A commentary published earlier this spring in the Journal of Clinical Oncology urges for improved training for medical professionals tasked with delivering bad news. Oncologists have to deliver bad news an average of 35 times a month, says lead author Ramy Sedhom, M.D., a medical oncology fellow at the Johns Hopkins University School of Medicine. But, despite the proven importance of these words, which influence medical decision making and have implications for patient care, there is not enough training for how to conduct such crucial family meetings.
Oncology fellows report that they are trained to be medically-oriented, not person-oriented, which means that they likely receive more training on how to perform a bone marrow biopsy and other technical procedures that how to consider the impact of their word choice with their patients.
According to Sedhom, there is explicit research that shows this impact that words have on patient preferences for treatment or palliative care. “For example,” as the commentary describes, “patients are more risk-averse when considering gains (choosing adjuvant therapy in breast cancer) and risk-seeking when considering losses (enrolling into phase I clinical trials at the end of life).”
Framing a conversation is particularly critical as more and more patients are coming to live with cancer as a chronic disease, which requires advanced monitoring of symptoms. This is complicated by the fact that oncologists are becoming more and more specific in their scope, specializing in one or two cancers as treatment options have become more complex.
Thomas J. Smith, M.D., professor of oncology and director of palliative medicine at the Johns Hopkins University School of Medicine commented, "As a consequence," he says, "the abilities of these doctors to predict patient outcomes becomes even more complicated and highlights the need for palliative care training."
Sedhom, Smith, and their fellow oncologists at the Johns Hopkins Kimmel Cancer Center say that of the accredited oncology training programs in the United States that they surveyed, none offered a combined or integrated medical oncology and hospice/palliative care medicine program. Instead, the programs are often offered separately, as found in 73 institutions in the survey, including Johns Hopkins Medicine.
The need for such dual training extends to the responsibility of oncologists as not only doctors but educators of the next generation of doctors. Young doctors learn from experienced doctors how to facilitate physician-patient interactions when delivering bad news; Sedhom and Smith argue that there is not enough emphasis placed on training for these conversations.
“Behavioral economics reminds us that patients (and physicians) can be nudged in their decision-making. Consequently, our training has an impact not only on the words we choose in patient care, but also in advising other oncologists on career choices. Because nearly all decisions are framed in some way, the onus lies with us as educators and influencers to prepare the next wave of oncologists to value training in palliative oncology. Because the field of palliative medicine is focused on communication, prognostication, and individualizing the needs of each patient, it is time to consider opening the doors to dual training,” concludes Sedhom and Smith.