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887

Communication Skills Training in Oncology


Description and Preliminary Outcomes of Workshops on Breaking Bad News and
Managing Patient Reactions to Illness

Walter F. Baile, M.D.1


Andrzej P. Kudelka, M.D.2
Estela A. Beale, M.D.1
Gary A. Glober, M.D.3
Eric G. Myers, M.A.1
Anthony J. Greisinger, Ph.D.4,5
Robert C. Bast, Jr., M.D.6
Michael G. Goldstein, M.D.7
Dennis Novack, M.D.8
Renato Lenzi, M.D.3
1

Section of Psychiatry, Department of Neuro-Oncology, The University of Texas M. D. Anderson


Cancer Center, Houston, Texas.

Section of Gynecological Medical Oncology, Department of Medical Specialties, The University of Texas
M. D. Anderson Cancer Center, Houston, Texas.

Department of Gastrointestinal Medical Oncology


and Digestive Diseases, The University of Texas
M. D. Anderson Cancer Center, Houston, Texas.

Department of Medicine, Houston Center for


Quality of Care and Utilization Studies, Houston
Veterans Affairs Medical Center, Houston, Texas.

Section of Health Services Research, Department


of Medicine, Baylor College of Medicine, Houston,
Texas.

Division of Medicine, The University of Texas


M. D. Anderson Cancer Center, Houston, Texas.

Clinical Education and Research, Bayer Institute


for Health Care Communications, West Haven,
Connecticut.

Department of Medicine, Division of Medical Education, MCP Hahnemann University, Philadelphia,


Pennsylvania.
Presented in part at the American Association for
Cancer Education 32nd Annual Meeting, Portland,
Oregon, November 5 8, 1998.
Address for reprints: Walter F. Baile, M.D., Section
of Psychiatry, Department of Neuro-Oncology, The
University of Texas M. D. Anderson Cancer Center,
1515 Holcombe Boulevard, Box 100, Houston, TX
77030-4095.
Received September 21, 1998; revision received
February 26, 1999; accepted February 26, 1999.

1999 American Cancer Society

BACKGROUND. Cancer clinicians do not receive routine training in the psychosocial


aspects of patient care such as how to communicate bad news or respond to
patients who have unrealistic expectations of cure. Postgraduate workshops may
be an effective way to increase interpersonal skills in managing these stressful
patient encounters.
METHODS. The authors conducted 2 half-day workshops for oncology faculty, one
on breaking bad news and one on dealing with problem situations. Participants
met in a large group for didactic presentations and then small groups in which they
used role-play and discussion to problem-solve difficult cases from their practices.
The small groups were assisted in their work by trained physician facilitators. The
workshops were evaluated by means of a follow-up satisfaction questionnaire as
well as a self-efficacy measure, which was administered before and after the
workshops.
RESULTS. Twenty-seven faculty and 2 oncology fellows participated in the training
programs. Satisfaction questionnaires showed that the programs met the educational objectives and were considered to be useful and relevant by the participants.
Self-efficacy questionnaires revealed an increase in confidence in communicating
bad news and managing problem situation cases from before to after the workshop. The majority of attendees welcomed the opportunity to discuss their difficult
cases with colleagues. A number resolved to implement newly learned approaches
to common patient problems they encountered frequently.
CONCLUSIONS. Communication skills workshops may be a useful modality to
provide training to oncologists in stressful aspects of the physician-patient relationship. Further research is needed to assess whether long term benefits accrue to
the participants. [See editorial on pages 738-40, this issue.] Cancer 1999;86:
88797. 1999 American Cancer Society.
KEYWORDS: communication, training, cancer, outcomes.

ublished reports indicate an increased desire among cancer patients for information regarding their illness and choices regarding treatment options.17 Furthermore, many cancer patients and
their families regard their physician as the primary source of cancerrelated information.8 11 Providing accurate information to cancer
patients and their families therefore may be regarded as an essential
component of the medical visit.
The quality and timing of information provided to cancer patients
and families are associated with important clinical outcomes such as
patient satisfaction and psychologic adjustment.1216 Having good
patient communication skills also may be important for the psychologic health of the physician.17 A recent survey of members of the
American Society of Clinical Oncology indicated that those who had
difficulty in communicating with patients at the end of life were more

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CANCER September 1, 1999 / Volume 86 / Number 5

