DELIVERING BAD NEWS: COMMUNICATION STYLES AMONG 1 ST YEAR IM RESIDENTS Carissa Pereda Internal Medicine R3

End-of-life Communication: Problems and Importance Patients report poor clinician-patient communication as primary concern 1 2 Trainees report being uncomfortable and untrained in end of life communication Trainees’ self-reported competence not associated with patient/family assessments Trainees benefit from experiential trainings

Improving Clinician Communication Skills Study Design: RCT of interdisciplinary communication intervention– “CodeTalk” 1 Goal: to improve end-of-life communication skills among MD, NP trainees Curriculum: experiential, adult learning Communication strategies (SPIKES, NURSE) Practice with simulated patients Evaluation: Outcomes: Patient, family, clinician surveys of trainee communication skills Process: Pre- and post- intervention audiorecordings of trainees with standardized patients 1 Curtis et al.

Study Goal: What Do Trainees Do? How do trainees respond to patients, prior to workshop training? – Recognizing diversity of communication styles – Identifying/describing these styles/techniques – Reproducibility with existing data? Standardized patient interviews with required behaviors or “triggers” – “I have to tell you, I’m really scared” – “Is there any hope for a cure”

Methods and Materials Sample: pre-intervention audiotapes (n=173) MUSC, n=60; UW, n= 113 Trainees: 1 st year IM residents Random selection of 50 pre-intervention recordings Standardized patient interviews “Cathy” with recurrent ovarian cancer “Thomas” with recurrent colon cancer

Interviews Resident task: Deliver results of a CT scan: – Recurrent cancer (colon and ovarian) with metastases Patient task: Stay in character! – Provide 3 behaviors at any point during the interview 20 second silence post bad news “I have to tell you, I’m really scared” “Is there any hope for a cure”

Analysis Goals: – Identify and describe communication techniques utilized by residents in response to target statements – Develop a framework of “codes” to describe/evaluate communication techniques Methods: – Team (n=3) established codes from 5 audios – Single investigator coded and compared subset of audiotapes to assess trustworthiness (n=25) – Trainees review subset (n=5-10) for validity

CODEBOOK EMPNORMNormalizes/reassures patient that emotion is appropriate ("very understandable/normal to be scared" "you have a right to be scared") CLININFOProvides clinical information/medical terminology to patient DEFERDefers conversation to oncology DIRECTProvides clear/direct explanation to patient ("cure for cancer is not possible" "there is hope for a cure") EXPLOREExplores patient's emotion with open ended inquiry into emotional statements. (Tell me what is most scary.)

Is there any hope for a cure? I can’t be a 100%. Right now it looks like your disease would actually be classified as stage 4. I don’t know if you know the stages of cancer, but stage 4 would be the end stage, meaning that it has spread from the colon to another part of the body. I can’t really answer that question. I wish I could. I think it’s better if you talk to the oncologist. If they could offer you surgery, maybe there’s a small chance for a cure. I can’t comment on exactly what your prognosis is going to be.

I have to tell you, I’m really scared. Tell me more about that. What is making you feel scared? That’s very understandable. It is normal to be scared.

“The single biggest problem with communication is the illusion that it has taken place.” -George Shaw MANY THANKS: -Research Team -Randy Curtis -Ruth Engelberg -Erin Kross -GOOGLE images -Invaluable mountain of prior research