Teaching communication skills for difficult conversations-Annabelle Rae C. Norwood, MD MMP Geriatrics

As professionals working in the medical field, we are often tasked with difficult conversations of delivering bad news, disclosing medical error, or initiating advance care planning and end-of-life discussions with patients and their families. More often than not, skills needed to effectively communicate with patients about these difficult topics are not developed fully during medical training.  As such, the Accreditation Council for Graduate Medical Education now requires competency in communication skills for residents and fellows.1 There are different methods available in order to hone these skills.

Tip 1: Use of case-based learning, didactics and video clips

Perhaps not as effective as other methods discussed in this article, these can be easily incorporated into routine department conferences. These can also be useful when you have a large audience. These methods can serve as a foundation for the other methods discussed below. Concepts such as the Ask-Tell-Ask model,2 the SPIKES (Setting, Perception, Invitation, Knowledge, Empathy, and Summary) mnemonic, a tool to present distressing information in an organized fashion,3 and the NURSE (Name the emotion, Understand the emotion, show Respect, Support and Explore) acronym, which is a method on how to respond to patient’s emotions with empathy4 can be discussed in these settings. Video clips can also be helpful in illustrating on how to set the stage for a family meeting, or what not to do when disclosing bad news.

Tip 2: Use of role-playing or sociodrama

These can portray social situations than merely describe them as in case-based discussions.  These can be a tool for learners to develop empathic understanding of a person’s point of view.5 Group size is a practical consideration. A small group of 4-8 learners, with a single role-play with a faculty facilitator can be successful as most or all of the learners can take an active role at some point. In a larger group, learners can pair up in a dyad or triad and practice simultaneously.6

Tip 3: Simulation-based learning and the use of standardized patients

These methods can ensure a consistent teaching approach and allow immediate feedback to the learner from the standardized patient and observing faculty. However, these methods may also entail a lot time for development of patient scenarios, and resources to train standardized patients. The Hannaford Center for Safety, Innovation & Simulation at the Brighton Campus is an excellent resource for this.7

Tip 4: Go to specialized workshops and training programs

The Oncotalk, a communication skills program developed for medical oncology fellows8 has been replicated and applied to other specialties giving rise to other iterations such as the Geritalk,9 NephroTalk,10 and CardioTalk11 to name a few. These are all mainly targeted towards fellows, but medical students, residents, attendings, advance practice professionals and nurses have also ben audiences in these workshops. These half- to multi-day retreats can be highly effective in developing communication skills as these studies have demonstrated. However, these can also be time-consuming and difficult to integrate into clinical training.

Tip 5: Give communication skills training in the “real world”

Clinical rotations are an underutilized venue for directly observed practice and feedback.12,13  Learners can be first an active observer during clinical encounters or family meetings. Later, the learner can play a more active minor role, such as giving an update about the clinical course using clear and concise terms, while a more senior person leads discussion about treatment options or goals of care discussions. In time, learners may also lead the entire discussion as well, with the faculty providing some support. Debriefing is an important component during these teaching sessions and should be done with the learner as soon as possible after the encounter. Specific feedback focusing on communication skills, not style, is key for the learner to reinforce good communication skills, and identify those that can be improved upon.13

Tip 6: Allot time for communication skills training

Whether it is allocating an hour a month during your weekly formal didactic sessions in your department, or having your learners attend a communication skills workshop, it is important in making sure that your trainees gain the skills they need to be “out in the real world”. Time may also need to be allotted for faculty development in this area.

  1. Accreditation Council for Graduate Medical Education [Internet]. [cited 2018 Jul 15];Available from: http://www.acgme.org/
  2. Back AL, Arnold RM TJ. Mastering Communication with Seriously Ill Patients: Balancing Honesty with Empathy and Hope. New York, NY: Cambridge University Press; 2009.
  3. Baile WF. SPIKES–A Six-Step Protocol for Delivering Bad News: Application to the Patient with Cancer. Oncologist 2000;5(4):302–11.
  4. Back AL, Arnold RM, Baile WF, Tulsky JA, Fryer-Edwards K. Approaching Difficult Communication Tasks in Oncology. CA Cancer J Clin 2005;55(3):164–77.
  5. Baile WF, Walters R. Applying sociodramatic methods in teaching transition to palliative care. J Pain Symptom Manage 2013;45(3):606–19.
  6. Jackson VA, Back AL. Teaching Communication Skills Using Role-Play: An Experience-Based Guide for Educators. J Palliat Med 2011;14(6):775–80.
  7. Hannaford Center for Safety, Innovation & Simulation [Internet]. [cited 2018 Jul 15];Available from: https://mainehealth.org/maine-medical-center/education-research/students-residents-fellows/hannaford-center-safety-innovation-simulation
  8. Back AL, Arnold RM, Tulsky JA, Baile WF, Fryer-Edwards KA. Teaching communication skills to medical oncology fellows. J. Clin. Oncol. 2003;21(12):2433–6.
  9. Kelley AS, Back AL, Arnold RM, et al. Geritalk: Communication skills training for geriatric and palliative medicine fellows. J Am Geriatr Soc 2012;60(2):332–7.
  10. Schell JO, Green JA, Tulsky JA, Arnold RM. Communication skills training for dialysis decision-making and end-of-life care in nephrology. Clin J Am Soc Nephrol 2013;8(4):675–80.
  11. Berlacher K, Arnold RM, Reitschuler-Cross E, Teuteberg J, Teuteberg W. The Impact of Communication Skills Training on Cardiology Fellows’ and Attending Physicians’ Perceived Comfort with Difficult Conversations. J Palliat Med 2017;20(7):767–9.
  12. Janicik R, Kalet AL, Schwartz MD, Zabar S, Lipkin M. Using Bedside Rounds to Teach Communication Skills in the Internal Medicine Clerkship. Med Educ Online 2007;12(1):4458.
  13. Hinkle LJ, Fettig LP, Carlos WG, Bosslet G. Twelve tips for just in time teaching of communication skills for difficult conversations in the clinical setting. Med Teach 2017;39(9):920–5.