TRAINING and EDUCATION
How I Teach
“How I Teach” is ASH Clinical News’ forum for sharing best practices in teaching hematology
to medical students, residents, and fellows. We invite essays providing insight into teaching
and modeling clinical practice (history-taking, the physical exam, informed consent, giving bad
news), successful research mentoring, disease-specific tips, or more general advice. In this issue,
Lidia Schapira, MD, shares her advice for teaching better communication skills and creating a
more productive and supportive patient-clinician relationship. Dr. Schapira is associate professor
of medicine at the Stanford University Medical Center in Palo Alto, California.
REFINING PATIENT-DOCTOR
COMMUNICATION
Lidia Schapira, MD
By Lidia Schapira, MD
Refining the patient-doctor relationship became a focus
early on in my career. Unlike many of my colleagues in
academic hematology and oncology, I also practiced
internal medicine for the first 12 years post-fellowship.
I quickly realized that I was drawn to caring for patients
who had serious, life-threatening illnesses like cancer, so
I came to oncology with a passion for both the science of
disease and the opportunity to develop strong relation-
ships with my patients.
Even as a fellow, I appreciated the importance of the
relationship that grew bet ween patients living with seri-
ous illnesses and their doctors. In many instances, those
relationships can be therapeutic and sustaining. A strong
patient-doctor relationship is an important part of treat-
ment; it has the potential to provide patients with solace
and comfort, even after treatments fail to control their
disease.
That led me to ask myself, “What are the skills clini-
cians need to bring to patient encounters and what do
we need to give of ourselves? How can we cultivate and
nurture that in ourselves and our fellows?”
Cultivating Communication
After exploring those questions with fellows and faculty
members while I was at Harvard Medical School, we
developed a communications retreat for fellows with
the help of colleagues in palliative care and psychosocial
oncology from Massachusetts General Hospital and
Dana-Farber Cancer Institute.
Our work as hematologists and oncologists can
be both incredibly rewarding and incredibly difficult.
Unfortunately, we often had to give bad news and experi-
ence the deaths of our patients. Together, we recognized
that fellows needed proper training in patient-centered
communication in a safe environment where participants
could share their experiences with fellow trainees and
with senior faculty members.
So, for one day, fellows signed out their beepers and
headed to a beautiful setting outside the hospital where
they engaged in a combination of learner-centered exer-
cises, including simulations, role-playing, and small- and
large-group discussions.
To ensure that we were providing the fellows with
relevant skills, we first asked them what types of con-
versations and situations were the most difficult. From
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that feedback, we devised scenarios that mimicked
real-life patient encounters. Faculty members and actors
portrayed doctors and patients, and instructors modeled
the skills to use in these situations – everything from
conducting a typical patient interview to navigating
tough conversations about treatments to delivering bad
news to patients and their families.
Over the years, we introduced new sessions to the
agenda, like creating a faculty question-and-answer panel
in which the younger doctors could ask more senior fac-
ulty about their experiences – what shaped their careers
and what they found most rewarding or challenging. It
was an opportunity for faculty to provide frank feedback
and it also had the benefit of opening fellows’ eyes to
some different career paths available to them.
In the small-group exercises, we invited fellows to
discuss the scenarios we presented and brainstormed
potential solutions. Taking this learner-centered approach
helped us tailor the training to meet their needs and un-
derstand exactly why these situations felt so difficult. We
encouraged reflection and, again, set up a safe environ-
ment where participants were able to voice their concerns
without judgment.
Talking Less, Listening More
It became clear, working with our trainees and fellows,
that they are not poor communicators. They did need
instruction, though, in the specialized skill of communi-
cating with patients and caregivers. Early-career doctors
are trained in how to present research, give lectures, and
persuade colleagues; they need more guidance in devel-
oping interpersonal skills and interacting with patients
and families.
Fellows occupy an interesting position: They know
more than they did as medical students and residents,
but they have much more to learn before they transition
into attending physician or faculty member roles. Be-
cause they want to demonstrate the knowledge they’re
gaining, they sometimes have a tendency to teach
patients or give “mini lectures.” In a rush to prove their
expertise, they provide a litany of data instead of devel-
oping a relationship and responding to the emotional
aspect of the encounter. As you progress through your
career, you realize that sometimes, you need to talk less
and listen more.
Practicing Presence
Fellows’ experience level works to their disadvantage in
some ways: A medical student with less training may
find it easier to respond to a patient who is emotionally
distressed because – as I have heard from several fellows
– the training experience can be dehumanizing. They
have strong instincts and intuition, but often what’s
missing is what I call “presence.”
Presence involves listening, conveying deep respect
and warmth, and providing the comfort that we all want
when we’re sick. It requires the clinician to be an expert in
the treatment of the illness and in the psychologic aspects
of the patient experience. This means exercising empathy,
helping people find sources of inner strength, knowing
how to comfort caregivers, and recognizing when it is
appropriate to refer someone to a colleague with expertise
in mental health.
Presence is a skill we can cultivate, much like we cul-
tivate knowledge about a disease state. We need to learn
how to be with someone who is emotionally distressed,
like a patient who has been told that his or her leukemia
relapsed or that a loved one has aplastic anemia. We have
to ask ourselves, “What does it take to simultaneously
display competence and provide a comforting presence to
patients, caregivers, and families?”
As we help trainees cultivate their compassion and
patient communication skills, we also need to ensure
that they are caring for themselves. Empathy can be a
slippery slope, so to speak. It has taken me a long time
to understand this point, but being empathic means that
you open yourself to experiencing patients’ distress or
even mirroring their suffering. If you live in that, you
can burn out quickly.
I believe that compassion is the component that is val-
ued most by our patients and families, but, unfortunately,
it is often not recognized in our curricula. So, practicing
compassionate communication should be a focus of our
training. At the end of the day, it helps us to be more
effective and find joy and meaning in our work – without
feeling that we’re completely spent emotionally. ●
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