likely to see themselves as having failed the dying


patient. This in turn was associated with a tendency
for the oncologists to prescribe chemotherapy in the
terminal phase of illness.18
Disclosure of negative information regarding diagnosis, prognosis, and disease progression often is
difficult because physicians may lack a specific
method for doing so19 and because disclosure can
elicit strong emotional or behavioral reactions on the
part of the patient that are awkward to address such as
sadness, anger, denial of the illness, or pressure to
continue aggressive treatment in the face of futility.
Communicating bad news also may be stressful when
a physician feels a sense of failure for not having met
patient expectations or is troubled over how to provide hope in the face of a poor prognosis.19 21
Many physicians do not feel adequately trained in
breaking bad news and managing the emotional and
behavioral reactions of patients.2123 The majority of
medical schools do not address specifically the communication and interpersonal issues likely to be encountered in the care of cancer patients.24 Likewise,
despite the rapid growth of medical oncology as a
profession, there has been little emphasis in oncology
training programs on the psychosocial skills needed
for the optimal care of cancer patients and/or their
families. In fact, current curriculum recommendations
for training in medical oncology make no mention of
the skills necessary to communicate the cancer diagnosis and other related bad news appropriately and to
address the emotional reactions of the patient and
family to cancer.25 A recent survey of 700 physicians
attending a symposium on Breaking Bad News at
the 1998 Annual Meeting of the American Society of
Clinical Oncology19 indicated that only 6% had any
formal training in breaking bad news and 74% had no
consistent plan or strategy in mind for accomplishing
this task. It is not surprising that the majority of participants rated their ability to disclose negative information as only poor to fair.
Gaps in the training of oncologists and other professionals in communicating effectively with cancer
patients can be manifested in a number of ways. Several studies document that poor communication has
potential negative consequences for patient-related
outcomes, including dissatisfaction with care,26,27 incorrect understanding of disease status and prognosis,28,29 and distrust of the physician.30
Some insight into how barriers to effective communication result in undesirable patient outcomes
has been provided by the work of Maguire31 and Ford
et al.32 Maguire31 observed that when some physicians
were faced with communicating negative information
(e.g., disclosing a poor prognosis) they adopted strategies that blocked patient emotional reactions that

caused them to feel uncomfortable. This occurred


when they selectively attended to physical concerns to
the exclusion of emotional concerns, changed the subject when sensitive questions were asked by the patient, or created unrealistic expectations or false hope
for cure in the patient and family.
Ford et al.32 audiorecorded visits between 117 ambulatory patients with cancer and their physicians. In
each case, the patient was given potentially distressing
information (disclosure either of the diagnosis of cancer or the failure of a treatment). They found that
physicians tended to inhibit patient disclosure of concerns regarding their diagnosis and prognosis by asking closed-ended questions, left little space for patients to initiate discussion, and were inattentive to
psychosocial concerns.
How can physicians caring for cancer patients
improve their communication and related patient
management skills? In this article we describe a
method for addressing these goals through interactive
workshops focused on formal teaching and experiential learning. The workshops involve five elements: a
didactic framework to guide practice; a learner-centered approach by which participants themselves are
encouraged to identify problems and explore solutions to them; the use of small groups to facilitate
individualized learning and establish a cohesive task
environment; the use of role-play, which encourages
participants to step into the shoes of their patients;
and lastly the use of facilitators to guide the group in
its work and create a constructive work atmosphere.
To date, nearly 150 faculty and fellows have participated in training sessions using this model at the
University of Texas M. D. Anderson Cancer Center.
This article will describe two workshops that incorporated these principles and will present the preliminary
results of our workshop evaluation.

OVERVIEW OF WORKSHOPS
Format of Workshops
The workshops addressed the themes of communication skills such as disclosing the cancer diagnosis and
related psychosocial management issues such as dealing with requests for futile treatment. These themes
were chosen because they reflected the interests of
our faculty33 and because the literature in this area
suggested that these topics presented challenges to
oncologists involved in patient care.2,34,35
Each 5-hour workshop started with a continental
breakfast. Figure 1 shows the workshop schedule. This
allowed the participants to get to know one another
and complete pretest questionnaires. These questionnaires collected demographic information and assessed the confidence of the participants in performing interview behaviors related to the workshop

Outcomes of Communication Workshops/Baile et al.

889

ing the interview. Ground rules were implemented


including allowing the interviewer to stop the interview temporarily and ensuring that cases selected for
role-play were not so difficult as to deskill the interviewer. Interviews were audiotaped to allow the group
to review essential components of the interview.

Course Facilitators

FIGURE 1. Schedule for each 5-hour workshop.

theme. The questionnaires were repeated after the


workshop.

Setting the Agenda


Because the workshops were learner-centered, participants were involved closely in developing the workshop themes. Through group discussion at the beginning of each workshop and questionnaires sent out
prior to the workshop, participants determined the
most important problems they would like to discuss in
large and small groups.

Large Group Meetings


Each workshop began with a didactic presentation or
a discussion period for all participants, which lasted
approximately 45 minutes. The purpose of these
meetings was to present the goals of the workshop,
introduce the facilitators, and present background educational material.

Facilitators for the workshops included oncologists


and psychiatrists, all of whom had received specialized training in facilitating workshops on the doctorpatient relationship.
Five facilitators were M. D. Anderson Cancer Center faculty and two additional facilitators were associated with the American Academy on Physician and
Patient. All facilitators previously had attended workshops as participants themselves and had facilitated
or cofacilitated training programs for faculty and fellows regarding communication skills in oncology at
the M. D. Anderson Cancer Center. The facilitators
worked with the participants to set goals and objectives for the workshop, presented the didactic material, and oversaw the work of the small groups.

WORKSHOP 1: BREAKING BAD NEWS


Introduction
We chose to offer the workshop on breaking bad news
first because the topics included under breaking bad
news are among the most common yet challenging
and stressful for the oncologist. They include, among
other situations, discussions of the following: the cancer diagnosis, the failure of therapy to be effective,
irreversible toxicity, disease recurrence, and the transition from aggressive therapy to supportive care.

