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Communication plays an important role in patient care. Research has shown that communication skills training in a medical curriculum should be longitudinal. Training should preferably be experience-based and take place in small groups with role play and (simulated) patient contacts. This chapter discusses the communication skills programme. Communication skills training is integrated with the teaching of underlying psychological theory, training in other clinical skills (i.e., physical examination skills), and the assessment system.

Several models of physicianȓpatient communication that have served as conceptual frameworks for communication skills training have been described over recent years. Studies have explored the efficacy of such training in altering physician behaviours. This chapter reviews these models and examines their strengths and weaknesses. It then focuses on a new model of communication skills training, the Comskil model, which was developed at the Memorial Sloan-Kettering Cancer Center in an effort to address critiques of these earlier models. A review of the literature indicates six established models of physicianȓpatient communication that have served theoretically to guide communication skills training programmes: the Bayer Institute for Healthcare Communication E4 Model; the Three-Function Model/Brown Interview Checklist; the Calgary-Cambridge Observation Guide; the Patient-Centred Clinical Method; the SEGUE Framework for Teaching and Assessing Communication Skills; and the Four Habits Model. For each of these, the conceptualisation of the model is first summarised and then the way in which its application is assessed is discussed.

Across the continuum of medical education, the focus is shifting from the teacher and the curriculum to the learner and the evaluation of educational outcomes. In the field of communication skills training, educators are now carefully examining the outcomes of their programmes. This chapter looks at assessment strategies used for communication skills training, describes how to design an effective evaluation methodology, and considers how outcomes have been measured in the oncology communication skills training literature. Evaluation of communications training programmes should follow standards and guidelines familiar in other types of research, meet standards of reliability and feasibility, and yield information that will be useful to the trainees and to programmes as a whole. A good test of usefulness is to ask whether learners will know how well they perform and what they need to do to improve as a result of assessment findings, and whether trainers will know how to improve training and curriculum as a result of the findings.

This chapter provides clarification of communication skills and Advance Care Planning (ACP), evidence for the value of effective communication in ACP, key communication skills with useful examples of opening gambits, examples of blocking behaviours, models of communication and suggestions for implementation, workforce issues, and recommendations for further education and training. It notes that communicating about end of life care is challenging but essential. Defining communication and communication skills can be a complex business. There is plenty of evidence to suggest that effective communication is a key element in allowing patients to decide how they are cared for at the end of life. Specific communication skills and models can be instrumental in encouraging patients to share concerns, ideas, and expectations, while some communication behaviours can inhibit patient disclosure. Meanwhile, a systematic approach to developing a workforce skilled in end of life communication is achievable and desirable.

The art of teaching communication skills for the clinician is about establishing practices that serve the patients' and their families' needs in a manner that is mutually fulfilling for all involved. It requires the tactful use of boundaries that are patrolled and negotiated and, at all times, mindful of the needs of both parties. As a result, a series of conundrums can plague the teaching of communication skills: the balance of art and science in clinical communication fluctuates throughout medical training and experience; communication involves skills, but it is more than behavioural skills, also requiring much practical wisdom; no one has yet described an effective training programme that captures both the art and the science of communication. Mindful of these challenges, this book seeks to combine the evidence base about communication in cancer care and palliative care with humanity in its practice. Its goal is to integrate the art with the science. This chapter examines four essential elements to the art of teaching communication: the task, the learner, the teacher, and the strategy.

In 2002, funding was recieved from the National Cancer Institute to develop a new teaching model for communication skills at the end of life, aimed at medical oncology fellows. Using this model, called Oncotalk, roughly 10% of the oncology fellows trained in the United States over a five-year period were taught. The aim of Oncotalk was to address shortcomings in communication between physicians and cancer patients. In developing the programme, key educational principles were utilised, some of which had been used in other communication skills training, others of which evolved as a result of the unique demands of the teaching context. Based on this Oncotalk experience, this chapter describes common evidence-based principles used in developing an advanced communication skills programme; identifies unique aspects of the learning context within an intensive retreat structure, and illustrates the lessons learned that can be tested in other settings. The aim is to provide tools and frameworks to facilitate teaching communication skills within oncology and other clinical training programmes that prepare clinicians to work with seriously ill patients.

In Australia, management of cancer patients occurs along a continuum starting with screening and diagnosis, through treatment and supportive care, to follow-up, and, in some cases, palliative and end-of-life care, with services provided in both tertiary and primary settings. Communication skills training for health professionals involved in cancer care is available in Australia through a number of avenues. Courses and workshops are provided through professional colleges representing different disciplines involved in cancer care, cancer organisations, and local service providers, in both the public and private sectors. The majority of formal communication skills training occurs at the postgraduate level, primarily in the form of interactive workshops implemented by one or more trained facilitators. This chapter describes current approaches to communication skills training for oncology health professionals in Australia, including the benefits and limitations of the current model, as well as future directions and priorities. It also describes the National Breast and Ovarian Cancer Centre's National Communication Skills Training Initiative.

