Download Dr. Keller`s Presentation - MD Anderson Cancer Center

How can communication skills training
ameliorate burnout and promote satisfaction at work?
Monika Keller, MD, PhD
Dept of General Internal Medicine &
Psychosomatics
University Hospital Heidelberg
Burnout among cancer clinicians – what is known so far?
Burnout is frequently observed among cancer clinicians:
‐ 20 – 50% high levels of emotional exhaustion (MBI) found in surveys from US, CAN, UK, Australia ‐ Burnout found to increase over time among UK cancer clinicians
‐ Oncologists‘ burnout levels equal to or lower than other specialties‘ (CH)
Burnout among cancer clinicians best
predicted by:
‐
‐
‐
High clinical workload with patient
contact
Insufficient institutional support
Perceived need for communication
skills training
Shanafelt et al. 2014/15
Ramirez et al. 1995
Taylor at al. 2005
Grunfeld et al. 2000
Girgis et al. 2009
Burnout among cancer clinicians – what is known so far?
Consequences of professional Burnout :
‐ Quality of patient care 
(medical errors, terminal sedation )
‐




Impact on Clinician
Satisfaction at work 
Risk of psych morbidity 
substance abuse, suicide, absenteism
stress‐related health problems
leaving oncology (early)
Shanafelt et al. 2014/15
Berman et al. 2007
Taylor at al. 2005
Grunfeld et al. 2000
Girgis et al. 2009
Professional Burnout as conceptualised & assessed with
Maslach Burnout Inventory (MBI)
Emotional Exhaustion EE
Depersonalisation* DP
Burnout ‐
Personal accomplishment PA
* ‚Treating patient like an object‘
What specific aspects contribute to burnout in Oncology/ Palliative Medicine? What cancer clinicians perceive as demanding & often stressful: Findings from qualitative research
 Breaking bad news to patients/family
 Discussing failure of anticancer therapy
 Applying highly toxic treatments to patients
 Grief over loss of patients
 Sense of helplessness, guilt, failure, sorrow
Pronounced by a ‚culture of invulnerability‘ in institutions ‚doctors don‘t talk to each other‘
‚You are not really expected to be affected by‘
‚They see it as psychological
weakness‘
Brown et al. 2009
Shaw et al. 2012
Friedrichsen 2006
Granek et al. 2012
What specific aspects may contribute to burnout in Oncology / Palliative Medicine? Cancer clinicians‘ perspective: What communication issues are most difficult?
Talking about...
Ending cancer‐directed treatment, transition to palliative care
End‐of‐life issues
Cancer recurrence
44%
23%
21%
ASCO 1998 Survey: 500 oncologists
Baile, Buckman et al. 2000
What specific aspects may contribute to burnout in Oncology / Palliative Medicine? Cancer clinicians‘ perspective: ‚what communication task do you find most difficult?‘
 Balancing honesty with hope
55%
 Responding to pat‘s emotions adequately
29%
ASCO 1998 Survey: 500 oncologists
Baile et al. 2000
Shaw et al. 2012
Friedrichsen 2006
Cancer clinicians‘ perspective: What communication
tasks are perceived most difficult?
KoMPASS participants 2008‐2011: 345 cancer physicians‘ initial accounts
highly
difficult
Mean
Score*
 Ending cancer‐directed treatment +
transitioning to pall care
76 %
5.5
 Treatment failure
75 % 5.3  Cancer recurrence
70 %
5.3
 Pat requests for hastened death
70%
5.1
 Poor prognosis Ca diag
66%
5.0
 Good prognosis Ca diag
8 %
2.4
Talking to patient about...
* ‚Perceived difficulty‘ re 20 communication tasks; range 1 to 7
‚High difficulty‘ val 5 ‐7
‚A recipe for burnout‘: strong negative feelings when sharing bad news about a poor prognosis with patients
Cancer clinicians are dealing with their own strong emotions when disclosing prognostic information to patients with advanced cancer Strong negative feelings
 Sadness, pain, guilt, heartbreak, stress....