Small Group Meetings

Participants

After the large group meeting, the participants were


divided into groups of four or five participants, each
with a facilitator. In each small group, a participant
volunteered to present a difficult patient encounter he
or she had experienced that was related to the workshop theme. The volunteer then role-played the patient from that encounter while another volunteer
conducted a simulated interview. Role-play allowed
one physician to assume the persona of the patient
with the purpose of facilitating his insight into the
patients feelings and behavior. The task of the interviewer was to provide a fresh approach to the problem. The other members of the small group acted as
commentators, observing the role-play scenarios, reinforcing the efforts of the interviewer, and making
suggestions for resolving impasses that occurred dur-

Fifteen oncologists on the faculty and 2 fellows attended this workshop. The faculty varied widely in
specialty, age, and experience. Three participants
were medical oncologists, five were from surgical specialties, two were from radiation oncology, and the
remaining participants were from a variety of other
oncologic specialties. Fourteen participants were male
and 3 were female. The faculty had been in oncology
practice for an average of 18 years and .80% were
involved at least 50% of the time in patient care. Participants ranged in age from ,30 years to .70 years
with the large majority ranging in age from 30 50
years. Eleven of the participants indicated that they
broke bad news to patients either very frequently or
frequently, 2 broke bad news occasionally, and 4 broke
bad news rarely.

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CANCER September 1, 1999 / Volume 86 / Number 5

FIGURE 2. Six-step SPIKES protocol for breaking bad news.

Methods
Prior to the workshop, participants were given two
articles to read. One explained a specific strategy for
breaking bad news36 and the second discussed the
particular stresses on the physician who must face this
task.37
After a brief introduction, during which the goals
and objectives of the workshop were set, participants
viewed a video illustrating two versions of a doctorpatient medical interview. The video illustrated the
limitations of an interview focused exclusively on establishing the physicians agenda. It contrasted this
type of interview with a second type of interview in
which the physicians used specific interviewing techniques such as open-ended questions to incorporate
additional information, such as patient concerns regarding the illness, into the data that were collected.38
A facilitator then discussed the techniques used by the
interviewer to encourage patient disclosure of illnessrelated concerns. After the discussion, one of the facilitators presented a six-step protocol (SPIKES) for
breaking bad news as described by Buckman36 that
incorporates the key interviewing skills touched on in
the tape (Fig. 2). After the didactic presentation, the
participants broke into small groups.
In each small group the facilitator introduced the
technique of role-play. The group members then were
asked to identify one or more situations in which they
broke bad news that they would like to address during
the workshop, applying the methods outlined in the
didactic lecture. For example, the topics selected in
one small group were the following: 1) disclosing the
diagnosis of anaplastic glioma to a patient; 2) reveal-

ing the diagnosis of lung carcinoma to a patient who


also is a friend; 3) disclosing the failure of treatment to
effect a cure when there are no other curative options
available; 4) dealing with cancer recurrence when
there are limited curative options; and 5) transmitting
the news of unexpected death or complications to a
family member.
An example of one such case discussion follows. A
medical oncologist played the role of a 64-year-old
woman who had progressive disease after third-line
treatment for metastatic ovarian carcinoma. The task
was to communicate to the patient that there was no
further curative treatment available and that palliative
care now was the most reasonable course to take. The
interviewer was a gynecologist with 25 years of experience in practice. He summarized the patients clinical treatment course in its entirety and arrived at the
point of communicating to the patient the bad news.
Doctor (somberly): Im afraid your cancer has
returned and at this point more chemotherapy is not
going to help. My recommendation is that we focus on
keeping you comfortable.
Patient (appearing shocked): I cant believe it.
There must be something you can do. You cant give
up now.
Doctor (appearing anxious): Well, maybe we can
try a different combination of chemotherapy treatments.
Patient (clearly relieved): Oh thank God theres
something else you can do.
After the case was presented, the facilitator encouraged the observers to provide feedback, first by
commenting on the positive aspects of the interview

Outcomes of Communication Workshops/Baile et al.

and then by making any helpful suggestions regarding


how to proceed. The group responded to this scenario
by complimenting the physician on the skill he demonstrated in summarizing the course of the illness and
previous treatment to the patient. They suggested that
the physician try several additional approaches to the
problem, such as reassuring the patient that the physician would not give up on her and telling the patient
that she may not survive more aggressive treatment.
The facilitator inquired as to how the patients desire
for further treatment made the physician feel, and he
replied that he felt very bad for the patient, especially
when she pleaded with him to do more and he could
not bear not to offer more chemotherapy, although he
had no expectation that it would improve the patients
condition significantly. The group discussed how difficult it is to be the messenger of bad news, especially
when a patient appears desperate or when one has
become attached to the patient. The facilitator acknowledged this and went over the steps for breaking
bad news.
The facilitator suggested that it might be useful for
the physician to also make an empathic statement
such as This must be difficult for you to hear. The
group acknowledged that it was difficult to remember
the steps of breaking bad news and discussed an acronym to describe the steps to follow in breaking bad
news. Finally, they discussed how one might prepare
the patient better for the bad news by raising the
possibility of an unfavorable outcome at the time of
initiation of salvage chemotherapy. The two volunteers then repeated the role-play, incorporating some
of the suggestions of the group.
Each of the small groups worked independently
for approximately 3 of the 5 hours that the workshop
lasted.
During the last half-hour of the workshop, the
participants all met together to provide feedback to
the facilitators and to report briefly on the work of the
individual groups. They completed a questionnaire to
assess their confidence in performing a number of
tasks associated with breaking bad news.

