Cancer doctors want to offer a sympathetic ear, but sometimes miss the cues from patients. To help physicians better address their patients' fears and worries, a Duke University researcher has developed a new interactive training tool.
The computer tutorial includes feedback on the doctors' own audio recorded visits with patients, and provides an alternative to more expensive courses. In a study appearing Nov. 1 in the Annals of Internal Medicine, the research team found that the course resulted in more empathic responses from oncologists, and patients reported greater trust in their doctors a key component of care that enhances quality of life.
"Earlier studies have shown that oncologists respond to patient distress with empathy only about a quarter of the time," said James A. Tulsky, M.D., director of the Duke Center for Palliative Care and lead author of the study. "Often, when patients bring up their worries, doctors change the subject or focus on the medical treatment, rather than the emotional concern. Unfortunately, this behavior sends the message, 'This is not what we're here to talk about.'"
Tulsky said cancer doctors have many reasons for avoiding emotionally fraught conversations. Some worry that the exchanges will cause rather than ease stress, or that they don't have time to address non-medical concerns.
Neither is true, Tulsky said, noting his research shows that asking the right questions during patient visits can actually save time and enhance patient satisfaction.
"Oncologists are among the most devoted physicians -- passionately committed to their patients. Unfortunately, their patients don't always know this unless the doctors articulate their empathy explicitly," Tulsky said. "It's a skill set. It's not that the doctors are uncaring, it's just that communication needs to be taught and learned."
The current gold standard for teaching empathy skills is a multi-day course that involves short lectures and role-playing with actors hired to simulate clinical situations. Such courses are time-consuming and expensive, costing upwards of $3,000 per physician. Tulsky's team at Duke developed a computer program that models what happens in these courses. The doctors receive feedback on pre-recorded encounters, and are able to complete the intervention in their offices or homes in a little more than an hour, at a cost of about $100.
To test its effectiveness, Tulsky and colleagues enrolled 48 doctors at Duke, the Veterans Affairs Medical Center in Durham, N.C., and the University of Pittsburgh Medical Center. The research team audio-recorded four to eight visits between the doctors and their patients with advanced cancer.
All the doctors then attended an hour-long lecture on communication skills. Half were randomly assigned to receive a CD-ROM tutorial, the other half received no other intervention.
The CD taught the doctors basic communication skills, including how to recognize and respond to opportunities in conversations when patients share a negative emotion, and how to share information about prognosis. Doctors also heard examples from their own clinic encounters, with feedback on how they could improve. They were asked to commit to making changes in their practice and then reminded of these prior to their next clinic visits.
Afterward, all the doctors were again recorded during patient visits, and the encounters were assessed by both patients and trained listeners who evaluated the conversations for how well the doctors responded to empathic statements. Oncologists who had not taken the CD course made no improvement in the way they responded to patients when confronted with concerns or fears. Doctors in the trained group, however, responded empathically twice as often as those who received no training. In addition, they were better at eliciting patient concerns, using tactics to promote conversations rather than shut them down.
"Patient trust in physicians increased significantly," Tulsky said, adding that patients report feeling better when they believe their doctors are on their side. "This is exciting, because it's an easy, relatively inexpensive way to train physicians to respond to patients' most basic needs."
Although the CD course is not yet widely available, efforts are underway to develop it for broader distribution.