50 %
729 medical oncologists‘ answer to mailed survey (2006)
Wallace et al. 2006
Baile WF 2015
‚A recipe for burnout‘: strong negative feelings when sharing bad news about a poor prognosis with patients
Cancer clinicians‘ reports how they tend to deny or avoid own strong emotions
 During encounters, concentrate on ‐ reducing own discomfort, ‐ less on the task and the patient (prevents empathy)
 Avoid uncomfortable encounters (visit length)
 Conceal or ‚cushion‘ bad news
Clinicians‘ coping efforts strive for self‐preservation against feeling helpless and being out of control, so they don‘t get emotionally attached ‐> risk of detachment and ‚Depersonalisation‘
Baile WF 2015
Morgans & Schapira 2015
Shaw et al.2012, 2013
Stiefel et al. 2008
A recipe how communication can ameliorate or prevent
burnout?
‐ Becoming aware of ...
‐ Being mindful of ...
one‘s own strong emotions
‐ through non‐judgmental observation
‐ through feedback and sharing with others
‐ experiencing relief & ‚self‐efficacy‘ with alternative interactions with patients vs fear of losing control
‐ ......
Burnout among clinicians – impact of interventions
Educational Program in Mindful Communication With Burnout,
Empathy, and Attitudes Among Primary Care Physicians
Krasner, Epstein et al. 2012 – USA
N = 70 Prim care physicians attended mindfulness communication training 45 h over 12 months. Eval after 2, 12, 15 months Burnout (MBI) improved on each subscale
Participation in a mindful communication program was associated with short‐term and sustained improvements in well‐being and attitudes
Burnout among cancer clinicians – impact of interventions
Intensive Communication Skills Teaching (CST) for Specialist Training in Palliative Medicine (PM)
Clayton J et al. 2012 Australia
N = 41 PM specialists/trainees attended 3‐day CST (Oncotalk model)with small group experiential learning & defined scenarios with simulated patients; 3 months post course, self‐assessed confidence in CS increased; Burnout (MBI) no sig changes observed Efficacy of a Communication & Stress Management Training on Medical Residents‘ Self‐Efficay, Stress to Communicate and Burnout‐ RCT Bragard J et al. 2010 Belgium
30‐hour communication and 10‐hour stress management skills training in small groups. Intervention group N = 49 medical residents. Significant increase in self‐efficacy and decrease in stress to communicate compared with controls
Burnout (MBI) no changes, no difference between groups observed
Burnout among cancer clinicians – impact of interventions
Effect of a 1‐day interventional workshop on recovery from job stress for radiation therapists and oncology nurses
Poulsen AA et al 2015, Australia
Improved recovery skills, satisfaction with self‐care practices and perceived sleep quality. “This intervention has the potential to enhance resilience and prevent burnout ..in a cancer worker's career”
Reply A Girgis: “One size doesn’t fit all”
“Good communication in cancer is tough business, not for the fainthearted…” (SM Dunn, 2010)
Physicians involved in the care of cancer patients and their
relatives are facing numerous challenging encounters, on a daily basis where they have to deal with:






conveying ‚bad news‘ of all kinds
building supportive patient‐centered relationships
relieving patients‘ physical and mental suffering
recognizing and transforming crises reactions
managing own emotional involvement
striving for a balance between committed professionalism and personal integrity and well‐being
How can comm skills training ameliorate
burnout among cancer clinicians ? KoMPASS project
Communication skills training program that aims
To enhance patient‐centered communication in cancer care
To foster supportive relationships between cancer patients/family and physicians involved in their care
To promote cancer physicians‘ satisfaction at work and
ameliorate/prevent burnout
Aim of KoMPASS training courses
Developing a training program that…
 Is relevant to physicians‘ practice
 Addresses and builds on their particular goals and needs
 Acknowledges their expertise & competence
