Troubleshooting difficult conversation

Why is it important?

Communication is an essential part of high-quality, person-centered care, especially in the context of a serious illness like cancer. The majority of people living with cancer want to have conversations with their clinicians about what to expect with their illness and what is most important. When people engage in these conversations, they tend to have treatments that match their goals and priorities and report better satisfaction with the health care system. In the setting of cancer, personal values must guide complex treatment decisions, and yet eliciting these values and matching them to a treatment plan require significant skill on the part of the clinician. Given these skills are not always taught in undergraduate or postgraduate radiation oncology training, as well as the significant emotion present, many clinicians find these conversations difficult. The good news is that patient-centered communication is a teachable and learnable skill. In this chapter, we will share the communication skills that can help both to respond to or even prevent challenging situations. The following are some helpful tips for you to navigate these conversations, as you meet patients at multiple points in their cancer trajectory.

Introductions

Creating connections, especially with those you have just met, can feel challenging. A kind greeting and deliberate introduction help clinicians establish rapport. Some patients may not know what a radiation oncologist is or how you fit into their cancer care team or may worry that their oncologist or other clinicians are not involved in this process. Consider developing a script to introduce yourself in new patient encounters that includes your name, role, and how you work in partnership with the oncology team. Ensure that you also ask how the person prefers to be addressed, who is accompanying them, and how they are all related (rather than guessing).

Hi, I’m Dana Howard, one of the doctors from the radiation oncology team. Your oncologist, Dr. Brown, has asked me to meet you to see if radiation therapy could be a helpful part of your treatment. How do you prefer I address you? Who is here with you today?

Nonverbal communication

Whether deliberate or not, a large portion of interpersonal communication is nonverbal. It is expressed by body position (posture, distance, touch), eye contact, facial expression, and vocal quality. The acronym SOLER includes tips for nonverbal communication ( Table 4.1 ).

When clinicians sit down, patients are more satisfied with the interaction and even perceive the encounter to last longer. It is also helpful to be mindful of technology use, and if there is a computer in the room, create a triangle configuration that allows you to look at both the patient and the screen without shifting your body. And if the conversation is more serious, consider completely disengaging from the electronic medical record altogether. Many clinicians ask about appropriateness of touch, and given the variety of preferences around this, it is recommended in general to ask permission prior to use of touch.

Information and decision-making preferences

Patients have the autonomy to receive truthful information. They also have the autonomy to choose when it is received (which may not be at today’s visit) and how it is received (details or numbers vs. big picture) or to not to hear it at all (and have the decisions made by a surrogate). For that reason, it can be helpful to use a number of “Asks” throughout a conversation that allow for checking-in on how patients prefer to receive information. Upon meeting someone for the first time, it can be helpful to gather some of these big picture preferences around receiving medical information.

We all have different ways that we like to receive information and make decisions about our health. Are you someone who prefers to hear numbers and details and data, or do you prefer the general big picture?

Do you prefer to make decisions on your own or with a family member or friend present, or do you prefer that we discuss details directly with your family member and then come back to you with the big picture?

It is ideal to ask these questions when the patient is on their own to ensure open, honest communication around whom they rely on for decision-making support. However, this may not be practical if patients are already accompanied by someone at their visit. If someone chooses either on their own, or disclosing to someone else, it can be helpful to explore, “Even if what we’re discussing is serious and will impact the treatments you are receiving for your illness.” The reason for sharing the big picture even if a patient declines the primary decision-making role, is that they will still need preparation for the experience of undergoing radiation therapy or any other procedures. If someone prefers to make decisions with a family member or friend present, you can encourage them to bring this person to future appointments either in person or via phone. This is both patient centered, allowing them assistance in both cognitive processing and emotional support, and efficient as it may prevent having multiple separate conversations with the patient and their family.