“Mrs. S, has anyone discussed moving toward comfort measures?”
I can still remember the question leaving my lips, followed by the look of surprise and discomfort on Mrs. S’s face. I was a first-year fellow caring for her husband, Mr. S, a dialysis patient whom I had admitted numerous times that year. This time he had been brought unresponsive into the emergency room, and he had been lying in bed for a week, receiving pressors and ventilator support but with no signs of neurologic recovery. As I sat with Mrs. S I felt helpless. How could I begin to explain to this devastated wife that her husband was dying?
I imagine I am not alone when I share these sentiments. As a third-year nephrology fellow at Duke University, I have frequently joined in many cafeteria lunch conversations with other nephrology fellows, discussing difficult situations similar to this one. Although many of us feel equipped to treat patients with advanced kidney disease, we often lack skills in delivering bad news.
We care for a sick, complex patient population. These patients are often burdened with numerous comorbidities, which affect their experience of illness, quality of life, and functional status. When approaching the care of these patients, we face difficult conversations that range from diagnosis to treatment options to end-of-life decisions. Although prognostic tools can assist nephrologists in predicting patients who are at risk for poor outcomes, effective communication of this message remains a challenge. The quality of a physician’s communication affects how patients respond to their illness and plan for the future.
Good communication is often seen as a bonus to the care we provide. However, communication is fundamental to the care we deliver. Good communication includes a set of learned skills that can be polished with practice. It includes the ability to recognize and respond to a patient’s concerns and need for information, along with the physician’s ability to recognize and attend to these concerns and needs in a way that is both therapeutic and supportive. Furthermore, it involves the delivery of sensitive information, balancing reality while maintaining hope.
Recognizing the need for communication education, the Duke Nephrology Division has developed a communication workshop specifically designed for nephrology fellows. This annual workshop has been led by Dr. James Tulsky, an experienced communication expert, director of the Duke Center for Palliative Care and coinvestigator in OncoTalk, a national oncology communication workshop funded by the National Institutes of Health. OncoTalk is dedicated to teaching oncology fellows how to communicate effectively with seriously ill patients, and it has expanded to include OncoTalk Teach, which teaches oncology faculty the skills for teaching communication to oncology fellows.
The Duke Nephrology Communication Workshop (NephroTalk) applies the OncoTalk communication skills training to clinical scenarios commonly encountered in nephrology. The workshop begins with a didactic session, which is followed by a role-play opportunity with scripted case scenarios using simulated patients. These cases are specifically written to represent scenarios frequently experienced by nephrology fellows.
The fellows surveyed thought that the workshop was helpful and relevant to their work. Most importantly, all fellows surveyed agreed that the workshop will change the way they practice. One fellow stated, “These techniques are a good foundation of tools, but one’s effectiveness in this can only come with experience and practice. I think I’ll try using many of the techniques we talked about and eventually learn which ones work best for me.” Regarding specific techniques taught, one fellow wrote, “The ‘Ask-Tell-Ask’ approach was particularly helpful in thinking about how to broach these discussions as well.”
Fellowship training is an intense time, full of learning opportunities. Reflecting on my own experience with Mrs. S, I wish I had been equipped with the communication skills necessary to attend to her emotional needs and, moving forward, to assist with care planning goals for her husband. Echoing the words of one Duke fellow workshop participant, a communication workshop “should be part of every nephrology training program.” With that goal in mind, the next step is to implement formal communication skill training nationally in fellowship programs and annual meetings.