PREFACE

There is a direct link between the quality of your
communication and the quality of your life.
—J. Stewart¹

I (Laura Cooley) will always remember the day when I truly realized the value of authentic communication and relationships in healthcare. My father was too weak from the cancer, chemotherapy, and radiation, and their side effects, to even walk into the clinic that day. It was hard to believe that only two years prior he had been a healthy 63-year-old man who was hiking and gardening regularly.

When the oncologist, Dr. Brown, finally rushed in (after failing to greet my mother or me), he stood over my father’s wheelchair, reviewed the chart, and abruptly flipped my father’s hands over to inspect the raw burns on his palms from the chemo. He then made yet another recommendation for chemo. We sat quietly. My father raised a couple of simple questions about his side effects and the new chemo, doing so haltingly, as the recent development of a brain metastasis had impaired his speech.

As Dr. Brown scribbled a few notes in silence and edged his way toward the door, I cleared my throat and halted his departure. I had prepared several delicate questions about life expectancy and choices. As my questions began to flow, Dr. Brown scanned our faces and eased himself onto a stool. He leaned in and proceeded to have a direct and honest conversation. In the next few moments, we learned that my father might expect about three to six months of low-quality life. As Dr. Brown delivered this devastating news, paradoxically, his humanistic side emerged. He sat quietly for a few moments, offered his sincere condolences, and then departed gently. As my family wept together, the nurse provided a calm, comforting presence, and stayed with us until we were ready to exit the exam room.

Those final moments of clear and compassionate communication allowed my family to digest the somber news and make more informed decisions in the direction of palliative care. My father died only three weeks later. I was so grateful for the opportunity to engage in a conversation that honestly prepared us for the inevitable future. Until that moment, my parents had not fully realized that there were alternatives to the aggressive treatment offered. I was saddened by the thought that we would have missed that communication opportunity had I not insisted. What happens to other patients and families? How many other opportunities are missed?

I believe that most healthcare clinicians truly want the best for their patients. I believe Dr. Brown did, too. I wish that he and other clinicians could regularly perform the fundamental skills that are essential for communicating effectively and for connecting authentically. Relationship-centered communication has the power to reduce suffering for patients and families like mine, and to reengage healthcare clinicians in the true spirit of caring and healing, even when a cure cannot be found.

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What do we mean by “communicating effectively”? Often, during our workshops, we’ll ask people to introduce themselves by sharing something interesting about their name. Our name, the Academy of Communication in Healthcare (ACH), deliberately includes the word Communication as a core aspect of not just what we do but who we are—it is literally our middle name! Admittedly, communication is a complicated word even within its own discipline of study. Derived from the Latin words communis and communicare, meaning “to share” and related to the word community, human communication is the use and interpretation of symbols (verbal and nonverbal) to create a shared reality with other people. We deliberately say communication to differentiate our work from technology, referred to as “communications.” Though electronic devices certainly permeate our lives, we focus on immediate interpersonal exchanges, rather than those involving organizations or the media. Even with this focus, given the range of symbols in healthcare (jargon, procedures, specialties, stories, and emotion, among many others), health communication is a particularly complex context in which to try to skillfully “share” meaning with other people.

As a reflection of our organizational mission, this book seeks not just to improve communication skills, but through those skills to develop deep and meaningful relationships that facilitate high-quality patient care and renew our joy for caring for others. In this sense, communicating effectively is so much more than the accurate exchange of information; it is about recognizing and strengthening our interconnections as a dynamic, professional system. Extra layers of challenge arise from the understanding that all communication has not only content (the meaning I am trying to share with you) and relationship (who we are to each other given our individual and common experiences) but also situational context (e.g., emergency versus anticipated, electronic versus face-to-face, etc.). We believe, however, given the costly, inefficient, and sometimes heartbreaking consequences of not doing so, that deliberate practice and attention to improving our skills is well worth the effort.

