Abstract
Viewed through the lens of a medical oncologist with 40 years of experience, the essence of the fine piece by Danaher and colleagues (hereafter, the authors) is that high-quality communication requires “an active, dynamic, nonlinear process where shared meaning is created through verbal (words), nonverbal (body language), and listening channels.” The article resonated deeply with me: effective, safe, and patient-centric bidirectional communication is key for all providers (physicians and advanced practice providers) to assure that patients fully engage in all healthcare decisions and that they are guided toward reaching genuine informed consent at each step of their care. It is particularly true in my subspecialty where we routinely prescribe anti-cancer agents which often carry the risk of severe and even fatal toxicity.
The importance of communication has been recognized by my profession, especially since the seminal publication by Gilligan, Bohlke, and Baile in 2017 (Gilligan et al. 2018). Centers like mine, the Dana-Farber Cancer Institute (DFCI), have recognized that oncology providers—even seasoned ones—benefit from focused training in communication skills, especially when patients must make decisions at key inflection points during their illness. The chief executive officers of each member of the Alliance of Dedicated Cancer Centers (which includes DFCI) articulated their belief in an open letter to the oncology community in 2021 (McNiff et al. 2021). Each site joined in a 3-year collaborative project, Improving Goal Concordant Care, in which, among other goals, they committed to train the majority of their providers in communication skills using evidence-based experiential learning programs such as Vitaltalk (www.vitaltalk.org).
My first experience with communication in cancer care, which dates to my adolescence over 50 years ago, was a profoundly negative one. My mother was discovered to have far advanced ovarian cancer in her late 40s and died 2 years later. She was bedridden most of that time, and after my sister left for college and my father returned to a 6 day workweek, I became her principal caregiver. At one point of her illness, she experienced rapid, severe hearing loss. Because the telephone was her last connection to the outside world, and she was a social person, the loss was terrifying. Her primary care doctor arranged for a house call after the office closed, then still common practice. He arrived bleary-eyed at 9:30 at night. After a proforma assessment, he pronounced his impression: he didn’t have a clue what was the cause of her hearing loss and didn’t know if she would improve. I still remember his expressionless eyes as he spoke without empathy or compassion. In hindsight, I understand how exhausted he was at the end of an 18 hour day and recognize what today we would call “burnout,” but I can never forget how completely he failed us. A half century later, when I am feeling burned out and have little left in my empathy tank, I force myself to remember that empty encounter and steel myself to do better. I am sure that there are times when I have failed.
“The Power of Words”
“The treatment of a disease may be entirely impersonal; the care of a patient must be entirely personal.” – (Francis Peabody, 1927; Peabody 1927)
The authors focus on three important components of verbal communication: metaphors, labels, and jargon. They highlight the potential benefits of each (for example, the use of metaphors and jargon to facilitate knowledge transfer between clinicians), but also the potential risks. Metaphors, which they define as “cognitive tools for understanding … one concept in terms of a superficially dissimilar concept” and which they note encompasses up to twelve percent of all speech, are commonly applied in healthcare settings. When used sensitively, metaphors can assuage suffering by simplifying complex topics into understandable terms. But when used carelessly, or when overused, they can result in loss of trust with the provider. A common example in oncology is the overapplied use of military metaphors to describe the treatment approach for a cancer patient; many patients are offended by the comparison (Ehrenreich 2001).
What I emphasize to trainees—beyond avoiding labels and jargon or overusing metaphors—is that the content of the discussion is really what matters. In oncology, effective communication takes time. It is about the work that must be completed before you encounter the patient. My goal when I meet a new patient is for her to think she is the only patient I have. I try to acquire as much information as possible about her case before I enter the room. This often entails reviewing extensive medical records from multiple sources and of varying reproductive quality (yes, faxing is still commonly used for sharing medical records), reaching out to the referring provider in advance to understand the goal of the consultation, and assimilating all that knowledge into a coherent story. When patients learn that I already know a great deal about them during their initial consultation, they visibly relax. Of note, “prepping charts” in advance of the visit has only recently been acknowledged by Medicare as relevant to providing high-quality care. Current Procedural Terminology (CPT) codes for non-face-to-face clinical care were introduced during the Covid-19 pandemic but remain tightly constrained.
