you are referred to a rapid-access clinic then it is because cancer is suspected. My concern was that not mentioning cancer might be to spare the students distress... not the patient.
    I wasn't familiar with Miller's work although our department does a lot of research on Shared Decision Making (SDM). I do think that preferences are unlikely to be fixed so I would wonder if scores on this scale truly are traits. Thanks for the conversation!

  13. It's a long time since I was a GP, so don't weight what I say highly...

    I recall being taught that patients are very good at not 'hearing' what they're not ready to take in. I believed this to be research-based; but have no idea where this was published.

    I believe that "establish the patient's hopes, fears, & expectations" is still taught as one of the cornerstones of the consultation. Is this not vital to the process of breaking bad news?

  14. Peter, of course that is central! The way that would play out here is that first of all the patient is asked about the circumstances leading up to the xray, their understanding etc... if I ordered the xray I wouldn't spend that much time about that because I'm imagining that we would have covered a lot of this territory before... and I wouldn't want to keep them on tenderhooks for ages if they seemed to want to know the result.
    But I wouldn't usually ask about their fears before I gave the result. I would probably go over that we had organised the test because we wanted to see if there could be something underlying their complaint and now we've found something that needs more investigation... and then check what that meant to them etc etc I'd probably say 'is there anything that you are worried about at this stage now?' and if they said ' well I'm worried that it could be cancer' I'd say that was possible and the reason that further tests are recommended as above. If they didn't specify cancer but said something 'serious' I would still mention cancer because I would worry that they didn't feel comfortable mentioning it.
    I guess when I was writing this I presumed that those reading would presume that those questions are all part of the process, and the only issue for me was whether cancer should be mentioned if it wasn't raised by the patient.
    Thanks for commenting.

  15. Peter, I think you're right that there are people who don't seem to recall (or at least relate/admit/talk about later), despite clear evidence (I believe there are video studies on this). They are, though, a small minority.

    AM, my issue on the probability is that subjective terms are meaningless (even docs interpret them very differently), and it can be useful to know. I also found myself that direct questions are not that common, so strongly agree we must not rationalise leaving it unsaid. But, and I suppose this is the only additional point I'm trying to make, I am concerned that it's extremely difficult, particularly with patients you hardly know (OP), to match the communication style to THEIR preferences and not default to ours.

    Great discussion, thanks.

  16. Ian and Peter,
    I'm sure you are right about patients forgetting as well. I'm not talking about masses of information here, just a clear indication that the patient is being referred because there is a possibility of cancer. Some think it is is wrong to bring this up unless the patient does first. I'm still not clear what your views are on this.

    Ian, and yes I completely agree that it is hard to match communication styles. I try my best and I thank you for your participation too.

  17. Just to follow up: this is an example of an information leaflet about the kind of clinic we are talking about making a referral too. It does seem a little strange to me that I could refer to a clinic like this and not indicate that the reason was the possibility of cancer.


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