 Provides protective, secure space  Facilitates experiential learning
 Ensures transfer to physicians‘ clinical practice
KoMPASS – methods  Relevant to cancer physicians from any seniority and oncology specialty
 Intense 2 ½ days (20 hours) workshop
½ day refresher 4 months later
 Small groups (8 to 12 participants) 2 experienced clinician trainers; familiar with real life (psycho‐) oncology; trained psychotherapists
 Emphasis on experiential learning, less on ‚teaching‘
 Learner‐centered approach: ensure each
KoMPASS training workshops initially conducted at
8 academic sites
participant practices with her/his individual issue (CIR)
KoMPASS – methods I
Learner‐centered approach
 Workshop agenda created jointly upon participants‘ needs & interest
 Critical incident reporting (CIR): each participant reports a case vignette of a challenging encounter with a patient/relative from his/her practice. These are shared with the group  Scenarios for role plays are created from physicians‘ case vignettes
Role play with trained professional patient actors (vs standardized patients)
 Able to take on difficult patient/relative roles
 Flexible: Immediate jump‐in; time‐out, variation, re‐play
 Authentic feedback from patient‘s perspective, responsive to physician‘s alternative interactions KoMPASS – methods II
Some structured cognitive input –
interactive discussions with ppt handouts
 Basic recommendations for patient‐centered communication
 Patients in crises – understanding pat‘s experience & opportunities how physicians can provide support
 Conveying bad news – how the SPIKES model can assist
 Dealing with strong – patients‘ and physicians‘ ‐ emotions  End of life issues KoMPASS – methods
Videotaped scripted encounter with patient‐actor
(Scenario: treatment failure under palliative chemo for advanced gastric cancer)
Videos viewed in small groups ‐> teaching opportunities
KoMPASS – methods III
 Small‐group role play, structured feedback & reflection
 Varying role play techniques
‐e.g. change of perspective through role reversal
 Encouraging feedback & enactment to jointly explore communication solutions adequate to the individual patient/family –physician relationship
 Facilitator moderates, observing the process while leaving activity with the group. Recognizes participants‘
emotional condition. Uses ‚teaching points‘
for suggesting communication ‚skills‘ as appropriate. Encourages non‐judgemental reflection and, sometimes,
‚take‐home‐message‘
KoMPASS
– experience
KoMPASS –
experience
Experience of interacting with patient‐actor in role play
 ‚Unexpectedly realistic scenario‘ – helps overcoming initial timidity towards role plays
 Opportunity to receive credible personal feedback ‐
 No risk of hurting/blaming the patient
 Sense of relief & achievement upon patient‘s response
to alternative intervention (skill, behavior)

Physician experiences beneficial impact on patient /relationship ‐> experience of self‐efficacy
Limitations ‐> additional methods required (Socio‐/Psychodrama – work in process guided by Dr. Baile)
KoMPASS – experience
Group experience
Feedback from colleagues & facilitator – mutual learning experience
Allows to integrate self‐perception with how one is perceived by others ‐> self‐reflective stance and confirmation
Group cohesion, shared achievement & mutual support – against sense of isolation
KoMPASS – participants‘ feedback
‐ at refresher 4 months later
Transfer into clinical practice?
 „dealing with difficult encounters has become much easier“
 „I reach the patient easier and within less time (!!)“
 „I put myself less under pressure to do something, I leave more space to the patient“
 „I feel less miserable when I have to convey those bad, mean things (bad news) to the patient“
Four months ago, I weren‘t able to have such a conversation.. The mountain has become accessible...
Studienzentrum
Universität Heidelberg
KoMPASS – participants‘ feedback
4 months later
Self‐efficacy?
 „...it‘s good for this patient that I‘m taking care of him“
(longtime not aware of..)