Results
As shown in Table 1, compared with their confidence prior to the workshop, the confidence of participants improved after the workshop in 18 of 21
items related to breaking bad news. The three items
not reaching significance were: detecting verbal
cues, encouraging family presence, and detecting patients anger.
Approximately 1 week after the workshop, we sent
a 3-page evaluation form to the participants. The
questionnaire included nine forced-choice questions
regarding the efficacy of the workshop in meeting the

891

TABLE 1
Breaking Bad News
Significance levels of changes in confidence for protocol components
Component of breaking bad news

P value

Creating comfortable setting


Assessing patients ability to discuss bad news
Detecting verbal cues
Encouraging family presence
Assessing current knowledge
Detecting patients anger
Including family in discussion
Detecting nonverbal cues
Assessing how much the patient wants to know
Detecting anxiety
Planning discussion in advance
Detecting patients sadness
Confirming patients understanding of cancer
Checking to see that information was received
accurately by patient
Providing information in small increments
Avoiding medical jargon
Reinforcing and clarifying information
Responding empathetically to patients feelings
Planning a strategy for disclosing information
Handling patients emotional reactions
Managing your own response to patient distress

0.007
,0.001
0.110 (NS)
0.396 (NS)
0.049
0.135 (NS)
0.038
0.015
0.019
0.004
0.001
0.009
0.002
0.027
0.006
0.001
0.020
0.023
0.004
0.020
0.008

NS: not significant.

learning needs of the participants. The questionnaire


also solicited suggestions for future workshops. The
last part of the questionnaire was comprised of six
questions evaluating the facilities and the arrangements for the workshop. All participants returned a
completed questionnaire.
Greater than 80% of the participants agreed or
strongly agreed that the workshop provided useful and
timely information, facilitated learning, and was well
organized. Sixteen of the 17 participants indicated that
25100% of the information presented in the workshop was new to them; the most frequent response
was that 25 60% of the information was new.
Comments from the participants regarding what
they liked best about the workshop included the small
group format, the information provided, and aspects
of the group process, including the ability to share
experiences with colleagues, the open discussion of
problems, and the supportive environment. Responses to a question regarding how participants
would change their approach to patient communication as a result of the workshop included finding out
more from family members regarding their concerns,
increasing ones observation of the patients body language, following the principles of breaking bad news
more systematically, and think before saying anything to the patient.

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CANCER September 1, 1999 / Volume 86 / Number 5

Regarding what the participants liked least about


the workshop, two participants did not find the roleplay useful and several commented unfavorably on
the Saturday schedule. Three others believed that the
didactic part of the workshop could have been lengthier.

WORKSHOP 2: MANAGING DIFFICULT PATIENT


SITUATIONS
Introduction
Approximately 6 weeks after the first workshop we
conducted a second workshop entitled Managing
Difficult Patient Situations. The workshop focused on
strategies for managing patient and family encounters
identified by our faculty as being particularly stressful.
The format of this workshop was similar to that of
Workshop 1. It also lasted 5 hours.

Participants
Twelve faculty who were not present at the first workshop attended the second. Three participants were
surgeons, four were from medical specialties, and the
remaining participants were from a variety of different
departments (medical oncology, radiation therapy,
dental oncology, cancer prevention, and pediatrics).
Participants were nearly equally divided between
more senior clinicians and those with ,5 years of
experience.

Methods
Prior to the workshop each attendee was mailed two
handouts. One was entitled Dealing with difficult situations. Individual strategy sheets for various problem
situations. The other was entitled The interview process. How to go about getting the information you
require. Both readings, which were intended as background information for the workshop, were developed
by the Psychological Medicine Group, Cancer Research Campaign, at the University of Manchester in
the United Kingdom for their own communication
skills workshops. As part of the preworkshop packet
each attendee also was given a list of 15 difficult
situations and asked to choose the most challenging
among these as potential topics for the workshop.
Some examples of these encounters included dealing
with patients demonstrating excessive anger or denial,
confronting a colleague regarding inappropriate behavior toward a patient, dealing with patients with
unrealistic expectations or who had been lied to, and
assessing depression and suicidal risk.
When they arrived for the workshop each participant supplied demographic and professionally related information. They also completed a 45-item
questionnaire39 to assess 3 areas of confidence in
communication. Fifteen items measured confidence

