Communicating with patients who have life-threatening illnesses is a core medical skill. Often after watching an experienced attending physician guide a patient through the transition from disease-modifying treatment to end-of-life care, students assume that this expertise comes naturally. Nothing could be further from the truth. In fact, end-of-life communication skills require deliberate intent, practice and reflective work—little of which can be detected by watching a master. An expert skier can make a black diamond run look easy; expert communicators can make difficult conversations look simple.
The myth about communication is that you can just jump metaphorically onto the skis and zoom down the slope. But, in the same way that simply throwing yourself down the hill will not make you a better skier, just talking to patients will not make you a better communicator. You will find that the moguls are bigger and icier than they look and that technique and practice are needed. The good news, though, is that you can learn to communicate more effectively with the right kind of practice. Physicians (and nurses) who speak of communication skills as a mystical, inchoate God-given talent are empirically wrong. In this article, we discuss some things medical students can do to maximize their learning.
Find a good role model that you can watch in action. In our opinion, most students have not seen enough examples of good communication. You need to learn how to approach an end-of-life conversation—we call this having a cognitive map that will tell you where you should go next. You can read these cognitive maps in the medical literature [1-5], but it’s like reading about how to ski; you need to watch someone put it all together—the map, the verbal skills, the nonverbal behaviors.
After the observed conversation, ask questions. When you are in a reasonably private space ask your role model two questions: (1) what were her goals for the conversation, and (2) what was one skill that she used to achieve that goal? Don’t expect any one person to give you a long tutorial—learn one thing from each conversation. You want to build a repertoire of communication tools that you can use with patients.
When you are ready to begin having difficult conversations, plan ahead.Before you enter the room to talk to the patient take a couple of minutes to plan what you are going to say, think about how the patient might respond and decide what your next step should be. Start small. As a student you should not be talking about end-of-life decisions by yourself. A better way to start would be telling a patient that he can’t go home that day (a bad news conversation). Or if you are working with a resident or attending physician, ask for a small role in a difficult conversation. For example, at the beginning, you might talk about some lab or CT scan results without discussing the meaning of these results for prognosis and treatment. The resident can pick up from there.
Ask for feedback. Ask the resident or attending who observed you talking to a patient for an assessment. Here you might want to be a bit cautious: not everyone can give useful and constructive feedback. Don’t open yourself up to a known character assassin. You can help the person who is critiquing you by asking for something specific. For example, “My goal was to be very clear about the CT results. What did you see that I did to help accomplish that goal? What could I have done better?”
Do your own written debriefing. After a difficult conversation, write for five minutes about your reactions to the conversation. Don’t censor what you write, just get it all on paper—what it was like for you, what you think it was like for the patient, how you would rate your communication, and other thoughts about the experience that come to mind. This is for you only, and not to be placed in the chart or to be seen by anyone else. There is a lot of information flying around during these conversations, and it can be hard to sort out. A day later, look over your notes and see if there is something to take away as a lesson.
Learn to respond to emotions—the patient’s and your own. Notice when a patient brings up his own emotions as a topic, e.g.,“I’m worried about this test result” and learn to respond empathically [1,6]. Emotions are the key to what’s going on in a difficult conversation. Once you recognize the patient’s emotions, you next want to notice and use your own emotional reactions as a diagnostic and therapeutic tool . Remember that you are not trying to fix yourself (very often the tacit message in medical professionalism is that you are supposed to simply suppress everything that does not make you look rational, detached and objective); you are trying to cultivate a different capacity—one that integrates the emotional and human side of people with the biomedical facts.
Ask yourself what the patient is trying to tell you. This is not the same as simply trying to detect how much a patient understands. Communication is not about delivering an information pill and seeing how much the patient can swallow; it is about sending messages to the patient and receiving messages in return. If you are too busy sending messages to read the replies, chances are that the other person will stop bothering to send. By failing to pay attention you will be missing many opportunities to understand what is going on.
Cultivate a beginner’s mind. This is something that we still use every day. By having a sincere desire to learn about a patient’s hopes, goals and worries, you can gain trust more rapidly than if you are content with what you think you know. Because the truth is, you don’t know more than a tiny fraction of what patients are thinking about, and pretending you do can come across as condescending.
Be patient with yourself. We all criticize ourselves because we lack patience, have an inadequate spiritual life, distract ourselves with petty aspirations or fail to understand dying, because we believe we’re supposed to be experts. Think of mistakes as indicators about where you should focus your learning. The capacity to be present with someone who is facing an enormous, life-changing existential situation is a life’s work . You’re not finished yet.
Pay attention when someone thanks you. This work, despite its difficulty, is incredibly rewarding. Don’t miss out on the rewards. If you have worked your tail off, and someone notices and says thank you, don’t brush it off. Don’t say “it was nothing” or “that’s my job”—that diminishes the compliment. Take a deep breath, enjoy the moment, and say “you’re welcome.”
- Back AL, Arnold RM, Baile WF, Tulsky JA, Fryer-Edwards K. Approaching difficult communication tasks in oncology. CA Cancer J Clin. 2005;55(3):164-177.
Platt FW, Gordon GH. Field Guide to the Difficult Patient Interview. Philadelphia, Pa: Lippincott Williams & Wilkins; 1999.
- Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES—A six-step protocol for delivering bad news: application to the patient with cancer. Oncologist. 2000;5(4):302-311.
Quill TE. Perspectives on care at the close of life. Initiating end-of-life discussions with seriously ill patients: addressing the "elephant in the room.” JAMA. 2000;284(19):2502-2507.
- Back AL, Arnold RM, Quill TE. Hope for the best, and prepare for the worst. Ann Intern Med. 2003;138(5):439-443.
- Suchman AL, Markakis K, Beckman HB, Frankel R. A model of empathic communication in the medical interview. JAMA. 1997;277(8):678-682.
- Novack DH, Suchman AL, Clark W, Epstein RM, Najberg E, Kaplan C. Calibrating the physician. Personal awareness and effective patient care. Working Group on Promoting Physician Personal Awareness, American Academy on Physician and Patient. JAMA. 1997;278(6):502-509.