„I found out again that and why this is my profession“
„I was able to face the greatest challenge during 10 years being an oncologist – medical error ‐> ‚take on responsibility, not guilt‘, maintained patient‘s trust“
Studienzentrum
Universität Heidelberg
Is KoMPASS communication training ‚effective‘ ?
How to assess ?  Physicians‘ perspective:  evaluation of training and methods
 Physician‐rated self efficacy, work‐related stress and ‚burnout‘
 ‚Experts‘ perspective
 ‚Objective‘ pre‐4 mo post rating of physicians‘ interaction according to validated classification system (RIAS) of video‐documented standardized scenario KoMPASS – Controlled non-randomized design
2,5 day
Kompass
training
T1
4 months
participants
Self-assessment
 Self-efficacy
 ‚Empathy‘
 work stress/
burnout
Controls - non participants
0,5 day
refresher
T2
Self-assessment
 Self-efficacy
 ‚Empathy‘
 work stress/
burnout
KoMPASS – Measures Physicians‘ rating
 ‚Self-efficacy‘- confidence & difficulty
→ 20 Items addressing characteristic communication
tasks in cancer care (expanded from previous work)
 ‚Maslach Burnout Inventory (MBI-D)’ (Maslach & Jackson, 1981)
→ work – related stress & satisfaction (‚burnout‘)
 ‚Jefferson Scale of Physician Empathy’ (Hojat et al., 2004)
→ self-assessed patient-centered attitude
Studienzentrum
Universität Heidelberg
Effect of communication training on ca physicians’
‘self-efficacy’ = confidence in ca-specific communication tasks
Participating physicians
Control physicians
Pre
4 mo post
ES (d)
N
M (SD)
M (SD)
Self‐efficacy
262
4.14 (0.92)
4.69 (0.88)
0.61
‐ Females
170
4.01 (0.92)
4.61 (0.88)
‐ Males
92
4.37 (0.88)
> 10
141
6–9
<5
N
Pre
4 mo post
M (SD)
M (SD)
181
5.08 (0.91)
5.06 (0.97)
0.66
104
4.96 (0.98)
4.89 (1.02)
4.83 (0.88)
0.52
77
5.25 (0.80)
5.28 (0.88)
4.35 (0.91)
4.81 (0.88)
0.52
122
5.28 (0.88)
5.24 (0.92)
51
4.09 (0.81)
4.66 (0.84)
0.70
29
4.81 (1.0)
4.93 (1.04)
70
3.73 (0.89)
4.47 (0.89)
0.84
30
4.57 (0.68)
4.43 (0.87)
‐ Medical practice (years)
The adjusted mean difference between groups confirms a significant group x time effect: ANCOVA M_diff = 0.23, [0.06; 0.40]; P‐value = .010
Effect of CST on ca physicians’
‘self‐efficacy’
= confidence in ca‐specific communication tasks 4 months following the training, participants report higher ‚self‐efficacy‘ when dealing with
challenging communication tasks whereas control physicians‘
‚self‐efficacy‘ has not changed
‐> Closer look into details ......
Self‐efficacy to communicate: perceived improvements of initial ‚most difficult‘ tasks?
262 training participants before and 4 months after CST
highly
confident*
T0
highly
confident
T1
 Ending cancer‐directed treatment +
transitioning to pall care
32 %
47%
 Treatment failure
35 % 53%
 Cancer recurrence
37 %
60%
 Pat requests to hasten death
38%
53%
 Poor prognosis Ca diag
34%
60%
 Providing sufficient emotional support
45 %
69%
Discussing with patient about...