As a nonprofit organization, our dedication to this effort is longstanding. The ACH originated in 1978 as a task force within the Society of General Internal Medicine. At that time, communication was rarely studied in the healthcare setting; best practices were born of physicians’ individual experiences, rather than from evidence-based science. The dearth of information and guidance led many founders of the original task force to do seminal research in this area. Such efforts resulted in the task force becoming an independent organization known as the American Academy on Physician and Patient (AAPP) in 1993. Recognizing the explicit exclusivity of that title, and wanting to honor the full scope of systems work we now embrace, members voted in 2006 to change the name to the American Academy on Communication in Healthcare, and more recently, to the Academy of Communication in Healthcare. Those name changes support an active expansion of our community by inviting the true diversity of professionals and perspectives involved in healthcare to join our mission.

Communication Rx covers selected communication scenarios that commonly arise in healthcare. Many others are detailed in a seminal textbook on physician communication skills,² written by early members of the AAPP, giants in the field on whose shoulders we stand. We have purposefully avoided duplicating many of the chapters that to this day remain clear and useful exemplars (e.g., conducting a family interview, using interpreters, conducting a sexual history, and addressing many aspects of psychosocial medicine, including patients with personality styles, alcohol use disorders, and others). Instead, we intend this book to be a resource for a much broader audience, including clinicians in all health professions, leaders and administrators, patient experience specialists, patient advocates, and companies that assist in the patient experience. In fact, as the skills in many cases are generic and transferable, we think their application goes well beyond healthcare.

We have organized this book into four parts to address different aspects of communication skills training and its applications. Part I (Chapters 1–2) provides an overview of the importance of communication skills, the research that supports the influence of communication on healthcare outcomes for both patients and clinicians, and the relationship between communication skills and patient experience.

Part II (Chapters 3–5) delves into the three evidence-based, fundamental skill sets that we teach in our courses. Because the evidence has accumulated relatively recently (in the past couple of decades), many practicing clinicians may never have undergone specific training in these fundamentals. If professional baseball players, who are paid much more than most clinicians, can do fielding drills before every game, clinicians—whose collective outcomes, we might argue, are more consequential to society—can also continue to work on their fundamental skills.

Part III (Chapters 6–15) shows how the fundamentals apply to almost every interaction involving communication in healthcare. This part begins with a chapter addressing common, as well as advanced, communication challenges that clinicians face (Chapter 6). Mostly, the same fundamental skill sets apply in the latter cases, along with extra finesse and self-awareness. Advanced applications in communicating with patients include working with the electronic health record (Chapter 7), motivational interviewing (Chapter 8), and shared decision-making (Chapter 9). We then offer applications of the skills to interactions with colleagues and team members, with chapters on feedback (Chapter 10), coaching (Chapter 11), teamwork (Chapter 12), and communication challenges with colleagues (Chapter 13). We address more systemic and societal factors in chapters on culture and diversity (Chapter 14) and communicating through hierarchy (Chapter 15).

Finally, Part IV (Chapters 16–18) addresses how health systems can adopt these ideals of communication. We include a chapter on teaching the skill sets (Chapter 16), which, as you will see, also incorporates the fundamentals from Part II. Chapter 17 discusses train-the-trainer programs that institutions may find helpful to jump-start and sustain communication skills improvement initiatives. Chapter 18 considers the institutional context in which change might take place and describes implementation methods and common pitfalls. Video examples for much of the content in this book can be found in the ACH’s online learning resource, DocCom, and numerous textbooks on fundamental communication, among them Smith’s Patient-Centered Interviewing.³

The authors of these chapters are current participants in or graduates of the ACH Faculty-in-Training Program,⁴ a relationship-centered distance learning community where expertise grows through iterative and deliberate practice fostered by safe and appreciative feedback. Authors are predominantly physicians from both the inpatient and outpatient worlds, with essential contributions from a midwife, a physician assistant, a marriage and family counselor, and health communication educators and scholars. As you glance through our affiliations, you’ll see that we represent 16 institutions across the United States and Canada. We absolutely welcome feedback on the book, particularly feedback that is honest, kind, and intended to improve the work in healthcare to which we are all committed.

In whatever capacity you give care to our patients, join us on this journey through fundamental and advanced skills in healthcare communication to better serve our patients, our colleagues, our institutions, and ourselves.