TRAINING and EDUCATION
Trainees and physicians in our communications clinic attend a full-day,
eight-hour course in which we present
fundamental ideas about how to build a
relationship and how to engage in it. Our
theory, which is built upon several other
learning principles, is that relationships
are at the center of medical care. If you
don’t pay attention to your relationship
with your patients, the human work that
takes place in the context of those relationships becomes much harder.
Our training is built on two guiding
principles: 1) communicating is a motor
skill and needs to be practiced, and 2)
the relationship is more important than
anything else, especially when you consider it to be long-term.
Model the Behavior You Want to See
Our approach is very learner-centered.
Instead of telling people what we think
they should work on, we ask what our
participants – often a fellow or attending –
want to work on; what frustrates them in
their daily patient encounters; and where
they think they need improvement. Then,
we practice those through role-playing
scenarios.
Let’s face it: If you put a group of doctors in a room, and tell them, “Today is
communication training day; we’re going
to role-play some scenarios,” the groans
are audible. However, when we start by
inviting physicians to share some of the
hard conversations and challenging patient situations they’ve had, the stories
start flowing. From there, we start practicing by building cases from their past experiences – opening it up to feedback from
the other attendees.
Similarly, it’s important for physicians to practice these skills in a “safe”
environment, in which we reinforce all of
the things they are doing well – and not
just criticize the areas where they need to
do better. In medicine, we tend to look
for people to make a mistake and then
pounce; if that person does 10 things well,
though, we just assume that’s normal because we expect that person to be competent. We’re trying to reverse that.
To create a safe space for learners, we
aim for a four-to-one ratio of positiveto-negative feedback. And people learn
better that way; they become much more
open to identifying areas where they
would like to improve. Again, similar to
our patient encounters, if we start naming
all of the things people are doing incorrectly, they are going to enter a closed-off,
defensive mode. That’s not the optimal
learning stance.
We actually don’t use words like “well”
or “badly.” Instead, we use terminology
around specific behaviors and the impact
of those behaviors. For instance, “What
did you do that was effective in achieving
your goals, and what could you have done
differently?” The process is not about
evaluating or ranking the communica-
ASHClinicalNews.org
tor; we are trying to define what types of
behavior work and what types of behavior
don’t work.
Stuck in a Lack-of-Feedback Loop
Placing an intravenous catheter, suturing,
doing a physical examination – these are
all skills that physicians are given the opportunity to practice and skills that they
must demonstrate competency in before
they graduate from medical school. There
simply hasn’t been the same structured
approach to measuring whether or not
medical students, residents, fellows, and
attending physicians are competent in
patient communication.
For instance, we all have to get consent from patients in order to administer
chemotherapy, but do we ever measure
how well our physicians do that? After
they get consent from the patient, is the
patient able to say what he or she was
consented for,