Tools to improve communication between physicians and patients

Toby Campbell, MD, MSci

Clear communication between health care providers, patients, and families is perhaps more important today than at any time in history. But in many ways, communication has never been more complicated. As innovations in medical technology have expanded the universe of what can be done for critically ill patients, health care providers often find that the same pace of progress has not occurred in medical communication techniques. To better guide decisions about what should be done for care to be consistent with patients’ values, faculty members and colleagues at UW Health and the UW School of Medicine and Public Health are developing new techniques—and implementing them across the nation.

"Today's doctors know that communication is a skill," said Toby Campbell, MD, MSci, associate professor (CHS), Hematology, Medical Oncology and Palliative Care. Dr. Campbell served as “master of ceremonies,” addressing hundreds of attendees at the June 1, 2017 Mini Med School event. The series was founded several years ago by Richard Page, MD, George R. and Elaine Love Professor and chair, Department of Medicine along with former Department of Surgery chair Craig Kent, MD. Currently, Dr. Page serves as "mini-Dean" for Mini Med School with Laurel Rice, MD, chair Department of Obstetrics and Gynecology.

“Communication is the most important procedure we do in the ICU," said William Ehlenbach, MD, MS, assistant professor, Allergy, Pulmonary and Critical Care Medicine. Technological innovation since the 1960s including positive ventilation and extracorporeal membrane oxygenation (ECMO) mean that the percentage of patients with critical illness who die in the hospital has declined, but many who do survive end up dying in the weeks to months that follow.

Even in absence of imminent death, ICU stays for critical illness can cause new health challenges. Studies have shown that survivors of critical illness are at risk of cognitive impairment equivalent to mild Alzheimer's disease or moderate traumatic brain injury. They are also at risk of being able to perform activities of daily living and to have depression, anxiety, and post-traumatic stress disorder. It's hard on family members, too: after caring for a loved one with critical illness, they have a 30 percent higher risk of psychological symptoms.

"As a critical care expert, I can tell you the likelihood of surviving, and I can give you some information about what that survival might look like, but I don't know how that fits into your values or your preferences," said Dr. Ehlenbach. That's where communication comes in.

Making time for difficult conversations
Given the minute-by-minute crises that arise in the ICU, what steps can clinical care teams take to make sure that communication isn’t inadvertently pushed out of the way? Dr. Ehlenbach and colleagues studied a relatively simple intervention: relocating an experienced palliative care nurse to the ICU who could be with the critical care team when they discussed any patient who was at high risk of dying. “She didn't meet with families or patients. She was like our conscience, and her presence alone was associated with significant improvement in communication,” he said.

By prioritizing communication with families, conversations about end-of-life care were moved to earlier stages. This didn’t lead to an increased death rate, explained Dr. Ehlenbach, but rather allowed decisions to be personalized to each patient's values by providing space for palliative care discussions. The approach was so successful that the critical care team at University Hospital now includes two full-time RN facilitators who meet with patients and families early in the ICU stay and enable discussions between providers and families during the duration of their care in the unit.

Best Case/Worst Case: Harnessing the power of scenario planning
Gretchen Schwarze, MD, associate professor, Department of Surgery and Department of Medical History and Ethics, described a communications methodology that she co-developed with Dr. Campbell. The duo is training surgeons and other health care professionals involved in high-stakes decision making. They have named the technique “Best Case/Worst Case.”

"This method uses a graphic aid - the surgeon draws a diagram - and is accompanied by a verbal story about what possible outcomes might look like,” said Dr. Schwarze. When talking with a patient or family member about whether to proceed with a high-stakes surgery, the physician draws one line representing a surgical outcome scenario, tells a story of the best-case outcome (e.g., survival but complete dependence on skilled nursing care in a long-term care facility) and worst-case outcome (e.g., rapid deterioration in condition with no opportunity for family to gather). The surgeon places a mark on the line indicating where they think the patient’s situation lies in this scenario. A second line represents a non-surgical, palliative care approach, with best case and worst case outcomes also conveyed through storytelling. During Mini Med School, Dr. Campbell demonstrated the technique in real time with actors playing the roles of a wife and a sister of a gravely ill, septic patient with cancer in the intensive care unit (ICU).

“Our approach is to get really close to the challenges that the family faces,” said Dr. Campbell, whose team has analyzed hundreds of doctor-patient conversations that lung cancer patients have given permission to study. By identifying patterns of unspoken collusion to avoid discussions about prognosis, for example, Dr. Campbell hopes to identify pragmatic steps that providers can take to improve communication. “We’re thinking about little ways that we could incrementally make the conversations better,” he said—many small steps, multiplied by thousands of physicians trained through programs he and colleagues have created such as WeTalk, a simulation-based training workshop for physicians.

Teaching empathy by exploring the emotions of experience
Empathy can be taught, believes Amy Zelenski, PhD, assistant professor (CHS), General Internal Medicine. And while the field of medicine tends to attract highly empathetic personalities, for many physicians, the rigors of training and the pain of living through one’s own emotional reactions to patients’ experiences can lead to emotional scar tissue and a decrease in empathetic behavior.

“Part of what I'm trying to do is prevent this," said Dr. Zelenski, who holds a PhD in education and has a background in theater. Quoting a passage from Henry David Thoreau, who wrote "Could a greater miracle take place than for us to look through another's eyes for an instant?," Dr. Zelenski said, "Thankfully, we have professionals who have been doing this for centuries: actors and theatre professionals."

Using theatrical improvisational techniques, Dr. Zelenski trains healthcare professionals in skills such as close listening, attention to body language, mirroring of expression, and spontaneity of communication. “Improv teaches you how to be authentic, how to listen closely to another person, and how to respond,” she says. These are exactly the same skills that can lead to improved patient-physician communication.

With care, time, and attention, medical communications experts at UW-Madison believe that providers can use new ways of approaching tough conversations that lead to reduced distress and care that aligns with the values that are most dear to each patient. Together, they are working toward a world where words themselves can play a role in the healing process.

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Robyn Perrin, PhD