{"id":5459,"date":"2019-04-08T12:54:39","date_gmt":"2019-04-08T16:54:39","guid":{"rendered":"http:\/\/www.silvercentury.org\/?p=5459"},"modified":"2019-04-08T12:55:22","modified_gmt":"2019-04-08T16:55:22","slug":"medical-students-learn-how-to-talk-to-patients-about-dying","status":"publish","type":"post","link":"http:\/\/78.142.243.82\/~silvercentury\/2019\/04\/medical-students-learn-how-to-talk-to-patients-about-dying\/","title":{"rendered":"Medical Students Learn How to Talk to Patients about Dying"},"content":{"rendered":"

Doctors are usually taught very little about how to deliver bad news to patients and their families, so they often do it badly. JoNel Aleccia describes how one medical school is changing that. She wrote her article for <\/span><\/i>Kaiser Health News<\/span><\/a> (KHN), <\/span>where she\u2019s a senior correspondent<\/span><\/i>, <\/span>focusing on aging and end-of-life issues. <\/span><\/i>KHN<\/span> posted her article on March 13, 2018. It also ran in <\/span><\/i>U.S. News & World Report<\/span>.<\/span><\/i><\/p>\n

The distraught wife paced the exam room, anxious for someone to come and tell her about her husband. She\u2019d brought him to the emergency department that afternoon when he complained about chest discomfort.<\/span><\/p>\n

Sophia Hayes, 27, a fourth-year medical student at the Oregon Health & Science University (OHSU), entered with a quiet knock, took a seat and asked the wife to sit too.<\/span><\/p>\n

Softly and slowly, Hayes explained the unthinkable: the woman\u2019s husband had had a heart attack. His heart stopped. The intensive care team spent 45 minutes trying to save him.<\/span><\/p>\n

Then Hayes delivered the news dreaded by doctors and family members alike.<\/span><\/p>\n

\u201cI\u2019m so, so sorry,\u201d she said. \u201cBut he died.\u201d<\/span><\/p>\n

The drama, played out on a recent Friday afternoon, was a scene staffed by actors and recorded by cameras, part of a nerve-wracking exam for Hayes and 143 other would-be doctors. OHSU officials say they\u2019re the first medical students in the United States required to pass a tough, new test in compassionate communication.<\/span><\/p>\n

By graduation this spring, Hayes and her colleagues must be able to show that, in addition to clinical skills, they know how to admit a medical mistake, deliver a death notice and communicate effectively about other emotionally and ethically fraught issues.<\/span><\/p>\n

It\u2019s a push started in the last two years by Susan Tolle, MD, director of the OHSU Center for Ethics in Health Care, who wants to improve the way doctors talk to patients, especially in times of crisis.<\/span><\/p>\n

How Doctors Go Wrong<\/b><\/p>\n

Tolle has seen doctors who don\u2019t make eye contact, those who spout medical jargon and still others who appear to lack basic compassion for patients and their families.<\/span><\/p>\n

\u201cThey\u2019ll stand in the doorway and say something like, \u2018You need to call a funeral home,\u2019\u201d Tolle said.<\/span><\/p>\n

Part of the problem is that, in the past, aspiring doctors were taught too little, too late about difficult communication and its nuances, said Tolle.<\/span><\/p>\n

\u201cMy generation of faculty were not taught,\u201d she said. \u201cI had history-taking, but it was more about, \u2018How long have you had chest pain?\u2019 I did not have [instruction in] how to give bad news.\u201d<\/span><\/p>\n

Bad news, badly delivered, can have far-reaching effects on family.<\/b><\/p><\/blockquote>\n

At Tolle\u2019s urging, the OHSU officials revamped the medical school curriculum to include new lessons in\u2014and standards for\u2014communication, ethics and professionalism woven through the course work, said Dr. George Mejicano, the senior associate dean for education.<\/span><\/p>\n

\u201cMost of the emphasis has been on the simplest aspects of communication,\u201d he said. \u201cThe whole idea here is, how do you tell someone they have a life-threatening or even a fatal illness? How do you tell someone, \u2018I\u2019ve actually made a mistake?\u2019\u201d<\/span><\/p>\n