* ‚High confidence‘ val 5 ‐7 (range 1 to 7)
Physician‐rated ‚self efficacy‘: impact of comm training
Übergang zu palliativer Behandlung
Transition to pall care
Tell pat how long to live
Angaben zur Lebenszeit
Responding to pat‘s strong emotions Emotionale Reaktionen
Mitteilung Therapiemisserfolg
Treatment failure Item
Wunsch sinnloser Tumortherapie
Wish for futile ca treatments
5‐7 T0
5‐7 T1
Conveying ca recurrence
Mitteilung Tumorrezidiv
Conveying ca poor prognosis
Mitteilung Krebs ungünstige Prognose
Conveying ca good prognosis
Mitteilung Krebs günstige Prognose
0
10
20
30
40
50
Prozent
60
70
80
90
100
Effect of communication training on ca physicians’
burnout and work satisfaction (MBI)
Participating physicians
Pre
4 mo post
N
M (SD)
M (SD)
‐ Emo exhaustion
260
18.02 (8.23)
18.37 (8.18)
‐ Depersonalisation
260
6.46 (3.92)
‐ Pers accomplishment
205
31.62 (4.90)
Control physicians
ES(d)
Pre
4 mo post
N
M (SD)
M (SD)
0.04
181
19.81 (8.44)
19.73 (8.67)
0.01
6.17 (3.87)
0.08
181
6.37
6.86 (3.68)
0.14
32.91 (4.44)
0.28
181
33.05 (4.19)
33.28 (4.26)
0.06
(3.41)
Adjusted mean difference between groups: significant group x time effect: ‚Depersonalisation‘ ANCOVA M_diff = ‐ 0.19 [‐0.31; ‐0.07] P‐value = .003
‚Pers accomplishment‘ ANCOVA M_diff = 0.09 [0.00; 0.18] P‐value =.059 ES (d)
Effect of communication training on ca physicians’
Burnout and work satisfaction (MBI)
intervention
control
ANCOVA
Emotional exhaustion
‐
‐
n.s.
Depersonalisation


P= .003
Personal accomplishment

‐
P= .059
Four months following the KoMPASS training, intervention physicians show  No effect on ‚Emotional Exhaustion‘
 Slightly less signs of ‚Depersonalisation‘ vs an increase among controls Higher sense of ‚Personal accomplishment‘ = work satisfaction
Effect of communication training on ca physicians’
Burnout and work satisfaction (MBI)

Empirical support from findings:
qualified communication skills training in fact does ameliorate and prevent burnout in cancer physicians
sustained effect after 4 months
+ CST outside clinical study (bias less likely) Large sample size
broad range of specialty and seniority
Controlled design ?
Bias due to highly motivated participants?
Small group of experienced & engaged trainers ?
Impact on patients‘ outcomes?
How ?? By reducing physicians‘ fears
Effect of communication training on ca physicians’
Burnout and work satisfaction (MBI)
 communication skills training does ameliorate and prevent burnout 
How ??
‐> By reducing physicians‘ fears ‐> awareness of own emotional involvement
‐> awareness of professional competence –‘self‐efficacy‘
‐> From lived experience of satifying interactions
‐> From facilitative environment to integrate behaviors learnt
‐> From group experience .....
‐> many questions & tasks for future research
Effect of communication training on ca physicians’
Burnout and work satisfaction (MBI)
 communication skills training does ameliorate and prevent burnout 
Where do we go from here?
‐ Refining, improving and differentiating training methods
‐ Research into training process (vs outcomes)
‐ Re‐thinking existing research paradigms & methods
‐ Ensuring benefit for patients‘ experience
........
Patients in crisis ‐ helpful interactions
‘Prescribing the doctor’ ( YOU) can be a powerful tool for giving that support in times of crisis of cancer
For patients who are distressed several simple techniques can make your relationship with the patient and family “therapeutic”
Patients will be grateful for your support which will also make you feel better
Walter Baile  Where do we go from here?
 Without Walter Baile and his dedicated, continued support and effort  The KoMPASS group‘s achievements would look quite different
 We gratefully appreciate his inspiring engagement for our work
 Looking forward to continuing our fruitful and enjoyable collaboration
Thanks for your attention !
www.kompass-o.org