Tough Talk

Some people at the University of Washington and colleagues from around the country run a wonderful website called Tough Talk: Helping Doctors Approach Difficult Conversations. They call it a “toolbox for medical educators” who want to teach about ethics and communication. Topics include:

Common teaching challenges plus tips for recovering from them • Optimizing small group dynamics • Providing effective, honest feedback • Helping clinicians develop and operationalize personal learning goals • Motivating engagement and self-assessment in reluctant participants

Look at this statement of philosophy:

Many argue that ethics and communication cannot be taught. Since these skills lie in the realm of the interpersonal, they do build on skills and practices we begin developing from our earliest interactions. However, evidence shows that practice and experience can lead to development and enhancement of these skills. This human element is where the moral work of medicine happens. We have a responsibility to attend to these skills and work to develop them, even as we strive to perfect our other core clinical skills. Quality patient care depends on it.

Teaching future medical professionals is a gift. When we interact with students, residents, fellows, or colleagues, we have many opportunities to learn and grow ourselves, in addition to promoting growth in others. We have approached this work of teaching by thinking about it as a service. We are not there to impart knowledge or impress others. We are there, working with learners, because we are genuinely interested in helping them become better doctors. Ultimately, attending to the interests of physicians-in-training will promote better patient care.

This is a nice exception from the findings made by Linda Pololi in her book about the often dehumanizing relationships among faculty in medical schools.

I was curious about how it all got started and how well it is being accepted. Here’s the note I received from Kelly Edwards at UW when I asked those questions:

This project started as “Oncotalk” which has a linked site to “Tough Talk”, an NCI-funded program to help prepare oncology fellows for difficult conversations with seriously ill patients. We ran two retreats a year, reaching 20 fellows each time, for four years and touched many of the training programs across the country through this program. We then received a five year grant to support a ‘train-the-trainer’ course to teach Oncology faculty to integrate more communication skills teaching into their clinical teaching of fellows. We have had one 20 person cohort per year for four years, and our last session is coming up in April.

Tough Talk was funded by the Greenwall Foundation and allowed us early on to study our process approach to teaching communication skills and post some teaching materials to share online. I know that our programs have impacted many practicing oncologists – and many patients in return – but we do not have specific data about the public websites that support these courses to know how many additional people find these resources.

Oncotalk was profiled in the New York Times about 5 years ago. And we have several published papers in the academic literature about our program, teaching model, and communication skills. I’d be glad to share any of these papers if you are interested.

We get emails from participants on nearly a weekly basis about how their clinical practice has been impacted by our programs. As one small sign of support, 50% of the Oncotalk alums wrote letters of support for our train-the-trainer course grant. To us, that was very moving, given how busy these oncologists are!

Other faculty-investigators involved with this program are: Tony Back (oncologist at UW, Seattle – Principle Investigator), Robert Arnold (Palliative Care physician, Pittsburgh), James Tulsky (Palliative care physician, Duke), and Walter Baile (Psychiatrist at MD Anderson). They are truly leaders in the field!

Paul Levy is the former President and CEO of Beth Israel Deconess Medical Center in Boston. For the past five years he blogged about his experiences in an online journal, Running a Hospital. He now writes as an advocate for patient-centered care, eliminating preventable harm, transparency of clinical outcomes, and front-line driven process improvement at Not Running a Hospital.

6 replies »

  1. > Many argue that ethics and communication cannot be taught

    Many? Who are they? The whole Western Tradition says they CAN be taught, since Aristotle at least. In point of fact, communication and ethics can ONLY be taught, and people get better at both through practice.

    And take it from someone who has first-hand experience with looking after a relative with dementia: you can’t pay people enough to do it as well as you can. It is true that she has dementia because she lived long enough to get it, and it was absolutely technology (primarily metoprolol and spironolactone and budesonide and various antibiotics) that enabled it. I’m not sure I want to forgo these things though. We don’t know what’s going to kill her, but so far it hasn’t been CHF or a stroke.

    Back in the day before greed became good the family was the first place people looked for care because only a family can care so well. It is silly for us to expect to pay someone else to do the normal, human things we should be doing ourselves — this is not a normal state of affairs: we can’t all be “autocrats” with servants cleaning up after us. I am very glad to have the help of an adult daycare and the staff is caring and competent in a “professional” sense, but there is absolutely no substitute for actual caring.

    Besides, we all know the joke: be careful how you treat your kids — they’ll be the ones choosing your nursing home. If you treat them well enough, maybe your nursing home will be their home. That’s what’s normal, and normally best. PPCA won’t change that — it simply can’t. It’ll probably make things worse by creating the illusion that family life is superfluous to humanity.

  2. “And, for those commenters who think I am the same commenter preceeding this one, take heart I know you are not demented. Just delusional!'”

    Get over it. I have. It was a legit question. It’s been resolved.

  3. “Many argue that ethics and communication cannot be taught. Since these skills lie in the realm of the interpersonal, they do build on skills and practices we begin developing from our earliest interactions.”

    i agree with you…

  4. Tough Talk? How about that people live too long, that technology does not enhance longer life spans but more often prolongs them when the quality of life is not what the individual with disease really will tolerate for years.

    Take CNN’s story today about the impact Alzheimers has on caregivers. Sorry I did not link it, but just go to cnn.com and go down to the bottom third of the home page to the Health section and you’ll find the story. While statistics show illnesses like heart disease and prostate cancer have alleged dropped between 2000-08, Alzheimers’ diagnoses have increase “a staggering 66%” in that same time frame.

    And the story seems to say just put these individuals in nursing homes when they become unmanageable for those at home with them. If only it was that simple and appropriate.

    Just ask yourselves under the age of 60: do you want to spend your last months to years lanquishing in a nursing home, away from your own personal space of your home, having your significant other ‘visit’ you daily, if that? Really, ask yourself that now when you are fully competent and cognizant to consider that scenario. How many will say “sure” so quickly and willingly? And if you do, maybe you are becoming demented already.

    Because what sane and rational person would easily agree to such a scenario. And yet, you think PPACA will pay for these services indefinitely? Again, if you think yes, I truly doubt your competency to answer this question reliably.

    Now there, you have some tough talk!!!

    And, for those commenters who think I am the same commenter preceeding this one, take heart I know you are not demented. Just delusional!

  5. Ethics: Managing the truth among competing interests who do not see the situation the same way.

    Duty: Honor your patient and the truth.

    Honor: A noun and a verb; respect it.

    Truth: Accept no substitutes. People can have their own opinions, but not their own facts.

    It can be taught. Best taught by example.