Monday, July 18, 2011

In Communications Training Program, Everyone is a Learner

Peter Greenspan, MD, has practiced medicine for many years, and, as vice chair of Pediatrics at Massachusetts General Hospital and medical director of MassGeneral Hospital for Children (MGHfC), he is no stranger to the hospital environment and its challenges.

But when called upon to deliver bad news to his colleague Shannon Scott-Vernaglia, MD, in a role-playing scenario, Dr. Greenspan was shocked by what happened.

Dr. Scott-Vernaglia, playing the mother of a critically ill child, began crying and shouting as soon as Dr. Greenspan introduced himself.

“I did not expect that at all; it just totally threw me,” says Greenspan, who is also a member of the MGHfC Quality and Safety Executive Committee. “In those few minutes I couldn’t back out of the situation, and that, I think, attests to the power and the potential power of this kind of exercise. You can listen to a million lectures and videos and you’ll just never feel the power of the experience unless you do it.”

The exercise was one session of a communications training program funded by a grant from the MGHfC Quality and Safety Program. Both MGHfC and the larger Mass General have an ongoing objective to improve communication between caregivers, patients and families. The MGHfC training program, led by specialists Sandra Clancy, PhD, and Patricia O’Malley, MD, joins families and caregivers of various specialties and levels of experience. In each session the group brainstorms ways to approach several difficult, real-life scenarios, and then after four of the participants simulate the encounter, the role players and the group discuss what happened.

“The model proposes that everybody in the room is going to be a learner,” says Clancy, who works in MGHfC’s Coordinated Care Clinic and Palliative Care Program, and organized the training. “It’s not as though one reaches the pinnacle of communication and then stops learning. We can all benefit from reflection and discussion.”

Multidisciplinary Lessons Learned

One of the program’s teaching points for clinicians is the benefit of bringing a partner along for support in an uneasy situation, such as relaying a difficult diagnosis. Dr. Greenspan put this lesson to use after the training when seeing a patient in the Pediatric Intensive Care Unit.

“It turned out to be so much better to have somebody else with me, providing mutual support in a difficult situation,” Greenspan says.
The communications program was launched as a result of an emotional Family-Centered Grand Rounds last year. The annual grand rounds event featured a parent and the patient’s physician, who had struggled with communication when the child was gravely ill. Last year the Quality and Safety group offered its first six mini-grants for projects to optimize the quality and safety of care provided at MGHfC, and an initiative to improve communication was an obvious candidate.

“I was thrilled to be a part of Quality and Safety program and be able to fund something that was so exciting,” Greenspan says. “That was wonderful.”

Clancy and O’Malley identified reading materials for the program, but O’Malley says, they developed more of a process than a curriculum. “It didn't take long, though, to begin trusting the process, which involves drawing on the resources of the many supporting disciplines--chaplaincy, child life, social work, nursing-- whose training includes much more explicit emphasis on communication skills than physician training does,” O’Malley says.

Each communication session featured at least one parent, several pediatric residents and attending physicians, as well as nurses, Child Life specialists, a chaplain and social workers. “The chance to work in an interdisciplinary setting, out of the frenetic pace of the wards-- that’s a big plus,” says Shannon Scott-Vernaglia, MD, who is also director of MGHfC’s pediatric residency program.

The value of communication is an integral element of care at MGHfC and Scott-Vernaglia adds, “Having more opportunities to formally teach that and to practice these skills is really critically important.”

Parent Perspective

Kathy Cadogan played the part of a parent in one training session, and brought to it her expertise as a parent intimately familiar with MGHfC, where her family has received care for about 14 years. The mother of a child with type-two neurofibromatosis, a genetic condition that causes tumors to grow in the nervous system, Cadogan had valuable insight for her fellow participants.

Cadogan observed a scenario about a teenager with terminal cancer whose parents didn’t want their child to know she was dying. After the role playing, Cadogan shared her own story.

“I told my personal story that my children were diagnosed at 6 and 7 [years] and we were always upfront” with them about their condition, Cadogan says. Her husband and one of her two children died from the illness.

Of the training, Cadogan says: “The one thing that I walked away with is that all of us in our daily living should never assume anything about anyone else. Take each family and child individually, no person is alike and no family is alike. Listen to what parents have to say.”

Listening and Reflection

The idea that parents know their child best and the importance of listening were also takeaways for Julia Von Oettingen, MD, who is now in her third year of residency at MGHfC.

Von Oettingen played the role of a provider talking to a teenager with cancer about her condition. In the scenario, the teen appeared to be in denial of her situation, until Von Oettingen spoke with her.

“It was really good because it made me realize that these adolescents can realize where they’re at with their cancer despite the fact that that’s not what they always portray,” she says. “Just being the one sitting there and listening to the child can make them open up, and can be helpful to the patient,” she added.

Speaking about the scenario with attending physicians was also useful for Von Oettingen. “It was very helpful that the more experienced physicians were able to give very concrete examples about how they phrase the discussion,” Von Oettingen says. “That in itself was great for learning.”

Adds Dr. O’Malley: “I was impressed that the workshop was able to offer not only a safe venue to practice these skills, but also a supportive place to process the difficult encounters we all have experienced as caregivers.”

Role playing can be an intimidating activity, but the program’s organizers ensured that the workshop was held in an open and welcoming environment, where all input and participants were valued equally.

“In that room there is really no hierarchy,” Sandy Clancy says. “There is no hierarchy of status; there is no hierarchy of knowledge. Everybody sitting at that table has really valuable wisdom to contribute.”

Von Oettingen says of the program is useful for “taking an afternoon to reflect on patient communication, to reflect on the importance of it, to have an exchange with other providers of it and that way being reminded that that is the most important part of your job.”

Plans are underway to continue the training program this fall, beyond the first grant-funded sessions. Clancy says the program is a work in progress and she hopes to involve caregivers in more disciplines as it continues.

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