Nonverbal Cues
“Remember: music is not the notes. It is between the notes.”(Denk 2022)
As the author and concert pianist, Jeremy Denk points out, what is written in the musical score only provides the most basic instructions for the musician. The same is true for communication. Words only go so far. It is the way in which words are shared with the patient – through eye contact and affirming body language and other nonverbal clues – that information is received and processed.
The authors point out that the patient often focuses on nonverbal cues, and when verbal and nonverbal messages conflict, the patient is more likely to rely on nonverbal cues as the source of truth. This is a potentially dangerous situation, because it can lead to misunderstandings that may limit the ability of a patient to make truly informed decisions and to provide meaningful informed consent.
Although medical educators recognize the importance of providing medical students and trainees formative feedback, this remains uncommon practice (Back et al. 2009). This is unfortunate because the commonly substituted approach of modeling behavior falls far short. Nor can these skills be learned in the classroom. Learning to effectively leverage nonverbal clues requires experiential learning and active, real-time feedback from trained instructors. Medicine has a lot to learn from other service industries in this domain.
Listening
“Attention is the rarest and purest form of generosity” – Simone Weil (Weil)
The authors make a critical distinction between hearing and listening and emphasize that for the latter to be successful, it must actively pursued. The most important message that I can impart to a trainee is that it is more important to listen than to be heard. Permitting a moment of silence is okay; it gives the patient and her family time to process information that may at first overwhelm them. Listening is among the simplest manifestation of kindness, but it is under mounting attack as providers are more and more placed under intense production pressure. The rapid shift of providers from private practice to employees of healthcare organization (only 30% of physicians in the United States remain self-employed), along with the growth of for-profit medicine and hedge-fund ownership, have had a significant negative impact on how long a provider can spend with a patient. Active listening thus becomes a luxury that is often jettisoned in the service of expediency. Everyone suffers.
The Challenges of Effectively Communicating Today
Medical providers face a series of challenges that threaten the future of high-quality communication. The first is the rapid, unanticipated growth of telemedicine. Although, as the authors note, usage may have plateaued or even decreased, it continues to be prevalent in some areas such as mental health. Telemedicine reduces the opportunity for providers to maximally utilize nonverbal cues and to process those provided by the patient. In addition, at least in my experience, telemedicine enables poor behaviors such as toggling to other applications (email, for example), which further limits the value of telemedicine as a communication tool.
The second challenge is the rapid emergence of asynchronous communication between providers and patients. This includes patient portals, which, in principle, should increase patient access to their providers. But these communication tools commonly default to non-medical personnel in practices, creating buffers that can reduce, rather than improve access. Open notes, in which patients gain near-complete access to their medical records is another potential risk. Among oncology patients, up to 50% of patients now access test results—some of which contain potentially terrifying information—before they learn of them from their provider. This important advance in transparency and patient autonomy risks augmenting rather than reducing patient anxiety.
The final challenge is the rapid availability of generative artificial intelligence applications which create two further types of risk. The first is the risk of communicating incorrect or misleading information. Information provided by applications is the product of AI synthesis of unimaginable amounts of information; errors are common; some applications have even been found to “hallucinate”—to create information from whole cloth. The second risk of these applications is their convenience. Already, there are reports of physicians using tools to create the script for difficult conversations (Kolata 2023). Although, in some circumstances, for example, for providers truly lacking language to convey empathy, this may be a good thing. But it is no substitute for personally crafting a conversation with a patient that assures that the provider is truly present.
The authors are to be congratulated on a successful synthesis of three disparate sources of literature to arrive at a new paradigm for improving service communication. Their attention to the particular challenges and opportunities of medical communication makes their contribution particularly valuable to clinicians, but the paradigm offers valuable insights into improving the quality of communication for other services and for identifying future areas of academic study.
Footnotes
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