in communicating with regard to the difficult patient


situations they were asked to choose among prior to
the workshop such as patient anger and denial; 7
items measured confidence in using general communication skills such as open-ended questions, and 23
items measured confidence in communication outcomes (e.g., is the communicator confident he will
achieve the intended result of the communication,
such as making an effective empathic response?).
There was no formal didactic session at the beginning of this workshop. Instead, we used physicianpatient case vignettes to initiate discussion. Several
sample vignettes are provided in Figure 3. Each participant received a booklet with eight cases that were
designed by the workshop facilitators and based on
the problem situations chosen by the participants
prior to the workshop.
The case vignettes included several challenging
statements made by patients or patients families and
examples of situations that may arise in the course of
a patients or family members consultation with the
oncologist. The task of the participants was to attempt
to identify the underlying emotional theme or hidden
message expressed by the patient or family members.
Participants also were asked to describe common feelings or reactions that might be elicited in the physician by the communication and to suggest a helpful
response that addressed the patients underlying concerns. The problem situations covered management
of the following: patients or families with unrealistic
expectations, the patient angry at not getting better,
the colleague who refuses to discuss the severity of the
illness with the patient, the spouse frustrated that the
patient is not getting better, the patient who refuses
narcotic analgesics, the patient who insists his child
not be told he has cancer, the patient who expects a
miracle, and finally the family who pleads not to tell
the patient his disease has returned. The facilitators
and workshop participants spent approximately 45
minutes discussing several of these vignettes. The participants then separated into small groups of four to
five each and role-played situations that they had selected.
After the workshop, we readministered the confidence-in-communication questionnaires. Precourse
and postcourse questionnaire responses were compared using the Student t test for paired data.

Results
As shown in Table 2 participants revealed improvement in 11 of the 45 communication outcome items
measured. There also was a trend toward significance
for four additional items. Participants rated themselves as more confident in dealing with 4 of 15 problem situations including managing overprotective

Outcomes of Communication Workshops/Baile et al.

893

FIGURE 3. Examples of case vignettes used to initiate discussion in Workshop 2.


families, dealing with the patient who had been lied
to, confronting a colleague regarding unacceptable
behavior toward a patient, and assessing depression
and suicide risk. They also showed increased confidence in four of seven items concerning general interviewing skills. Finally, they reported increased confidence in several areas of communication outcomes,
all related to the management of the emotional aspects of the patients illness.
Approximately 1 week after the workshop, we sent
a satisfaction questionnaire to all 12 participants. The
questionnaire was identical to the questionnaire sent
after Workshop 1. All but one of the participants returned the questionnaire.
All the participants agreed that the workshop met
the educational objectives of identifying areas of difficult communication with cancer patients and using a
group format and case presentations to discuss techniques and practice skills.
Participants again identified the ability to work
with colleagues from different areas on very practical
communication issues in a small group format as a

positive aspect of the seminar. Participants identified


the format as too ambitious in terms of the amount of
material covered. The Saturday schedule again was
brought up as a drawback. As in the first workshop, a
number of participants indicated that they would alter
their communication approach to patients. Participants indicated that they would listen more actively,
pay attention to body language, check the patients
knowledge, and never tell a patient their cancer has
been cured. Suggestions for future seminars included
having a lecture on basic principles of communication, offering the workshop on a department-by-department basis, and including ethical dilemmas as a
topic.

DISCUSSION
Several recent articles and surveys have suggested the
need for further physician training in communication
skills and effective management of emotional concerns of cancer patients and their families.20 22,40 Despite the call for increased attention to this area, a

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TABLE 2
Outcomes of Communication
Significance levels of changes in confidence in communication (45-item
questionnaire)
Confidence in communication (15 items)
Managing overprotective families
Dealing with a patient who has been lied to
Confronting a colleague regarding inappropriate behavior
Assessing depression and suicidal risk
All others NS
Confidence in interviewing skills (7 items)
Ask questions to increase disclosure
Respond in a way that encourages elaboration
Summarize a concern
Make a statement that moves the patient to discuss
additional concerns
All others NS
Outcome of communication (23 items)
Patients will become upset if you discuss feelings
You believe the patient will break down if you talk about
concerns and feelings
Patients will show such strong emotions that you will be
overwhelmed personally
All others NS

P 5 0.045
P 5 0.003
P 5 0.004
P 5 0.004
P 5 0.005
P 5 0.005
P 5 0.017
P 5 0.038
P 5 0.048
P 5 0.012
P 5 0.037

NS: not significant.

number of questions remain to be resolved: what specific communication topics should oncologists be
taught, what is the best format, and how do we best
measure outcomes? Because currently there are few
answers to these questions, we described in detail one
possible format and evaluation for such training,
which we believe was well received by participants.
Several aspects of our workshop incorporated important educational principles used by others in similar communication skills programs. One was the use
of a learner-centered model.41 43 This approach promotes ownership of the educational process by requiring participants to provide case material from
their own practice experience, which also ensures the
relevance of the material for the workshop participants. It challenges physicians to participate in finding solutions to the communication problems they
think are important through the use of role-play and
collaborative group effort. We attempted to apply this
approach by soliciting participant input into workshop topics and by asking their reactions to a videotaped interview and written case scenarios. These
tasks also served as a warm-up to allow group members to be introduced to the more intense participation required of the small groups. A potential drawback of this learner-centered approach is that it may
limit the number of communication topics that can be
discussed.
Both workshops included a didactic component

