In this blog, Liz O’Riordan reflects on the Cochrane Review Communication skills training for healthcare professionals working with people who have cancer from her perspective as both breast surgeon and someone with recurrent breast cancer.
The objectives of this recent Cochrane Review were to assess whether communication skills training improved the well-being of healthcare professionals and patient satisfaction. Research has suggested that skills do not improve with experience, hence the need for regular training.
I’ve been on both sides of the table, as a consultant breast surgeon and a breast cancer patient, and this review gave me a lot to think about. As a trainee I had very little training in how to break bad news. It was pure luck which consultations I was allowed to sit in with, trying to work out which phrases to copy and use myself when the time came. As a consultant, I was sent off to attend the two-day course for members of the multi-disciplinary team. No-one was looking forward to it, but I learned a lot. Being able to re-do a bad conversation with an actor helped me play around with other ways of breaking bad news. But after a few weeks or so, I slipped back into my old, familiar ways. Breaking bad news had to become habitual for me. I had so much information to give to my patients at the time of diagnosis, using set phrases helped keep me on track.
The review found that the benefits of communication skills training start to fade after three months. When the course I went on is only offered every 2-3 years, it made me think – what’s the point? In between the courses, I didn’t get assessed. I didn’t get feedback. I just got on with it. The only other people who heard me break bad news were my breast care nurses. I never asked them for feedback. I didn’t think I needed it. I never knew whether I made my patients cry when I left the room because of something I’d said in good faith.
When I heard that I had cancer, everyone was already crying – my breast consultants (a mentor and a friend), the nurse and my husband. I didn’t. I’d been expecting it ever since I saw my ultrasound when they took the biopsy. I didn’t take anything else in. I knew what I was being told. It’s what I tell my own patients. But to hear it as a patient, to realise that I needed chemotherapy. I couldn’t believe it. Every time I went back to clinic I would have a list of questions that I never got around to asking. I’d either had more bad news and my questions seemed irrelevant, or I didn’t want to take up any more of my consultant’s time. There were more couples outside waiting to go in. The chronic pain I was struggling to cope with could wait for another day.
When I started working again after I’d finished breast cancer treatment the first time around, I spent several months shadowing consultants in a different hospital to get an unbiased opinion as to whether I was ready to return properly. It was nervous for all of us. They had never had another consultant sit in with them. It felt like they thought I was assessing them, criticising them – and in a way I was.
My first instinct was to look at the patient’s reaction to hearing she had cancer, viewing how I must have looked to my own surgeon when she had to tell me. Picking up on her body language, the cues she was giving as the news sank in that I’d never noticed in my own previous practice. Seeing her husband reach for a hanky and start to sob. Then I listened in to the words the consultant was using. So very different from my own technique, and now I’d been a patient, was it what I really wanted to hear?
As a doctor I’ve told patients that it’s good we’ve caught their cancer early and they’re lucky that it hasn’t spread. I’ve seen the very worst of breast cancer and I simply wanted to reassure my women that it wasn’t as bad as I thought. As a patient, no-one can prepare you for hearing that you’ve got cancer. All cancer can be bad in a patient’s eyes, even if it’s a tiny 5mm Grade 1 cancer, it’s still cancer. No-one is lucky to get it and no cancer is good to have. It was only with the hindsight of being a patient that I realised how damaging my well-chosen words could be.
The first time I told someone they had cancer when shadowing did not go well. She was young and her family lived overseas. Although it was a ‘good’ cancer, she broke down. I could imagine everything running through her mind, and instead of telling her it wasn’t that bad, I said yes, it does look pretty bloody awful at the moment, but I would help her get through it. I wanted her to know that I understood what she was going through. Thrilled that I’d done a good job, I asked for feedback, expecting to hear good news. Instead, they told me how bad I’d been. They said I should never tell a patient that having cancer is awful. I was deflated for the rest of the clinic, mulling over their criticism and unable to focus. It made me realise that there’s a time and place for feedback, and that you have to want to hear it, be able to accept criticism and reflect on whether you change your practice.
When I did start back at work, I did change how I broke bad news. I was more aware of the language I used. No more ‘lucky’ or ‘good’. I made myself count to ten after saying “it’s cancer” to give the patient time to think and ask questions before I carried on with my spiel. My phone was always turned off and out of sight. Instead of saying “any questions?” when I’d finished everything I had to say, I started asking it at the beginning. I told patients to bring their questions with them, and it felt good being able to give them the time to ask them. I also realised that I couldn’t be as empathetic as I wanted to be. I was trying to be a breast care nurse at the same time as a surgeon. On the one hand offering comfort and a shoulder to cry on, whilst the other offered surgery, chemotherapy and an instant menopause. I had to step back and let the nurses do their job. Instead, I always spoke to them afterwards to find out what they’d learned, so I could do my job better the next time I saw that patient.
Communication skills training is important. It does improve empathy and help clinicians move away from the safety net of cold hard facts and take a moment to imagine themselves in their patient’s shoes. But it’s not enough. Consultants need regular training and feedback. Could you make the time to sit in on colleagues’ consultations? Listen to your own transcripts. Really hear the words being used. Imagine hearing them as a patient yourself. Create a safe environment for your nurses and juniors to give you feedback, remembering that you won’t always like what you hear – but then, neither will your patients.
Most of us aren’t great communicators all of the time. It’s impossible to get on with every patient you see. Stress, fatigue, problems at home all creep in. There’s nothing satisfying about telling people they have cancer, day in, day out, for twenty years. I had no idea what a huge emotional burden this would be as a consultant when the patients in clinic became my patients, my responsibility. Doctors don’t get coaching or counselling to deal with the negative emotion they absorb on a daily basis. We’re meant to leave it at the front door when we leave to go home.
To really improve healthcare practitioner well-being, we need to focus on what happens afterwards. How do we look after our team so they can come back the next day, ready to go again? Perhaps a quick debrief at the end of every clinic, sharing who made you laugh and who made you cry? Talk to the juniors. Show them that you do get upset at times and that you’re not superhuman. Remember that you’re not alone, and it’s not meant to be easy.
Featured image: Liz chose the image shown at the top of this blog and in the above slide, ‘Hope’ by Andy Farr / @andyfarrart, saying: “This picture really hit home for me. It resonated with how I felt when I started chemotherapy. I couldn’t see the wood for the trees, wallowing in despair, but then a tiny chink of light appeared. The promise that the treatment would work, if I could just hang on until the end”.
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Moore PM, Rivera S, Bravo‐Soto GA, Olivares C, Lawrie TA. Communication skills training for healthcare professionals working with people who have cancer. Cochrane Database of Systematic Reviews 2018, Issue 7. Art. No.: CD003751. DOI: 10.1002/14651858.CD003751.pub4.
Dr. Liz O’Riordan has nothing to disclose.
Read the rest of the blogs in the “Contemplating Cancer” series:
- Informal caregivers: the invisible people caring for cancer survivors by Beverley Lim Høeg and Pernille Envold Bidstrup
- Prostate cancer: “To treat, or not to treat?” by Francisco Lopez, Freddie Hamdy and Alastair Lamb
- Communicating about cancer: experiences and reflections by Sarah Chapman
- Cancer and Post-Traumatic Stress by Sally Crowe
- Communication with cancer patients: does practice make perfect? by Charlotte Squires
- Contemplating Cancer: a special series from Cochrane UK by Sarah Chapman