OHSU isn\u2019t the only center to focus on communication. All medical schools and residency programs in the United States are required to include specific instruction in communication skills to gain accreditation, according to Lisa Howley, senior director of strategic initiatives and partnerships for the Association of American Medical Colleges, or AAMC. Residents are required to prove competency in order to graduate from training and be eligible for board certification for individual practice. And there\u2019s been a <\/span>larger effort nationwide<\/span><\/a> to help practicing doctors learn to talk to patients about dying.<\/span><\/p>\n

But Mark Siegler, MD, director of the <\/span>MacLean Center for Clinical Medical Ethics<\/span><\/a> at the University of Chicago, who closely follows communication issues, said he believes OHSU\u2019s approach is new.<\/span><\/p>\n

\u201cSo far as I know, there is no other school in the United States that has any such standard,\u201d said Siegler. \u201cNo other program has both a teaching effort and an evaluation effort.\u201d<\/span><\/p>\n

What Happens When Students Fail<\/b><\/p>\n

Hayes, the OHSU medical student, said she and her fellow students were nervous before the recent exam. But the practice with \u201cstandardized patients\u201d\u2014actors trained to portray people undergoing medical care\u2014was crucial to understanding the right way to talk to families in a real-world situation.<\/span><\/p>\n

\u201cYou realize you have this horrible information they don\u2019t have yet,\u201d she said.<\/span><\/p>\n

Hayes did quite well and passed the test, Tolle said. So did most of the other OHSU medical students. But several\u2014she wouldn\u2019t say exactly how many\u2014will need remedial coaching and testing before graduation.<\/span><\/p>\n

Some of those students failed to introduce themselves properly or to find out what the family member had already been told, Tolle said. Instead, they bluntly announced they had bad news and quickly added that the patient was dead.<\/span><\/p>\n

\u201cYou watched the screen and it looked like you hit [the spouse] with a truck,\u201d Tolle said. \u201cIt comes across as incredibly uncaring.\u201d<\/span><\/p>\n

Med school faculty will also be offered a chance to learn how to communicate compassionately. <\/b><\/p><\/blockquote>\n

In real life, such botched conversations can have far-reaching effects. Mary George-Whittle was just 24 when her father had emergency, open-heart surgery in 1979. When the surgeon emerged from the operating room to face the family, his message was jarring.<\/span><\/p>\n

\u201cHe blurted out that Dad had died, that he had too little to work with, that Dad\u2019s veins were like working with the veins of a turkey,\u201d recalled George-Whittle, now 63 and retired after a career as a chaplain in Oregon. \u201cHe told us he had Dad\u2019s blood all over him.\u201d<\/span><\/p>\n

Nearly 40 years later, she and her 11 siblings can still remember the shock.<\/span><\/p>\n

\u201cThe impact that that still has is like PTSD,\u201d she said. \u201cThe experience gets caught up in how poorly the news was given.\u201d<\/span><\/p>\n

Changing the Medical Culture<\/b><\/p>\n

This year\u2019s test is a first step, Tolle said. It will be reviewed and refined for future classes. Students who need help will get it. At the same time, OHSU faculty will be offered sessions to help improve their communication skills so they can model what students are taught.<\/span><\/p>\n

The long-term goal is to raise the bar across the profession, said Tolle, who\u2019s had some practice shifting paradigms. She\u2019s the co-creator of the <\/span>Physician Orders for Life-Sustaining Treatment<\/span><\/a>, known as POLST, a document credited with revolutionizing end-of-life instructions across the United States.<\/span><\/p>\n

In the same way, Tolle said, the culture of communication among doctors can change too, starting with the latest generation.<\/span><\/p>\n

\u201cOur biggest goal is not to do a kind of \u2018gotcha\u2019 thing for the current medical students,\u201d she said. \u201cIt\u2019s to find where the pieces are missing.\u201d<\/span><\/p>\n

KHN\u2019s coverage of these topics is supported by <\/span><\/i>Gordon and Betty Moore Foundation<\/span><\/i><\/a> and <\/span><\/i>John A. Hartford Foundation<\/span><\/i><\/a>.<\/span><\/i><\/p>\n","protected":false},"excerpt":{"rendered":"

The distraught wife paced the exam room, anxious for someone to come and tell her about her husband. She\u2019d brought him to the emergency department that afternoon when he complained about chest discomfort.<\/span><\/p>\n

Read more Medical Students Learn How to Talk to Patients about Dying<\/span> ›<\/span><\/a><\/div>\n

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