By Timothy D. Gilligan, MD, FASCO, and Walter F. Baile, MD
Co-Chairs, ASCO Physician-Patient Communication Expert Panel
In September 2017, ASCO published its first ever guideline on patient-clinician communication.1 Better communication results in better medical outcomes, better patient experience, and improved patient safety. And yet communication skills have often been regarded as something that one can simply “pick up” through observation and practice. Sometimes, communication skills have been confused with basic relational skills, as if being good in social conversations sufficed for clinicians discussing complex medical issues and emotionally fraught diagnoses with patients and their loved ones.
Clinical education has made significant progress addressing the challenges that clinicians face when communicating with patients and their loved ones.2 We’ve identified certain specific skills that can help us when giving bad news or discussing therapeutic options or end-of-life care. These conversations can be organized and broken down into steps, much as we do with medical procedures.3,4 A second development has been the appreciation for empathy and the benefit patients derive from feeling that their clinician cares about their concerns and their experience.5
The ASCO communication guideline is grounded in the relationship with the patient, which we view as the cornerstone of comprehensive health care. Relationship-centered care involves a greater focus on listening skills in the service of understanding who our patients are, what their experience of illness has been, and what matters to them. It involves prioritizing the establishment of trust and a willingness to partner with patients and personalize their care by being responsive to their individuality.
The ASCO communication guideline provides specific recommendations for accomplishing these goals. Here we highlight some of the specific recommendations and provide some examples of how they can translate into practice.
1. How do we learn to communicate more effectively? Improving our communication involves behavior change, similar to improving at a musical instrument or sport. We need a clear understanding of the skill to be practiced and opportunities to practice it under observation so that we can receive specific feedback on our performance. Readings and lectures on communication skills do not measurably improve performance, whereas high-quality experiential learning with opportunities to practice and receive feedback does.2 We encourage clinicians to participate in communication skills training. Academic training programs and professional societies should make this a part of their continuing medical education activities.
2. How do we form stronger relationships with patients? Listening and watching are central to forming relationships. If we learn who our patients are and what matters to them, then we can respond to them as individuals. Starting visits by exploring the patient’s understanding of their illness and allowing the patient to help set the agenda for the visit are specific steps that support the clinician-patient relationship and ensure that the visit meets the patient’s goals. We can ask a new patient, for example, “What have you been told about your cancer?” Or, for a significant follow-up visit, “What’s your understanding about your illness at this point?”
One of the greatest challenges oncologists face is to present accurate information while sustaining and supporting hope in the face of a devastating diagnosis. It can be tempting to provide false reassurance. We can do a better job of sustaining hope honestly if we know who our patients are as individuals, if we have developed a trusting relationship, and if their experience with us confirms to them that we care.
3. How do we show patients that we care about them? Feedback from patients shows that our concern for them and our devotion to their well-being are often not apparent to them. There are specific things we can do to make our caring more apparent. Remembering some personal facts about patients and then asking about them resonates as caring. Listening also helps. Clinicians often focus on what we have to tell patients more than on what patients have to tell us. We exaggerate the value of giving additional medical information and undervalue the benefit to patients of being allowed to talk about their experience and how they are navigating and coping with their illness. Listening to our patients also creates opportunities to express empathy. We can learn to respond to strong patient emotions by acknowledging the emotion and showing the patient that we care and are there to help them.
4. How can we do a better job exploring and establishing goals of care and navigating end-of-life issues? Goals of care and treatment plans should align with the patient’s priorities and values, and that’s only possible if we find out from patients what is most important to them. For instance, for a patient trying to decide on surgery versus several forms of radiation therapy for prostate cancer, we might ask “What are the most important factors to you with regard to choosing among these options?” Or for a patient whose disease is progressing after receiving multiple systemic therapy regimens, “What is most important to you at this point, given where things are with your cancer?”4 End-of-life care discussions are a particularly important area with regard to communication skills. We human beings, patients and clinicians alike, tend to be uncomfortable with our mortality. Discussions of end-of-life issues are too often delayed until death is imminent. The ASCO communication guideline calls on us to discuss patients’ end-of-life preferences early in the course of terminal cancer and to use an organized framework to structure such conversations.4 Because these conversations can feel difficult and because both patients and clinicians would often rather avoid discussing difficult subjects, having a structured approach can help avoid postponing or shortchanging such conversations.
Communication represents a large portion of our work caring for patients with cancer and our skill at communicating has a substantial impact on patient experience and patient outcomes. Our effectiveness as communicators also has a large impact on us. When we communicate better, our relationships improve. Our days are better when we are able to establish strong, trusting and resilient relationships; when we feel that we have meaningful and rewarding connections with the people around us. It is our hope that the ASCO communication guideline will contribute to making improved communication a higher priority in health care.
Areas Addressed in ASCO Patient-Clinician Communication Guideline
- Core Communication Skills
- Discussing Goals of Care and Prognosis
- Discussing Treatment Options and Clinical Trials
- Discussing End-of-Life Care
- Using Communication to Facilitate Family Involvement in Care
- Communicating Effectively When There Are Barriers to Communication
- Discussing Cost of Care
- Meeting the Needs of Underserved Populations
- Clinician Training in Communication Skills
- Gilligan T, Coyle N, Frankel RM, et al. J Clin Oncol. DOI: 10.1200/JCO.2017.75.2311. Epub 2017 Sep 11.
- Tulsky JA, Beach MC, Butow PN, et al. JAMA Intern Med. 2017;177:1361-6.
- Baile WF, Buckman R, Lenzi R, et al. Oncologist. 2000;5:302-11.
- Childers JW, Back AL, Tulsky JA, et al. J Oncol Pract. DOI: 10.1200/JOP.2016.018796. Epub 2017 Apr 26.
- Gerretsen P, Myers J. J Clin Oncol. 2008;26:5294-6.