TMC PULSE

t m c » p u l s e | n o v e m b e r 2 0 1 7 15 1 communications training to renal medicine fellows at Baylor College of Medicine. As part of a separate effort, more than 400 doctors working in the Memorial Hermann Health System recently underwent "patient experience training." The goal was to offer health care providers the tools they need to connect with patients, with a focus on compassion and empathy, said Matt Harbison, M.D., a leader in physician training with Memorial Hermann's physician network. His training emphasizes that doc- tors should avoid "doc speak," a best practice that others recommend, as well. "When I talk about blood pressure, I talk about garden hoses," Harbison said. "That makes a better connection. It's something [patients] can really understand." The training also urges doctors to "be in the moment" when seeing patients, especially during difficult conversations. Figuring out how to have a chal- lenging conversation with a patient is, in some ways, similar to figuring out a complex procedure or operation, Baile said. Doctors must plan carefully and draw from proven strategies. And the stakes are high, since research indi- cates patients with serious illnesses suffer when their health care providers communicate poorly. Baile and his colleagues urge doctors to avoid common pitfalls, like speaking in overly optimistic terms for fear of upsetting patients. Research actually shows that discussing a patient's prognosis doesn't harm his or her relationship with the doctor and may even offer some peace of mind, even if the outlook is poor. The goal is to find ways of being open and honest with patients without traumatizing them, Baile said. In addition to researching the best ways to communicate with patients, Baile and his colleagues are studying the best way to teach those skills to other doctors. Lectures and videos don't work, Baile said. Instead, doctors need to simulate the interactions they have through role-playing. That includes interacting with simulated patients, who may provide candid, surprising feedback. "It may wake them [doctors] up to things they haven't been doing well," he said. Another technique involves teaching physicians "talking maps," or standardized guides to conversa- tions around difficult topics. Baile, for example, is part of a group that devel- oped SPIKES, a method for breaking bad news to cancer patients in six steps: from setting up the patient interview to asking if the patient is ready to discuss a treatment plan. Baile points to an oncology fel- low he recently observed who shared detailed results of a CT scan with a patient, quickly overwhelming her with information. A better approach would have been asking the patient if she wanted to see the CT scan results, and then thinking carefully about how to explain them. Some patients might not want to see that information at all. Baile also encourages oncologists to find ways of addressing patients' most pressing concerns. Instead of simply asking, "Do you have any questions?" for example, he encourages them to say something like, "Can you tell me your biggest concerns?" Doing so is import- ant, since patients with unaddressed concerns are more likely to become depressed, he said. He urges doctors to learn ways of finding out what patients want, rather than assuming—particu- larly when it comes to end-of-life care. "Some patients don't want to continue therapy because it's toxic, and their quality of life is poor," Baile said. "We don't need to emphasize our agenda to the patient; we need to understand their concerns, needs and desires." Six Steps for Delivering Difficult News Walter Baile, M.D., and other physicians developed SPIKES, a six-step process for delivering difficult news to cancer patients. Full guide at bit.ly/oncology-SPIKES Source: The Oncologist 2 3 4 5 6 S SETTING UP the Interview Physicians should review their plan for telling the patient the bad news and think about how to respond to the patient's reactions or questions. Sit down, involve loved ones and arrange for privacy. P Assessing the Patient's PERCEPTION Before discussing medical findings, the clinician should ask open-ended questions to ascertain how the patient perceives his or her situation. For example, "What is your understanding of the reasons we did the MRI?" I Obtaining the Patient's INVITATION Most patients want full information about their diagnosis, prognosis and illness, but some don't. Physicians can ask questions such as, "How would you like me to give the information about the test results?" If patients don't want details, the physician should still offer to answer questions in the future. K Giving KNOWLEDGE and Information to the Patient Physicians shouldn't simply deliver the bad news; they should first warn that they are about to deliver bad news, in order to reduce the shock. Doctors should use nontechnical language, avoid excessive bluntness, and provide information in small pieces, checking to make sure the patient understands. E Addressing the Patient's EMOTIONS with Empathic Responses Patients may react with shock, isolation and grief after receiving bad news. The doctor should offer support and solidarity and acknowledge those feelings by saying something like, "I can tell you weren't expecting to hear this." S STRATEGY and SUMMARY Physicians can help reduce a patient's anxiety by helping him or her understand the treatment plan. But it's important that physicians first ask the patient whether he or she is ready to go over next steps and to ensure the patient's specific goals are understood.

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