and an opportunity for practice. This combination


appears to provide the best environment for learning
communication skills.44 Practice is important because
of the role of anticipatory anxiety in thwarting effective communication.21 In the case of delivering bad
news, apprehension regarding how the patient will
respond emotionally to bad news may cause the physician to consciously or unconsciously adopt unproductive coping strategies such as postponing the bad
news to reduce his or her stress. The objective of a
communication training program in oncology would
be to provide strategies to reduce the anxiety associated with breaking bad news and for managing patient
(and ones own) emotional and behavioral reactions.
Small groups can provide an environment in
which to develop and practice responses to communication dilemmas through discussion and practice
using role-play. Although the use of role-play usually
is new to the majority of participants, our evaluations
showed that most group members believed it was a
valuable way to present their difficult communication
problems. Role-play also allows physicians to develop
skills in a relatively nonthreatening environment with
the support of colleagues through a sharing of experiences. The perception that colleagues have similar
communication problems encourages the sharing of
experiences, thus increasing the groups cohesiveness.
Our use of trained facilitators in the small group
sessions served several purposes. Occasionally, discussion of patient care issues can arouse issues of
self-appraisal45 and in fact questioning the choice of
oncology as a profession, discussion of balancing professional and personal life, and discussion of personal
reactions to patient death were themes that occasionally emerged in our workshops. Facilitators must be
trained to legitimize the importance of such issues
and to help the group understand how physician emotions may affect interaction with the patient. Another
important role of the facilitator is to intervene in a
case that is too charged emotionally or when any one
group member dominates the discussion. In our experience, having facilitators receive specialized training in small group dynamics and physician-patient
communication has been important in making them
more effective.
We have found that the workshop format is adaptable to a number of different learning situations. In
our faculty evaluations some workshop participants
indicated a preference for a workday week venue
rather than a weekend. Still it may be difficult for
participants to cancel clinics and make other arrangements to attend. For this reason the same workshops
may need to be scheduled several times per year. For
faculty, we offer 5-hour workshops because of time
constraints. Moreover, the staff appears more inclined

Outcomes of Communication Workshops/Baile et al.

than fellows or other trainees to present cases in front


of colleagues because they usually do not worry about
being embarrassed or having these skills evaluated.
Conversely, for oncology fellows workshops of a
longer duration (1 and 1.5 to 2 days) may be necessary
to permit these less experienced participants to overcome any inhibition associated with exposing possible
limitations of communication skills.
Many oncologists believe that they already are
good communicators, although it has been shown that
even senior oncologists can encounter difficulties
when dealing with issues such as communicating bad
news and other emotionally charged patient encounters28,31,35 This may make recruitment into communication skills programs challenging. At our hospital we
were able to encourage physician participation by offering risk management credits on an hour-by-hour
basis for the course. This satisfied the annual risk
management requirements of the institution. We also
received explicit support from the physician-in-chief
for our workshops in the form of a letter sent to faculty
supporting the workshop and encouraging participation.
We have attempted to evaluate our workshops
through two means: participant satisfaction questionnaires and assessment of increases in the participants
confidence in the types of communication covered in
the workshops.
We were gratified to find an increase in confidence in communication skills as measured by our
questionnaires. In Workshop 1 participants reported
nearly across the board improvement in confidence in
steps for breaking bad news.
In Workshop 2 the results were less impressive,
with only 4 of 15 items relating to difficult encounters
showing improvement. The different ways we conducted the workshops and the different assessments
we used may in part explain this.
In Workshop 1 we taught a specific stepwise procedure for breaking bad news and then applied it to
the bad news situations brought up by the participants in the small groups. This apparently was effective in increasing the confidence of the participants
that they could apply the procedure that was taught.
In Workshop 2 we took a more general approach
because for different problem situations different
strategies may be called for to resolve the clinical
dilemma. For example, with the angry patient making an empathic response would be an appropriate
initial strategy to defuse the emotion whereas a patient in denial might require one to explore what the
patient has been told about the illness. We attempted
to illustrate several of these approaches in the large
group through the use of case scenarios. However, we
left it up to the small groups to decide which specific

895

problems they would attempt to address through roleplay and discussion. Although we did note that participants reported increased confidence in managing
several problem situations, we did not attempt to correlate improvement in these areas with topics discussed in the small groups. Thus we are unable to say
whether improvement in these areas is a result of
role-play/rehearsal or a general effect of the workshop.
With regard to the Outcomes of Communication
scale, several items regarding the patients emotional
reactions also showed improvement. This is important
because physician discomfort in dealing with patient
emotional reactions is one of the most important barriers to making effective exploratory responses, a key
communication skill in understanding and resolving
problem situations.
In using confidence measures as an outcome we
have been troubled by whether this represents a true
change or self-report bias due to workshop participation. We also recognize that an increase in confidence
does not necessarily represent skill acquisition or increased effectiveness in communicating in clinical
practice. The literature suggests that positive responses on self-efficacy measures such as the one we
used can be associated with subsequent behavior
change,46,47 especially when accompanied by intent to
change behavior.48 However, we have not investigated
whether course participants are using new communication techniques learned in the workshop.
Others also have demonstrated favorable results
from communication skills courses. For example, Garg
et al. have shown that medical students using the
SPIKES protocol successfully can learn a strategy for
breaking bad news49 and a number of other authors
have conducted workshops on physician-patient communication with positive outcomes.35,50,51
One legitimately could argue that workshops of
the type we describe are too labor-intensive or too
brief and that the majority of trainees learn their skills
by observing more senior clinicians. However, given
the challenges of these communication problems
there is no guarantee that without specific training
they are effective role-models.21 Workshops for faculty
in physician-patient communication can provide a
knowledge base for transmitting skills to fellows and
other trainees. Advanced communication skills workshops for faculty involved in training fellows and using
a model adapted to focus on the teaching process
should be an important part of faculty development.
Future research efforts should be directed at devising strategies to evaluate the impact that physician
communication courses have on patient outcomes
such as patient satisfaction, stress, and acquisition of
disease-related information and to determine the