In the last two decades, communication skills training programmes, designed for healthcare professionals working in cancer care, have been the focus of several of the research endeavours of the Brussels research group. The efficacy of these programmes has been tested in studies using a controlled design. Studies varied in the type of healthcare professional, the type of teaching method, the length of training, and the outcome measures. As a result, research efforts have focused on communication skills to be taught and on training techniques to be used. The aim of the randomised controlled trials was to determine the optimal duration of a training programme in order to ensure training effects. The choice of the skills taught was based on results of studies indicating the positive impact of using specific communication skills on cancer patients' disclosure of concerns. The results confirm the usefulness of communication skills training programmes for healthcare professionals working in cancer care.

Improving clinicians' communication is necessary, but not sufficient to achieve the best possible communication in a clinical encounter. This chapter focuses on an area that has received much less emphasis — training patients to be good communicators. The physician–patient interaction is a dynamic, socially-constructed, and reciprocal process that relies on at least two participants. Effective communication in a physician-patient relationship, therefore, requires both parties to be actively involved and competent communicators. Moreover, patients' communication may influence physicians' responses. Thus, to understand fully and improve physician–patient communication requires a focus on both sides of the interaction. Considerable research has indicated that there is room for improvement in patients' communication skills, including asking questions, explicitly stating concerns, and verifying information. This chapter begins with a review of studies of patient communication training, both in and out of the oncology setting. It then explains the concept of concordance in the physician–patient relationship and how concordance provides a fruitful conceptual grounding for patient communication training.

Communication is increasingly understood to be a fundamental clinical skill. It is critical to effective diagnosis and management, as well as to connecting with patients on a cognitive and emotional level. In addition, communication skills themselves have been linked with patient outcomes, including satisfaction, adherence, and decreased malpractice incidence. For medical students, communication skills training generally begins in the pre-clinical years and extends into the clinical years, where increasing levels of sophistication and more in vivo experiences can be taught. This chapter reviews general approaches to teaching communication skills in medical schools and then considers several specific aspects to communication skills in oncology and palliative care for medical students. Approaches to communication teaching and assessment in medical school include small-group teaching and role play, interviews with real patients, and interviews with simulated patients. This chapter also considers the SEGUE framework for teaching and assessing communication skills and the link between communication and teamwork in palliative care.

Over the last thirty years of research in primary care settings, considerable attention has been given to physician communication skills, but comparatively little to patient communication skills. This trend is also true for research involving specialist physicians and cancer patients. This chapter examines interventions designed to enhance cancer patients' communication with physicians. There is ample research in primary care supporting the value of enhanced patient participation. Thus, it is reasonable to ask if cancer patients might also benefit from taking a more active role in medical consultations. While there is variance in research findings, the majority of cancer patients prefer at least a collaborative role in consultations, which requires a good degree of participation (for example, asking questions, expressing preferences and opinions). Thus, most cancer patients will be open to, and can benefit from, communication skills training. Researchers should examine the work on patient participation, shared decision-making, and reviews of patient communication skills interventions for ideas about important communication skills to consider in developing interventions for cancer patients.

The past three decades have witnessed a considerable growth in the amount of research directed at examining communication skills in healthcare. Earlier efforts set out to describe the problems in communication between patients and providers, whilst later studies focused on the skills to be taught and the training techniques to be used. Whilst much of this early work concentrated on the primary care setting, subsequent work developed from within the field of oncology. This chapter describes a number of key communication challenges for nurses working in a modern cancer and palliative care setting in the United Kingdom. It provides an overview of the growing evidence base for communication skills training, and relates these findings to experiences of developing and delivering training as part of the English National Advanced Communication Skills Training Programme. Finally, it makes recommendations for the future provision of post-registration nurse training by outlining a core curriculum for communication skills.

Communication occurs in cultural contexts, which are in turn determined by a host of variables — ethnicity, religion, geographic origin, gender, sexual orientation, social role, and age, among others. Anthropologist Edward Hall noted that social interactions and associated communication can be broadly classified as being relatively high or low in their cultural context. Low-context communication is task-oriented, emphasizing straightforward, unambiguous spoken or written communication, while high-context communication embeds large amounts of meaning within the actual situation (or context), within which communication is occurring and tends to compress meanings in spoken, written, and non-verbal communication. Current medical training tends to focus almost exclusively on low-context aspects of communication. This chapter provides an introduction to high-context intercultural communication, as it applies to palliative care, and discusses educational strategies for improving related communication skills. It also examines the relevance of high-context communication to palliative care, the culture of biomedicine, ambiguity, compression of meaning, and subtexts.

