Basic communication frameworks

Introduction

Communication skills can be broadly defined as “the cognitive and emotional abilities used by clinicians to enable patients and their families to understand the nature of the illness, to partner with patients to make sound medical decisions, and to facilitate patient and family adjustment to the illness.” Over the past three decades there has been increasing appreciation of the importance of communication skills in medicine. ^, Effective communication skills can facilitate shared decision making, strengthen the patient-clinician relationship, and improve patient outcomes, including satisfaction with care, health-related quality of life (QoL), mood, symptom management, psychological functioning, coping ability, and treatment adherence. Conversely, ineffective communication can weaken the patient-clinician relationship, create mistrust, and reduce treatment adherence.

There is a frequent misconception that skillful communication is an innate talent which only certain individuals possess. Yet, importantly, communication science has revealed that communication skills can be effectively taught, learned, and retained. In turn, this has led to the development of evidence-based communication frameworks and a greater emphasis on communication skills training in many undergraduate and graduate medical education programs.

Radiation oncologists frequently engage in complex communication tasks, including delivering difficult news, sharing prognostic information, obtaining informed consent, managing uncertainty, managing patients’ expectations, disclosing medical errors, and clarifying goals of care. Patients are frequently referred for palliative radiotherapy for management of worsening tumor-associated symptoms which often occur in the setting of disease progression or recurrence. Radiation oncologists are well-positioned to provide prognostic estimates or to clarify questions about illness trajectory that patients may be hesitant to ask of other members of the cancer care team. Furthermore, radiation oncology clinic schedules often allow sufficient time for more in-depth, candid discussions about patients’ illness understanding and communication preferences. Unfortunately, communication skills training has remained largely underprioritized in radiation oncology, and few radiation oncologists receive formal training in how to skillfully complete complex communication tasks. This chapter introduces several evidence-based practical strategies to enhance patient-clinician communication and provides resources for more in-depth communication training.

Building rapport

Building rapport is the process of establishing a positive connection with another individual in a way that fosters trust, understanding, and open communication. Each visit between a patient and provider offers a valuable opportunity to establish and build rapport. Although this is particularly important in the initial encounter, when patients form long-lasting first impressions of their clinician efforts to establish and maintain rapport should be considered during all patient encounters. Rapport plays a critical role in forming a trusting and therapeutic relationship, which, in turn, contributes to better care experiences, helps alleviate patients’ anxiety and distress, and empowers patients to become involved in decisions about their care. Rapport can also impact behaviors such as returning for a second visit or adhering to the recommended treatment plan.

Establishing and maintaining rapport is an important communication skill that can be taught and acquired with practice and training. Rapport building depends on both verbal and nonverbal communication, and therefore it is critical that clinicians are attentive to both sets of behaviors. Specifically, actions that convey traits such as open-mindedness, honesty, respect, thoroughness, humanism, attentiveness, and confidence are important for establishing rapport during the patient encounter.

When first meeting a patient, clinicians should introduce themselves, clarify the patient’s preferred name (and pronunciation if needed), acknowledge friends or family accompanying the patient, and set a shared agenda for the visit. The use of open-ended questions and paraphrasing patients’ responses can demonstrate active listening and engagement in the encounter. Other verbal communication skills include responding to emotion, using reflective statements, and summarizing, among others.

Nonverbal actions are especially important in establishing a tone for the encounter as well as building and maintaining rapport. Nonverbal cues have been shown to influence clinical outcomes such as patient satisfaction and treatment adherence. ^, Nonverbal cues include eye contact, body positioning, facial expressions, head nodding, hand gestures, postural change, and body lean. Tone of voice and rhythm of speech, also considered nonverbal cues, are similarly important considerations in establishing rapport. Table 3.1 highlights use of the mnemonic EMPATHY in recognizing and responding to nonverbal cues. Importantly, when verbal and nonverbal cues are discordant or inconsistent, nonverbal cues have been shown to be significantly more influential than those communicated verbally. ^,

Screening for distress

Distress is “a multifactorial unpleasant experience of a psychological (i.e., cognitive, behavioral, emotional), social, spiritual, and/or physical nature that may interfere with the ability to cope effectively with cancer, its physical symptoms, and its treatment.” Clinically significant distress interferes with the patient’s ability to function and should be identified early so that effective measures can be taken, such as referral to a mental health provider or utilization of spiritual care services. Clinically significant distress is highly prevalent among patients with cancer, estimated to impact 25% to 50% of oncology patients, and can occur at any stage of their disease trajectory. Clinically significant distress has been associated with worse clinical outcomes, including treatment nonadherence, poorer QoL, and even decreased survival. ^,

It is recommended that clinicians routinely screen all cancer patients for distress and connect patients who screen positive with the appropriate resources. ^, There are several tools available to screen for distress, although the Distress Thermometer, created by the National Comprehensive Cancer Network (NCCN), is the most widely implemented. The Distress Thermometer is a single-item self-report measure of global distress and is available in more than 20 languages. ^, Patients use a visual analog thermometer to indicate their level of distress, from 1 (no distress) to 10 (extreme distress) within the past week. As a complement to the Distress Thermometer, there is also a Problem List that patients may fill out, which asks patients to identify their problems in five different categories: practical, family, emotional, spiritual/religious, and physical. The NCCN currently recommends that if the patient scores their distress as greater than or equal to a 4 out of 10, a member of the oncology team should review the Problem List to identify key areas of concern to determine which resources may benefit the patient the most (e.g., psychology, psychiatry, social work, palliative care, and/or chaplain services). An elevated score on the Distress Thermometer should also prompt specific screening for anxiety and depression. Importantly, distress screening can provide an opening for a more in-depth discussion about the patient’s particular concerns and worries and may allow for more targeted interventions to better address these issues.