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CANCER September 1, 1999 / Volume 86 / Number 5

most appropriate time for communication training


during the development of a career in clinical oncology.
Objective measures of participant improvement
such as videotaping or audiotaping of patient encounters and the rating of simulated or actual videos is one
approach we and other authors currently are trying to
develop. We also are attempting to determine whether
reductions in physiologic measures of physician stress
can be obtained by teaching a specific strategy for
breaking bad news. Until these outcomes are established, results should be considered as promising but
preliminary.

16.

17.

18.

19.
20.

REFERENCES
1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

Newall DF, Gadd EM, Priestman TJ. Presentation of information to cancer patients: a comparison of two centres in
the UK and USA. Br J Med Psychol 1987;60:12731.
Levenson PM, Pfferbaum BJ, Copeland DR, Silberg Y. Information preferences of cancer patients ages 11-20 years. J
Adolesc Health Care 1993;3:1326 37.
Blanchard CG, Labrecque MS, Ruckdeschel J, Blanchard EB.
Information and decision-making preferences of hospitalized adult cancer patients. Soc Sci Med 1988;27:1139 45.
Meredith C, Symonds P, Webster L, Lamont D, Piper E, Gillis
CR, et al. Information needs of cancer patients in the west of
Scotland. BMJ 1996;313:724 6.
Dunsmore J, Quine S. Information, support and decisionmaking needs and preferences of adolescents with cancer:
implications for health professionals. J Psychosoc Oncol
1995;13:39 56.
Davison BJ, Degner LF, Morgan TR. Information and decision-making preferences of men with prostate cancer. Oncol
Nurs Forum 1995;22:1401 8.
Cassileth BR, Zupkis RV, Sutton-Smith K, March V. Information and participation preferences among cancer patients.
Ann Intern Med 1980;92:832 60.
Foltz A, Sullivan J. Reading level, learning presentation preference and desire for information among cancer patients. J
Cancer Educ 1996;11:32 8.
Johnson J, Meischke H. Womens preferences for cancer
information from specific communication channels. Am Behav Sci 1991;34:74255.
Molleman E, Krabbendam PJ, Annayas AA, Koops HS, Sleijfer DF, Vermey A. The significance of the doctor-patient
relationship in coping with cancer. Soc Sci Med 1984;6:475
80.
Bilodeau BA, Degner LF. Information needs, sources of information and decision-roles in women with breast cancer.
Oncol Nurs Forum 1996;23(4):692 6.
Wiggers JH, Donovan KO, Redman S, Sanson-Fisher RW.
Cancer patient satisfaction with care. Cancer 1990;66(3):
610 6.
Barbarin OA, Chesler MA. Relationships with the medical
staff and aspects of satisfaction with care expressed by parents of children with cancer. J Community Health 1984;9(4):
30213.
Last BF, van Veldhuizen AM. Information about diagnosis
and prognosis related to anxiety and depression in children
aged 8-16 years. Eur J Cancer 1996;32(A):290 4.
Roberts CS, Cox CE, Reintgen DS, Baile WF, Gibertini M.
Influence of physician communication on newly diagnosed

21.
22.

23.

24.

25.

26.
27.
28.

29.

30.

31.
32.
33.

34.

35.

breast patients psychological adjustment and decisionmaking. Cancer 1994;74:336 41.