This chapter discusses a proposal to raise awareness of the communication skills that are necessary for promoting the principles of high-quality care, which is the aim of the Liverpool Care Pathway for the Dying Patient (LCP). It also addresses the communication skills needed to handle the many difficult situations that frequently arise when caring for dying patients. The various blocking tactics that may hinder communication are also examined.

Most of the history of communication skills knowledge and teaching derives from work and studies done in general medicine, or further afield, rather than in cancer care. Cancer care has been advanced in attempting, as this book reflects, to codify the processes required to accomplish some key goals: to help cancer patients to accept their diagnosis and prognosis; to accept or reject tests and difficult treatments according to their core preferences; to participate in studies; to enable them to participate meaningfully when curative care is futile; and to facilitate dying with dignity. The importance of communication in medicine generally was understood by prehistoric human healers. In 1995, the American Academy on Communication in Healthcare published its authoritative reference text, which covered clinical care, education, and research as an exposition of communication training for internal and family medicine. Since then, although there have been serial syntheses and consensus efforts (always a moving target), the core principles of communication skills training have remained quite stable, once one translates the babble of new language for common concepts.

Experiential role play is the most essential component of a communication skills training program. In facilitator-led role-play sessions, learners act out simulations of consultations, frequently using an actor taking the role of the patient. In such sessions, learners are able to attempt the use of new skills within the safe environment of a confidential and constructive practice session. Without such practice and feedback on communication skills, a learner's sustained behaviour change in clinical settings is improbable. The success of communication skills training programmes is dependent on adept facilitation, wherein skilled facilitators engage learners and conduct role-play sessions in a learner-centred approach. Effective facilitation includes beginning and structuring the session, running role-play, facilitating feedback, and closing the session. This chapter first describes common variations on role-play sessions. Then, it delineates the important elements of facilitating skills practice in a role-play session. It also outlines processes that are helpful in conducting train-the-trainer programmes and in sustaining a core of competent facilitators.

The Swiss Communication Skills Training (CST) for oncology clinicians was initiated in 1998 by the Swiss Cancer League (SCL), who mandated a national task force to elaborate a concept for a CST for oncology physicians and nurses. The task force developed a concept for a national CST for oncology clinicians. Initially, a train-the-trainers' course was organised for the members of the task force allowing them to experience the CST as participants and to gain insight into its dynamics. Following a pilot CST, organised in the German, French, and Italian parts of Switzerland for local chiefs of oncology services and head nurses, the Swiss CST was implemented; it was officially endorsed by the Swiss Society of Medical Oncology (SSMO), and sponsored by two pharmaceutical companies who were willing to support financially this training during the first years. In 2001, the SSMO declared this CST to be mandatory for physicians specialising in oncology. By the end of 2007, about four hundred physicians and nurses working with cancer patients had participated in this training.

A multidisciplinary team is a collection of individuals who are interdependent in their tasks, who share responsibility for outcomes, who see themselves and are seen by others as an intact social entity embedded in one or more larger social systems. Although there are emerging descriptions of the composition of multidisciplinary teams in cancer care, there is a paucity of research data to guide recommendations about the particular strategies that are likely to be of benefit in promoting optimal team functioning. In addition to the ‘obvious’ members of a team, such as pathologist, radiologist, surgeon, medical oncologist and radiation oncologist, the presence of allied health professionals enhances capacity for comprehensive treatment of cancer patients. This chapter also considers the impact of poor communication within multidisciplinary teams on outcomes and how communication skills training can address this problem.

Within the United Kingdom, general practitioners (GPs) will manage the care of the majority of patients with life-limiting and terminal disease, including those with complex problems requiring specialist palliative care involvement. The consultation is at the heart of general practice and communication skills, underpining the UK General Practitioner Vocational Training Scheme (GPVTS). To attain membership of the Royal College of General Practitioners, trainees are required to undertake learning methods during their training programme as outlined in the RCGP Curriculum, which include video analysis of consultations, random case analysis of a selection of consultations and patients' feedback on consultations using satisfaction questionnaires or tools. This chapter discusses the Cardiff University Post Graduate Course's specialist palliative care education designed to meet the needs of specialists and of GPs with a developing specialist interest, the Cardiff six-point toolkit (listening, reflection, summarising, question style, comfort, language), the use of role play for developing communication skills, and reflective practice/portfolio learning.