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Psychiatrist Walter Baile aims to improve the way doctors deliver bad news to patients


Dr. Baile Walter Baile, M.D., is professor of behavioral science and psychiatry at The University of Texas MD Anderson Cancer Center. Baile also directs MD Anderson's I*CARE program, which helps health care providers manage their interactions with patients and their families.
By Ryan Holeywell | November 01, 2017

Cancer treatment is advancing quickly, thanks to innovations like personalized medicine and immunotherapy, but some doctors are working to improve treatment through a decidedly low-tech technique: stronger communication.

A growing body of evidence shows patients do better when they feel their doctor is a true partner in their treatment. One way doctors can show that connection is by taking a more deliberate approach to the way they speak and interact with patients, said Walter Baile, M.D., a psychiatrist at The University of Texas MD Anderson Cancer Center.

“In times of crisis,” Baile said, “that relationship counts as much as a clinician’s technical ability.”

Baile directs MD Anderson’s Interpersonal Communication and Relationship Enhancement (I*CARE) program, which aims to train health care providers in managing their interactions with patients and their families.

Though one might assume cancer doctors would be expert communicators—particularly when it comes to delivering bad news—many of them aren’t, and most have not had specialized training to handle such pivotal moments, Baile and other experts said.

Doctors need training in how to have difficult conversations with patients—such as explaining a patient’s cancer has had a recurrence—and how to interact with patients who are having strong emotional reactions, such as crying or getting angry, Baile said. He recently co-chaired an expert panel convened by the American Society of Clinical Oncology that developed national guidelines to improve the way doctors communicate with patients.

“The relationship between the clinician and the patient can be a very therapeutic one,” Baile said. “When we provide appropriate hope and we’re honest, in the context of that relationship, the patient can feel supported.”

In recent years, health care providers have worked to improve communication in a more direct sense, by making sure patients understand which medicines to take or how to follow post-surgery recovery instructions. But Baile and his ilk are focusing on the nuances of more personal exchanges.

Nationwide, those efforts are increasing—and they extend beyond oncology. The trend is driven largely by evidence that communication has a huge impact on health care outcomes and patient satisfaction, said James Tulsky, M.D., who chairs the department of psychosocial oncology and palliative care at the Dana-Farber Cancer Institute in Boston.

“It’s just a very different way of approaching a conversation,” said Tulsky, who co-founded VITALtalk, a nonprofit that aims to improve the way clinicians communicate with patients about serious illness. “Physicians realize the patients will open up more. They feel connected to the patient, and they realize the conversations are easier.”

The trend coincides with growing recognition of the value of palliative care, but in some cases it is also tied to funding. The federal Centers for Medicare and Medicaid Services, for example, use consumer surveys to measure how patients perceive their hospital experience. That information plays a role in determining how hospitals are paid, so health care providers have a stake in ensuring patients feel their doctors are valued partners.

Locally, Baile has provided communications training to renal medicine fellows at Baylor College of Medicine. As part of a separate effort, more than 400 doctors working in the Memorial Hermann Health System recently underwent “patient experience training.” The goal was to offer health care providers the tools they need to connect with patients, with a focus on compassion and empathy, said Matt Harbison, M.D., a leader in physician training with Memorial Hermann’s physician network.

His training emphasizes that doctors should avoid “doc speak,” a best practice that others recommend, as well.

“When I talk about blood pressure, I talk about garden hoses,” Harbison said. “That makes a better connection. It’s something [patients] can really understand.”

The training also urges doctors to “be in the moment” when seeing patients, especially during difficult conversations.

Figuring out how to have a challenging conversation with a patient is, in some ways, similar to figuring out a complex procedure or operation, Baile said. Doctors must plan carefully and draw from proven strategies. And the stakes are high, since research indicates patients with serious illnesses suffer when their health care providers communicate poorly.

Baile and his colleagues urge doctors to avoid common pitfalls, like speaking in overly optimistic terms for fear of upsetting patients. Research actually shows that discussing a patient’s prognosis doesn’t harm his or her relationship with the doctor and may even offer some peace of mind, even if the outlook is poor. The goal is to find ways of being open and honest with patients without traumatizing them, Baile said.

In addition to researching the best ways to communicate with patients, Baile and his colleagues are studying the best way to teach those skills to other doctors. Lectures and videos don’t work, Baile said.

Instead, doctors need to simulate the interactions they have through role-playing. That includes interacting with simulated patients, who may provide candid, surprising feedback. “It may wake them [doctors] up to things they haven’t been doing well,” he said.

Another technique involves teaching physicians “talking maps,” or standardized guides to conversa-tions around difficult topics. Baile, for example, is part of a group that developed SPIKES, a method for breaking bad news to cancer patients in six steps: from setting up the patient interview to asking if the patient is ready to discuss a treatment plan.

Baile points to an oncology fellow he recently observed who shared detailed results of a CT scan with a patient, quickly overwhelming her with information. A better approach would have been asking the patient if she wanted to see the CT scan results, and then thinking carefully about how to explain them. Some patients might not want to see that information at all.

Baile also encourages oncologists to find ways of addressing patients’ most pressing concerns. Instead of simply asking, “Do you have any questions?” for example, he encourages them to say something like, “Can you tell me your biggest concerns?” Doing so is important, since patients with unaddressed concerns are more likely to become depressed, he said. He urges doctors to learn ways of finding out what patients want, rather than assuming—particularly when it comes to end-of-life care.

“Some patients don’t want to continue therapy because it’s toxic, and their quality of life is poor,” Baile said. “We don’t need to emphasize our agenda to the patient; we need to understand their concerns, needs and desires.”

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Six Steps for Delivering Difficult News

Walter Baile, M.D., and other physicians developed SPIKES, a six-step process for delivering difficult news to cancer patients.

1. SETTING UP the Interview: Physicians should review their plan for telling the patient the bad news and think about how to respond to the patient’s reactions or questions. Sit down, involve loved ones and arrange for privacy.

2. Assessing the Patient’s PERCEPTION: Before discussing medical findings, the clinician should ask open-ended questions to ascertain how the patient perceives his or her situation. For example, “What is your understanding of the reasons we did the MRI?”

3. Obtaining the Patient’s INVITATION: Most patients want full information about their diagnosis, prognosis and illness, but some don’t. Physicians can ask questions such as, “How would you like me to give the information about the test results?” If patients don’t want details, the physician should still offer to answer questions in the future.

4. Giving KNOWLEDGE and Information to the Patient: Physicians shouldn’t simply deliver the bad news; they should first warn that they are about to deliver bad news, in order to reduce the shock. Doctors should use nontechnical language, avoid excessive bluntness, and provide information in small pieces, checking to make sure the patient understands.

5. Addressing the Patient’s EMOTIONS with Empathic Responses: Patients may react with shock, isolation and grief after receiving bad news. The doctor should offer support and solidarity and acknowledge those feelings by saying something like, “I can tell you weren’t expecting to hear this.”

6. Strategy and Summary: Physicians can help reduce a patient’s anxiety by helping him or her understand the treatment plan. But it’s important that physicians first ask the patient whether he or she is ready to go over next steps and to ensure the patient’s specific goals are understood.

Full guide at bit.ly/oncology-SPIKES

Source: The Oncologist

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