Radiologists get a lesson in conveying empathy to patients.
Imagine your 6-month-old patient's parents are anxiously waiting in the next room. Ultrasound images confirm a tumor in their son's liver. Now you must convey the bad news.
You walk into the room, readying yourself to pass on the difficult information. The parents look up at you expectantly as you walk in. However, these aren't actual parents, and there is no son with a liver tumor. It's only a simulation.
The nervous people in the next room are professional actors who specialize in improvisation and are trained to respond to various medical scenarios. They are part of an innovative workshop — offered by the Program to Enhance Relational and Communications Skills (PERCS) — held at Boston Children's Hospital (BCH) to teach radiologists and other practitioners how to communicate effectively with patients and their loved ones.
Few doubt the importance of teaching interpersonal and communication skills to health-care professionals. Recently, the ACR created Imaging 3.0™, an initiative that includes encouraging radiologists to get out of the reading room and interact with patients (visit http://bit.ly/ACRImaging3 for more information and resources). These critical skills are core ACGME competencies mandated for radiology residents. However, traditional instruction through lectures and readings "place learners in a passive mode, merely absorbing information," write two former PERCS participants in Academic Radiology.1
At BCH, several leaders realized the need for more hands-on instruction regarding communication with patients. Simulation has become commonplace in medicine, but only for practicing technical skills. "Usually, simulation focuses on procedural learning with mannequins," says Elaine C. Meyer, PhD, RN, director of BCH's Institute for Professionalism and Ethical Practice (IPEP), and associate professor of psychology at Harvard Medical School in Boston. "We thought, 'Wouldn't this be a great way to learn how to interact with patients?'"
The PERCS workshops began in 2002. PERCS has subsequently developed workshops to improve communication and interpersonal skills in various medical disciplines. As Meyer notes, however, radiology was not an initial focus because radiologists have not historically practiced frontline patient communication. But times are changing, and Imaging 3.0 and PERCS are helping radiologists adapt.
PERCS soon extended its curriculum to include radiology workshops through a program called PERCS-Radiology. Stephen D. Brown, MD, pediatric and obstetric radiologist at BCH and PERCS-Radiology director, first developed a program with IPEP about difficult conversations in prenatal care. The program focuses on communication after ultrasound diagnoses of fetal abnormalities. Brown immediately realized that similar programming would benefit radiologists, especially because initiatives to provide patient reports directly, either through web-based portals or direct communication, are becoming widespread.
In 2011, Brown secured a two-year grant from the RSNA Research Education Foundation to establish PERCS-Radiology. The funds have been used for several purposes, such as bringing non-local radiologists to Boston to attend the day-long workshops. Brown has run a dozen radiology-specific workshops, each with up to 25 participants, including attending radiologists, radiologists-in-training, radiology technologists, nurses, non-radiologist physicians, medical interpreters, social workers, and even psychologists. "If you put physicians together with nurses and psychologists and other individuals, their learning tends to be much richer," says Meyer. Also present during the sessions are several faculty members, including Brown; Meyer; David M. Browning, MSW, IPEP senior scholar emeritus; Robert L. Lebowitz, MD, emeritus professor of radiology at BCH; Michael J. Callahan, MD, division chief of BCH abdominal imaging; and one patient-family representative, usually a parent whose child has complex medical issues and who is well-equipped to weigh in on the patient or family member perspective. This diverse group makes for productive and supportive workshops. "It's a safe learning environment," says Meyer. "Nobody's going to get hurt. Nobody's going to get humiliated."
Meyer and a hired performing arts consultant screen, prepare, and educate the actors around particular patient or family member characters. "We use improvisational actors," says Brown, noting that actors do not read off scripts but are prepared to respond the way a patient or family member would. Consequently, "professionals are trained to make [the situations] not too easy, but also not too hard," says Meyer. "They hit a sweet spot where something is challenging but can still be mastered."
Mary H. Scanlon, MD, FACR, diagnostic radiology residency program director at the Hospital of the University of Pennsylvania (HUP) in Philadelphia, and a PERCS-Radiology participant, is establishing a similar program at her own hospital. Scanlon is creating a video of best practices for difficult conversations. Each year, she plans to run one in-person simulation on communication topics used at BCH, while adding scenarios her own trainees have faced. "Other people can use the scenarios Boston Children's Hospital wrote up or create their own local scenarios like I'm doing," Scanlon explains. "Radiologists in general should be out talking to patients every day." PERCS paves the way for these conversations by increasing radiologists' ease and confidence with patient interaction.
Over the course of the day, PERCS-Radiology participants learn to talk with patients about three important topics;
Bad news. Before the actors step in, participants each give an example of a difficult conversation they've had and then watch a 90-second video in which an obstetrician conveys to a women that she has had a miscarriage. Individuals then briefly discuss the dynamics of conveying bad news.
Next, one volunteer goes into a separate room to tell the parent — an actor — of a child with an unexpected liver tumor found through ultrasound. "Everyone else watches on closed circuit TV," says Brown. Each scenario has been vetted by Brown and IPEP faculty. "All of the conversations that we have emanate from my own experiences in radiology and the challenges that I and my colleagues have had," Brown emphasizes.
Medical errors. The workshop then moves on to the second module, which includes a didactic lecture, practical pointers, a model coaching session, and, finally a conversation with actors in which there has been a delayed diagnosis of a child's cancer. For this particular scenario, the radiologist goes in with an oncologist. According to Brown, parents are asking to speak with radiologists more frequently, and it's something for which the specialty ought to be prepared.
Radiation risk. The third workshop module provides radiologists with tools to interpret radiation risk in layperson's terms. "We discuss essential concepts of medical radiation risks and talk about the debates surrounding radiation going on in the medical literature," says Brown. "Then we enact a scenario around a child who needs a CT scan to exclude appendicitis but has a very anxious parent."
Despite diverse topics, the day's main objectives remain to enhance the competence, confidence, and comfort of learners. "We talk about verbal and nonverbal ways of communicating — such as tone of voice, body posture, and eye contact — and the fact that one size does not fit all," says Brown. "Not every provider is going to be comfortable with certain things, like physically touching a patient to comfort them, and not every patient is going to respond the same way."
Expending the Reach
So far, participants have given positive feedback about PERCS' effect on their daily practice. "Participants report that they feel better and are more prepared to have difficult conversations," says Meyer. "They have some concrete communication skills and are better able to establish trustworthy relationships with patients and families."
For radiologists who would like to get involved in PERCS or similar training, Brown is running a PERCS-Radiology refresher course at this year's RSNA annual conference. "In the spirit of the RSNA grant, we're doing what we can to disseminate this model," Brown emphasizes. "We are trying to partner with professional organizations and put on workshops in educational forums nationally. We're hoping people from around the country will see its value."
1. Brown BP, Gunderman RB. “Teaching Interpersonal and Communication Skills.” Academic Radiology. 2012;(19)12:1589–90.
By Alyssa Martino