Communication is a cornerstone in providing appropriate medical care. A recent article in AJKD discusses a novel communication skills course for nephrology fellows. Dr. Robert Cohen (RC) discusses his paper with AJKDblog editor Dr. Kenar Jhaveri (AJKDblog).
AJKDblog: How did you realize that fellow–patient communication may be a problem in nephrology?
RC: As a nephrologist practicing for over 25 years, I came to recognize that I was often having serious discussions with my patients with advanced kidney disease, whether it involved letting them know that their kidney function was deteriorating, that they were approaching kidney failure, or that their clinical situation was worsening and more palliative approaches might be considered. It is well known that patients with advanced kidney disease have a very high level of morbidity and mortality. I had never received any communication skills training and had to learn on my own.
As the nephrology education director at Beth Israel Deaconess Medical Center (BIDMC), I noticed that nothing had changed from when I was a fellow in the 1980s, and the gap in teaching skills to enhance these discussions was still present. Furthermore, I knew that fellows in other subspecialties were getting training in these skills, particularly in oncology and palliative care. I made it a point to seek advanced training in patient–doctor communication and palliative care and decided to create a curriculum in 2011 to fill the gap. The result was a course for all first-year nephrology fellows at training programs associated with the Harvard hospitals (BIDMC, Brigham and Women’s, and Massachusetts General Hospital).
AJKDblog: Could you briefly summarize this QI project?
RC: The intervention is an annual full-day communication skills workshop. This is very different from the type of learning most of our fellows experience in that it is primarily skills based. Although we have brief didactic sessions, the fellows spend most of the day practicing communication skills with simulated patients—professional actors who trained in medical communication. They practice several different conversations: breaking the bad news that kidney function has worsened to kidney failure; engaging in a goals-of-care discussion with a patient who, as kidney failure approaches, is doing much worse clinically; and discussing dialysis withdrawal with the same patient who had elected a time-limited trial of dialysis.
The fellows are observed closely and receive supportive feedback that focuses on what went well and what might be done differently in the future. In the process, they learn how to listen actively, and practice recognizing and responding to emotion. We surveyed 26 fellows before and after the course about perceived changes in 8 different communication skills taught during the course. Three months after the workshop, we assessed fellows’ perception of improvement in skills through an online survey. The surveys measured both quantitative and qualitative changes. The latter included questions about how they had applied skills with patients and family members since the workshop concluded.
AJKDblog: Were you surprised that a day-long course could lead to such improvement?
RC: I was not surprised that the fellows’ perceived improvement in these skills rose immediately after the course. I was, however, somewhat surprised and very pleased that the level of perceived improvement in these skills was sustained at three months.
AJKDblog: How do you envision this program could be implemented nationally?
RC: Very few nephrologists have experience in teaching advanced communication skills. A faculty member interested in starting a similar workshop could partner with others who have more experience in teaching communication skills to trainees and students. Such faculty can often be found in palliative care, geriatrics, or oncology. In terms of scale, one might start with a half-day program and practice two cases with simulated patients. The most expensive component is hiring professional actors.
In terms of implementing this nationally, one train-the-trainer course for academic nephrologists was held in 2015, which 12 faculty members attended. Additional train-the-trainer programs would increase the pool of faculty members who are able to teach these skills and coach fellows who have received some training. I provide ongoing feedback to my fellows regularly, but not every fellow is able to find faculty willing to provide this type of coaching or capable of it.
The goal is for the next generation of nephrologists to be more capable of discussing serious topics with an increasingly complex population of patients with advanced kidney disease. It’s an essential component of the quality of care that we provide.