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Could patients' health be directly affected by their doctors' bedside manner? According to recent studies, it's more than likely. And what's more, according to the founders of Children's Hospital Boston's new Institute for Professionalism and Ethical Practice (IPEP), the quality of clinicians' relationships with patients and families may also substantially impact doctors' own sense of professional integrity
and satisfaction.
In 2002, Robert Truog, MD, and Elaine Meyer, PhD, RN, along with Jeffrey Burns, MD, MPH, interviewed parents of patients who had been in the ICU years after their children's hospitalizations. "What they consistently told us was that they forgot virtually all of the medical details," says Dr. Meyer. "What they remember is the way people spoke to them and treated them. Sometimes they felt reassured or comforted. Other times, they describe bad experiences they can't get out of their minds." To further explore these issues, doctors Truog and Meyer, with the help of David Browning, MSW, BCD, director of the Initiative for Pediatric Palliative Care Education Development Center, Inc., began offering a series of one-day educational workshops called the Program to Enhance Relational and Communication Skills (PERCS). The success of their efforts led, in March 2007, to the establishment of the new institute, with Dr. Truog serving as director, Dr. Meyer as associate director and Browning as senior scholar. Elizabeth Rider, MSW, MD, a pediatrician, recently joined the group as director of faculty development. The institute's efforts are coordinated with existing hospital initiatives to promote effective communication using SBAR (situation, background, assessment and recommendation) and other strategies.
The institute's mission is "to promote relational learning for health care professionals that integrates patient and family perspectives, professionalism and the everyday ethics of clinical practice." The initial focus of the group's work was on preparing clinicians for challenging end-of-life conversations in pediatric and neonatal ICUs, but its current programs have expanded to examine a broad range of difficult conversations, such as helping parents during invasive procedures and resuscitation and intervening with
families in the aftermath of medical error. Dr. Rider is developing a new program, specifically for primary care pediatricians, to be launched later this fall. "Community pediatricians face a wide range of unique communication challenges," she says. "I have found that many clinicians are interested in enhancing their skills in communicating with patients and families, especially around complex psychosocial and emotional issues." The IPEP founders are intent on responding in effective and innovative ways to the growing
awareness that emotional balance and spiritual well-being are integral
components of health. A sign of positive change is that the Accreditation Council for Graduate Medical Education (ACGME) recently delineated "professionalism" and "interpersonal and communication skills" as two of the six core competencies for physician education. The institute aims to cultivate these competencies by exploring with adult learners the moral and ethical challenges inherent in the entire range of difficult conversations occurring between clinicians, patients and families on a
daily basis.
"We begin with how to establish a human-to-human connection," says Dr. Truog. Once you do that, everything flows naturally. We don't focus on words or phrases; if you memorize a script, parents can tell it's rehearsed." Instead, participants are encouraged to actively listen to patients and their parents by being mindful and present rather than rushing them through a protocol. Then comes the hard part: live enactments. In the critical care program, for example, an interdisciplinary group of clinicians is invited to practice sharing bad news with a patient and family members, who are portrayed by actors. Faculty
facilitators set up a scenario, such as a child's near-drowning, then videotape the encounter between the clinicians and the parent-actors, while team members observe from a separate room on closed-circuit TV.
When the enactment ends, clinicians review the conversation with their fellow learners, the actors and the IPEP faculty, which includes psychosocial professionals, physicians and parents of children with life-threatening onditions. The group discusses key aspects of the conversation, including body language, tone of voice, timing and choice of words. In addition, they investigate the moral and ethical dynamics of these complex and demanding interactions. "We ask learners, 'What is this family member struggling with?' or 'How might I share the moral burden of this parent's decision?'" says Browning. "We hope they will be
remember what brought them into this work to begin with."
Evaluative data from 600 participants points to a promising future for IPEP. Learners report feeling better prepared, more confident, better attuned to their innate capacities and more appreciative of the importance of cross-disciplinary dialogue and knowledge-sharing. An impressive 99 percent of participants say they would recommend it to their colleagues. "Just having the opportunity to practice this type of conversation was invaluable," said one clinician. "We have so few opportunities to do that, and when we do, it is usually in an actual crisis situation." Another said, "What I learned is that one doesn't have to have all
the answers—one has to be genuine and real."
The IPEP founders' latest article, "Difficult Conversations in Health Care: Cultivating Relational Learning to Address the Hidden Curriculum," was recently published in Academic Medicine.
For more information about the institute or Dr. Rider's new book addressing some
of these issues, A Practical Guide to Teaching and Assessing the ACGME Core Competencies,
visit childrenshospital.org/percs.
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