A complex communication skills training program for physicians providing advanced cancer care – content development and barriers and solutions for implementation

Figures & data

Figure 1. The 5-step approach of developing, implementing and evaluating the PALLiON educational program.

Table 1. Learning objectives and skills.

Learning objectives	Skills
1 A good start	1 Agenda
2 Explore and examine	2 Symptoms and functional level 3 Perspective 4 Understanding 5 Psychosocial issues 6 Preferences 7 Needs
3 Care	8 Listen 9 Empathic statements
4 Provide information	10 Palliative care 11 Serious news 12 Prognostic information 13 End of life phase
5 Decide	14 Shared decision-making
6 A good ending	15 Summary 16 Information about what lies ahead

Table 2. Lectures with specified learning objectives and related communication challenges.

Topic	Learning objectives	Communication challenges
2 x PALLiON	Knowledge of the project	NR
The educational program	Knowledge of the program	NR
Systematic symptom assessment	Knowledge of and skills in using systematic symptom assessment Basic symptom treatment skills	Detect symptoms and assess functional level Explore patient’s thoughts about symptoms
Prognostication and prognostic tools	Knowledge of prognostic tools and how to use them Provide prognostic information	Balance hope and realism Handle patients’ and carers’ information needs
Palliative radiotherapy	Knowledge of indications for palliative radiotherapy Knowledge of fractions and responses	Provide information about treatment intention
Palliative chemotherapy	Basic knowledge about chemotherapy given in the non-curative setting Make treatment decisions together with the patient	Provide information about treatment goals, start and stop criteria Elicit the patient’s understanding and preferences Handle demands of futile treatment and unrealistic expectations
End-of-life care	Recognize signs of the terminal phase Manage good symptom treatment at end of life	Talk with patient about death and dying

Table 3. Content of the discussion groups.

Topic	Film	Queries for reflection in groups
Set the agenda	1	How does the physician set an agenda for the visit? What are the benefits of setting an agenda?
Eliciting cues and concerns	1	How does the physician detect the patients’ concerns?
Systematic symptom assessment	1	How should the physician use the symptom assessment scores in the consultation?
Referral to palliative care	1	Why is early referral to palliative care important?
Delivering serious news	2	What is most important when providing bad news? How to do it?
Conveying empathy	2	How does the physician convey empathy? Should he have done something else?
Providing information	2	Why (or why not) is it important to provide information about stop criteria when starting a new line of chemotherapy?
Prognostic communication	2	What do you think about the physician’s answer regarding prognosis?
Prognostic evaluation	2	What is the patient’s functional level now? How should this influence choice of treatment?
Handling carer’s perspective	3	How to handle demanding spouses?
Patient involvement	3	How is the patient being involved in decisions?
Ending anti-cancer treatment	3	Which five arguments does the physician use to end anti-cancer treatment? Are there other arguments?
Shared decision-making	3	The patient and the physician disagree regarding further treatment. What could the physician have done to reach a common understanding?
Talking about death and dying	4	How does the physician talk about dying and death?
Patients with small children	4	How can the physician facilitate conversations between patients and their children regarding the disease and the future?
Involvement of the carers	4	How and why should carers be actively involved in the consultations?
Talking about values, goals and preferences	4	What are the reasons to talk about values, goals and preferences with the patient?
Ending the consultation	4	How would you summarize and end this consultation?

Table 4. Content of skills training.

Themes	Assignment for role-play	Case
Provide information about palliative care services	How to introduce the palliative care unit when the patient does not have specific symptoms yet?	The patient has a bad association to palliative care due to previous loss.
Delivering serious news	How to break bad news?	The patient is in good shape and does not expect bad news.
Prognostic information provision	How to answer questions about prognosis?	The patient demands an answer to: how long will I live?
Listening and being empathic	How to address explicit expressions of emotions?	The patient expresses fear.
Shared decision-making	How to involve the patient in decision-making?	The patient has an ECOG of 2 but still wants to continue treatment.
Listening, empathy, ask-tell-ask	How to handle demands of futile treatment? How to solve a situation where the patient and physician disagree?	The patient demands anti-cancer treatment that the physician thinks is useless.
Provide information about end-of-life care	How to talk with the patient about death and dying?	The patient is not so communicative.
Psychosocial issues - children	How to facilitate conversations between patients and their children regarding the disease and the future?	The patient is reluctant to talk about cancer with his/her children.
Psychosocial issues - spouse	How to handle when patient and carer disagree?	The spouse demands continued treatment. The patient is reluctant and tired.

Table 5. Coaching guide.

Coaching guide
Before the consultation (approx. 5 min):
Tell me about the patient and what the consultation will be about. What do you want out of this coaching session? Is there anything specifically challenging in this consultation or anything you would like me to pay specific attention to?
After the consultation (approx. 15 min)
What are your own thoughts about the consultation? Did it go as expected? Depending on the answer. Continue: How could the conversation have become even better? OR how could you have done that (referring to what he/she said) even better? Then say: I have also made some more specific notes: (Choose maximum three things to emphasize). Something general and positive (about structure, patient rapport etc). A skill that could have been more explicitly conducted. Another skill to improve or maintain. Explain with examples from the conversation. Summarize the three points. It is important to let the physician explain/elaborate after each point is made.

Figure 2. Reported learning benefit in percent for skills training program for residents and consultants (N = 53).

Data availability statement

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.