In this blog, Charlotte Squires, Specialist Trainee in Geriatric Medicine and General Internal Medicine, reflects on the importance of communication skills for healthcare professionals working with people who have cancer, from her perspective both as a doctor and a patient with advanced Hodgkin Lymphoma.
A recent Cochrane Review Communication skills training for healthcare professionals working with people who have cancer looked at whether communication skills training had a positive effect on how healthcare professionals embark on conversations that often prove to be pivotal in the life of the person before them. Interestingly, we know that communication skills do not always automatically get better with experience, but this review implies that some aspects such as asking open ended questions, and showing empathy, may improve with training, if only for a short period of time.
Analysing this sort of research is always going to be wrought with difficulty. This review considered the effect of communication training on patient satisfaction, for example, but as a patient receiving bad news, I am unsure whether anyone has ever walked out of a clinic room, and felt ‘satisfied’ with the outcome. It’s a strange choice of wording, yet remains a yardstick we use regularly when gathering feedback in health care, and what we mean in this context, is whether they were treated well enough that the conversation itself did not add to the trauma of the content. As a clinician who has also been a cancer patient, I sometimes feel that there is an assumption amongst healthcare workers that if you break bad news well, with all the recommended structures and stock phrases, that the patient on the end of it will be OK. The reality is that being skilled at breaking bad news has the capacity to reduce trauma, but is rarely going to erase it completely. Understanding that our patients will leave our rooms with the knowledge that their life has just changed, often beyond comprehension, goes a long way. We can soften the blow, but that blow is still coming, and will still be felt.
When I was diagnosed with advanced lymphoma, to some extent, the conversation should have been a communication skills hole-in-one. I had visited my GP with a list of possible explanations for my symptoms, and lymphoma was at the top of that list. As one of the more treatable cancers, it was also the result I was hoping for. My diagnosis was not a surprise, but more of a confirmation, and resultantly, I was reasonably prepared. What stands out in my memory is that after explaining the extent of my cancer, the consultant rounded off by saying that there was ‘also an issue with the liver’. Unlike the initial conversation, this was completely unexpected, out of the left field, and shocked me enough that I jumped so high and jarringly off my seat that my hand was wrenched from my partners hold. It transpired that my liver has a common anatomical variant of no significance aside from being a curiosity, but those few seconds of fear were extreme enough that even now, eighteen months on, my heart still skips a beat, and my mouth dries up, when I think of them.
Those few words caused me unnecessary trauma, and better communication skills might have prevented it. As a doctor who also delivers bad news and who has been trained to do so, I am able to dissect this conversation and think of ways this information could have been delivered more sensitively. This is not however an insight available to most patients, and again, I wonder how much as clinicians, we can truly expect patients to feedback examples of both good practice, and inadequacies. Was I satisfied with this encounter, on what would reasonably be considered the worst day of my life? I find this hard to answer, and can only assume that other patients will feel similarly conflicted.
One of my biggest insights into clinical practice that I have gained since becoming a cancer patient is a heightened awareness of the way in which statements can appear benign or loaded, reassuring or catastrophic, depending on whether you are delivering or receiving them. As a clinician, we might feel that quoting a survival rate of 85% is very positive, and indeed, within cancer circles, it truly is. As a patient however, it feels quite different, and is not very positive at all. As a 30-year-old, if you lined me up with one hundred peers, and told the group that fifteen would die within five years, there would be a significant sense of unease, if not disbelief. Yet, as a cancer patient, I am expected to be reassured by this figure. Liz O’Riordan has spoken about her habit of telling breast cancer patients before her own diagnosis that ‘at least we found it early’ – another example of the mismatch between doctors, constantly considering the way in which the news we are giving could be worse and patients, who are already receiving the worst news of their lives and who do not benefit from their situation being unintentionally trivialised.
This theme also extends to the imparting of information that from a clinician perspective might not fall within the realms of ‘formal, definitive bad news’, and that does not make us reach for our metaphorical communication skills toolbox, but that is still difficult for the person on the end of it to hear. This might be something that increases logistical difficulties, such as needing additional trips to hospital, or a change in treatment with a likelihood for unpleasant but not life-threatening side effects, or perhaps a need for an additional and unexpected scan that leads to weeks of worry until the result is available. For me, the effect of what felt like small, repeated set-backs, was significant, yet it sometimes felt that these issues didn’t even register with the person delivering them.
I wonder as healthcare professionals, if we have come to rely too heavily on ringfencing certain circumstances as requiring particular attention, and particular skills, at the expense of other situations. A cancer diagnosis quickly dumps patients onto a conveyor belt of appointments and encounters, often with little time to stop and take stock. As a patient, all we need is to feel that the person speaking to us has a small insight into the challenge of managing substantial health issues, and how difficult it can be to have to once again adjust expectations and plans and come to terms with yet more change. When this happens, we feel as though we are being seen as an individual, as opposed to a scan on a computer screen, or an interesting slide under a microscope.
This Cochrane Review is helpful in highlighting the pitfalls surrounding communication skills training and how we analyse it. It suggests that formal training is useful, regardless of experience, as it improves empathy and reduces a burdensome reliance on cold facts. The lack of evidence around long-term benefits following training suggests that regular sessions might help clinicians maintain better skills. As a clinician still in training, this helps me to remember that regardless of how good I may feel my skills are, that I should still seek regular training. It is also a humbling reminder that seniority does not infer automatic excellence, something that is very much assumed amongst clinicians, and that should be addressed when considering the training needs of both junior and senior doctors. As a patient, I am not surprised that intervention did not improve demonstrably improve satisfaction and wonder if overall, this review raises the question of whether we are asking the right questions, to measure the right outcomes, with the right yardsticks.
Featured image: Charlotte chose the image shown at the top of this blog and in the above slide, ‘Lost’ by Lorraine Sleator, saying: “‘I really loved this painting that features a small boat tossed on the sea. It resonated partly because this image seemed apt for the uncertainty of managing a cancer diagnosis, but also because it features the lighthouse guiding the boat in, reflecting the role of communication in challenging times”. Lorraine painted ‘Lost’ shortly after diagnosis and the piece is part of the Breast Cancer Art Project.
Join in the conversation on Twitter with @CochraneUK and @CharSquires or leave a comment on the blog. Please note, we cannot give medical advice and we will not publish comments that link to commercial sites or appear to endorse commercial products. We welcome diverse views and encourage discussion. However we ask that comments are respectful and reserve the right to not publish comments we consider offensive.
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 In systematic reviews we search for and summarize studies that answer a specific research question (e.g. is paracetamol effective and safe for treating back pain?). The studies are identified, assessed, and summarized by using a systematic and predefined approach. They inform recommendations for healthcare and research. More 2018, Issue 7. Art. No.: CD003751. DOI: 10.1002/14651858.CD003751.pub4.
Charlotte Squires 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
- Does communication skills training improve cancer care? by Liz O’Riordan
- Contemplating Cancer: a special series from Cochrane UK by Sarah Chapman