Barriers to distress screening exist, for both patients and clinicians. First, patients may have difficulty understanding what the term “distress” means. It has also been shown that language, cultural differences, and literacy may all affect the efficacy of distress screening. On the provider level, notable barriers to screening are time constraints and insufficient training. Importantly, once distress has been identified, there may be a lack of intervention or appropriate follow-up support—studies have shown that only 20% to 30% of patients with a positive distress screen received psychosocial care after they were identified. Furthermore, even if appropriate support is offered, some patients may not accept it.

Responding to emotion

Emotional distress is common in cancer patients. The way that clinicians respond to these emotions impacts patients’ disclosure of concerns and, if done skillfully, can decrease the level of emotional distress that patients experience. Responding to patients’ emotions with empathy is a key communication skill. Empathy allows the clinician to imagine or understand how the patient might feel but without necessarily experiencing those feelings themselves. Empathy should not be confused with sympathy, in which the clinician shares the emotional experience of the patient (e.g., feeling sad when the patient is sad, or angry when the patient is angry). A clinician can be empathic even when he or she cannot be sympathetic. ^,

The use of empathy in the medical encounter is known to generate a more therapeutic patient-clinician relationship. ^, Yet, clinicians infrequently respond empathically when patients express emotion, ^, which may be, in part, due to poor recognition of the emotion to begin with. ^, Clinicians may fail to offer empathic responses to patients’ emotion if they do not feel equipped to successfully navigate the emotional response or if they are concerned that doing so will take too much time.

The NURSE mnemonic is a helpful tool to use when responding to patients’ emotions. It is summarized in Table 3.2 and discussed in detail as follows. It is not necessary to complete all of the outlined steps in response to an emotional cue; rather, it is simply an array of tools that can be used alone or in combination.

• Naming: Naming involves identifying the emotion that the clinician suspects the patient is experiencing based on verbal or nonverbal cues. This helps to open the conversation further around the emotion. When naming the emotion, it can be helpful to pose it as a question or a suggestion, rather than an assumption. For example, by saying: “Some people in this situation would feel angry, is this the case for you?” rather than, “I see that you are angry,” the clinician allows the patient an opportunity to correct or clarify their emotion.

• Understanding: Once the clinician has established an empathic connection by naming the patient’s emotion, it can be tempting to try to alleviate it by providing immediate reassurance. However, doing so is likely to close off further exploration and may be perceived as dismissive. In this step, the clinician takes a moment to pause and acknowledge the impact of the emotion. For example, the clinician can state: “Thank you for sharing, this helps me to better understand what you are feeling.” This validates the patient’s experience and communicates an investment in the patient’s well-being. Clinicians can also use statements such as, “I can’t imagine what you are going through right now,” which, paradoxically, conveys understanding.

• Respecting: Clinicians can demonstrate respect for the patient through both nonverbal (eye contact, body posture, etc.) and verbal cues. An effective way to demonstrate respect is through commenting on a particular strength or positive coping mechanism that the patient or family member displays. For example, a clinician might say to a patient’s family member: “You have been so dedicated to your mother’s care” or to a patient: “You are doing a wonderful job making it to all of your treatments—I realize it can be difficult, especially with everything that you have going on right now.”

• Supporting : Patients are often fearful of being abandoned, particularly in the later stages of their disease process. Support statements, such as, “I will be here to support you throughout your illness,” can help alleviate patient fears. It is important to only say this if this is true. If the clinician will no longer be seeing the patient after that visit (e.g., if the patient is transitioning to hospice care), a more appropriate phrase might be, “You are not alone in this. The hospice team will continue to support you from here.”

• Exploring: In this step, the clinician can ask focused questions which build on something the patient has mentioned previously during the course of the conversation. This can help deepen the empathetic connection with the patient and encourages further disclosure.

Clinician empathy has been associated with decreased burnout and greater satisfaction at work and is one of the traits that patients most value in their clinicians. Unfortunately, empathy has been shown to decline during medical training and some have argued that this blunted empathy may be an adaptation to highly stressful environments or personal distress in response to repeated exposure to suffering. Several strategies exist to mitigate the clinician experience of personal distress, including mindfulness meditation, narrative medicine, and appreciative inquiry. These strategies have been shown to not only cultivate empathy but to also decrease emotional exhaustion and increase a sense of personal accomplishment.