Butow PN, Kazemi JN, Beney LJ, Griffin LJ, Dunn SM, Tattersall MH. When the diagnosis is cancer: patient communication experiences and preferences. Cancer 1996;77(12):
2630 7.
Ramirez AJ, Graham J, Richards MA, Cull A, Gregory WM,
Leaning MS, et al. Burnout and psychiatric disorder among
cancer clinicians. Br J Cancer 1995;71:12639.
Mayer RJ, Cassel C, Emmanuel E, Schnipper L. Report of the
task force on end of life issues. Presented at Presidential
Symposium, 34th Annual Meeting of the American Society
of Clinical Oncology, Los Angeles, California, May 16 19,
1998.
Kramer P. Doctors discuss how to break bad news. ASCO
Daily News May 17, 1998;1(4):8 9.
Buckman R. Breaking bad news. Why is it still so difficult.
BMJ 1984;288:15979.
Ptacek JT, Eberhardt TL. Breaking bad news. A review of the
literature. JAMA 1996;276(6):496 502.
Frankel RM, Speice J, Branca L, Roter D, Komblith AB,
Holland JC, et al. Oncology providers and patients experiences with communication problems. Proceedings of the
American Society of Clinical Oncology, 1997;16:45a.
Ellershaw JE, Boyd K, Fallon M, Quigley C. Breaking bad
news-the house officers experience. Psychooncology 1995;
4(2):86.
Novack DH, Volk G, Drossman DA, Lipkin M. Medical interviewing and interpersonal skills teaching in US medical
schools. Progress, problems and promise. JAMA 1993;
269(16):21015.
American Society of Clinical Oncology. Training resource
document for curriculum development in medical oncology. J Clin Oncol 1998;16(l):3729.
Lind SE, DelVecchio Good MJ, Seidel S, Csordas T, Good B.
Telling the diagnosis of cancer. J Clin Oncol 1989;7:5839.
Chan A, Woodruff RK. Communicating with patients with
advanced cancer. J Palliat Care 1997;13(3):29 33.
Taylor C. Telling bad news: physicians and the disclosure of
undesirable information. Sociology Health Illness 1988;10(2):
120 32.
Eidinger RN, Schapira DV. Cancer patients insight into their
treatment, prognosis and unconventional therapies. Cancer
1984;53(12):2736 40.
Lerman C, Daly M, Walsh WP, Resch N, Seay J, Barsivick D,
et al. Communication between patients with breast cancer
and healthcare providers. Determinants and implications.
Cancer 1993;72(9):261220.
Maguire P. Barriers to the psychological care of the dying.
BMJ 1985;291:17113.
Ford S, Fallowfield L, Lewis S. Doctor-patient interactions in
oncology. Soc Sci Med 1996;42(11):15119.
Baile WF, Lenzi R, Kudelka AP, Maguire P, Novack D, Goldstein M, et al. Improving physician-patient communication
in cancer care: outcome of a workshop for oncologists. J
Cancer Educ 1997;12:166 73.
Siminoff LA. Cancer patient and physician communication.
Progress and continuing problems. Ann Behav Med 1989;
11(3):108 11.
Fallowfield L, Lipkin M, Hall A. Teaching senior oncologists
communication skills: results from phase I of a comprehensive longitudinal program in the United Kingdom. J Clin
Oncol 1998;16(5):1961 8.

Outcomes of Communication Workshops/Baile et al.


36. Buckman R. Breaking bad news: a six-step protocol. In:
Buckman R, editor. How to break bad news. A guide for
health care professionals. Baltimore: Johns Hopkins University Press, 1992:6597.
37. Espinosa E, Gonzalez Baron M, Zamora P, Ordonez A, Arranz P. Doctors also suffer when giving bad news to patients.
Support Care Cancer 1996;4:613.
38. Drossman D, Retchin S, Jensen E, Fiedler D. Doctor, whats
wrong with me. McClean, VA: American Academy on Physician and Patient, 1993.
39. Maguire P, Booth K, Elliott C, James A. Helping health professionals acquire the interviewing skills. The impact of
workshops. Eur J Cancer 1996;32A(9):1486 9.
40. American Society of Clinical Oncology. Cancer care during
the last phase of life. J Clin Oncol 1998;10(5):1986 96.
41. Bird J, Maguire P, Heavy P. Workshops for consultants on
the teaching of communication skills. Med Educ 1993;27:
1815.
42. Maguire P, Faulkner A. How to do it. Improve the counseling
skills of doctors and nurses in cancer care. BMJ 1988;297:
8479.
43. Schon DA. Educating the reflective practitioner. Towards a
new design for teaching and learning in the profession. San
Francisco: Josey-Bass, 1987.
44. Parle M, Maguire P, Heaven C. The development of a train-

45.
46.

47.

48.

49.
50.

51.

897

ing model to improve health professionals communication


skills, self-efficacy and outcome expectancies when communicating with cancer patients. Soc Sci Med 1997;44:231
40.
Mount B. Dealing with our losses. J Clin Oncol 1986;4(7):
112734.
Poloi LH, Potter S. Behavioral change in preventive medicine. An efficacy assessment of a physician education module. J Gen Intern Med 1996;11(9):5457.
Schwartzberg JG, Guttman R. Effect of training on physician
attitudes and practices in home and community care of the
elderly. Arch Fam Med 1997;6(5):439 44.
Manning PR, Lee PV, Clintworth WA, Denson TA, Oppenheimer PR, Gilman NJ. Changing prescribing practices
through individual continuing education. JAMA 1986;256(2):
230 2.
Garg A, Buckman R, Kason Y. Teaching medical students
how to break news. CMAJ 1997;156(8):1159 64.
Razavi D, Delvaux N. Communication skills and psychological training in oncology. Eur J Cancer 1997;33(Suppl 6):S15
21.
Maguire P, Booth K, Elliot C, Jones B. Helping health professionals involved in cancer care acquire key interviewing
skillsthe impact of workshops. Eur J Cancer 1996;
32A:1486 9.