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Jul 24, 2020

Dr. Anthony L. Back, MD, a specialist in gastrointestinal oncology and palliative medicine at the University of Washington Medical Center and professor of medicine at the UW School of Medicine, discusses palliative care skills and practical applications to help improve patient-clinician communication and interventions to make clinicians more effective.

 

Transcript

ASCO Daily News: Welcome to the ASCO Daily News podcast. I'm Geraldine Carroll, a reporter for the ASCO Daily News. I'm delighted to welcome Dr. Anthony Back to the podcast today. Dr. Back specializes in GI oncology and palliative medicine at the University of Washington Medical Center, and is Professor of Medicine at the UW School of Medicine. His research focuses on patient-clinician communication and interventions to make clinicians more effective. Dr. Back, do you have any conflicts of interest to disclose in relation to the issues we'll discuss in the podcast today?

 

Dr. Anthony Back: Well, I would like listeners to know-- and thank you for that lovely introduction, Geraldine, and please feel free to call me Tony. I would like listeners to know that I co-founded a nonprofit called VitalTalk using work that had been funded by the National Cancer Institute over a number of years. And I am on the board of that organization, and it is a nonprofit, but listeners should know.

 

ASCO Daily News: Great. All right, Tony, you have dedicated your career to improving communication between physicians and patients. Can you tell us about the work you've been doing to bring humanism and medical expertise to the oncologist-patient relationship? And I'd love to know why you decided to focus on this approach in palliative medicine.

 

Dr. Anthony Back: Yeah, sure. I started to focus on this-- really, it was out of kind of necessity. It turns out my mother died of a blood cancer when I was a sophomore in college. And so I was confronted with this issue of mortality quite early, and it really did shape my college career and my medical school career, because I suddenly thought, wow, I just I just can't do all this career stuff, I have to figure out how to live, and that led me to a college career of reading the great novels. And it turned out that my senior thesis, which was about narrative technique, was the beginning of my learning to closely study human conversations.

 

And so when I was an oncology fellow, what really struck me was the way that doctors cared so deeply about the patients that they saw, and yet when they interfaced with them, when they got together with them, what they said seemed so limited and so-- like a partial truth. Like what was said in the conference room wasn't at all what was said in front of the patients.

 

And over time what I could see is that patients suffered from not getting the full story in a way they could listen to. As we've gotten more and more data about how patients do, we have more data to present to them, but very often it's presented in a way that doesn't quite resonate for them. And so I think very often it fails to land, basically. There are a number of studies that show that patients hear information or receive information but that it doesn't affect their decision-making, it doesn't affect their understanding.

 

And what I think that speaks to is that just giving information is not enough. Like we have to engage patients in the way they live at the emotional level in some way, because for all of us-- actually, how humans are built, we process the most important things about our lives through our emotions and our intellects. And so I came to this as a way of trying to enable patients to live better even in the face of their cancer.

 

I cut my teeth early in the movement of palliative medicine, and that movement started with a lot of emphasis on having a good death, which was, of course, a revolutionary idea that had come from hospice. But I think what has landed now and what resonates with patients now is this idea of, how do I live as much as I can in whatever time I have? And I feel like that's the way we ought to be approaching this now.

 

And bringing that to a large number of patients really required that I go beyond my role as an academic and learn to take a kind of communication training that we had developed over years with funding from the National Cancer Institute and scale it using tools developed by social entrepreneurs and startups.

 

And so VitalTalk was started about five years ago as a startup, and basically I took lessons from all the social entrepreneurs in Seattle and San Francisco about how do you start a company, how do you change people's behavior, how do you get people to pay attention? Because doctors are pretty busy. So that's been a little bit of my journey.

 

And what's really moved me about this is that as palliative care has come to be seen as a essential part of what oncologists do and what cancer patients need, there is a large group of clinicians who recognize that and are willing to work on it and are really interested in those kinds of connections with the people that they work with. And so that's really interesting and gratifying to see.

 

ASCO Daily News: Well, I know many listeners will agree with you, but they will also say they work in a system that doesn't really reward oncologists for having the skills to navigate difficult conversations with patients or to take the time to be more present - to practice that compassionate silence you talked about. How do you teach oncologists to listen effectively and ask the right questions in this kind of complex environment?

 

Dr. Anthony Back: Yeah. So first, I mean, I've got to acknowledge that the environment, in many ways, doesn't prioritize this. I actually think that if you ask oncologists what are the really important things they do, virtually all of them would name connecting with patients in the top couple of things.

 

And I think, for many oncologists, those connections are the deepest satisfaction in their careers. And so even though the environment is rushed, it focuses a lot on time pressure, it grades oncologists by their productivity, what I can do is remind oncologists of how satisfying it is to have these connections, and to show them that a small investment in doing this kind of work pays off in spades over and over and over.

 

And once you start to see that, you really can't unsee it, and I think that's what really changes oncologists' practice. It's not by other people telling them what to do, it's by them feeling like this is really the right way to practice. And it's still a challenge, and it's also kind of busting this myth that if I just had more time, I could do this. Actually, you don't need that much more time. What you really need is skill. If you don't have very well-developed communication skills, it takes a really long time to communicate effectively. And so that is where this idea comes that you need lots of time.

 

But if you have well-honed communication skills, you can take advantage of whatever piece of time you have and make that meaningful for your patient and make that meaningful for you.

 

ASCO Daily News: Right. And so what are some of those key questions to ask a patient? How does an oncologist practice very good primary palliative care?

 

Dr. Anthony Back: Yeah. So a couple of the things that oncologists can do are make sure that they have thought to themselves-- and this is in an article that we wrote for the ASCO Educational Book about palliative care and communication, and I mentioned that oncologists can take a moment before they go in the room to be clear about a couple of things-- what's happening, how does the patient feel or how might they feel, how do I feel, and then the third one is, what does it all mean?

 

And by being clear about those, you can manage both the information and the emotions needed to make that encounter valuable for both you and the patient. And by valuable, I don't mean just that they understand, but I also mean that they take appropriate action, because the big goal is for every patient to have treatments that match their values, right? And so that's where this comes from.

 

So how you do that is-- I think the number one recommendation I have for oncologists is, make sure that as you present information, that you also listen for the emotions that are underneath the surface, and that you acknowledge them by saying, wow, it sounds like that's a big issue, or wow, I can see why that's so important to you, or I can't imagine what it would be like to be living with these kinds of challenges.

 

I think those little things, which seem, on the one hand, almost like throwaways, actually can change the course of a conversation. And what the studies show is that when clinicians acknowledge patients' emotions explicitly, that patients actually give them more information, because what you're doing as a clinician there is you are creating psychological safety, an atmosphere in which patients will tell you what's really on their minds.

 

And it turns out, getting to that point quickly, having the patient tell you what's really on their minds, actually saves time in the long run. You don't have all those follow-up calls after the visit because the patient didn't say what they really wanted to ask. You don't have long visits where you go around and around and around because the patient isn't able to say what's on their mind.

 

It's really up to us to create that environment where patients can really speak freely, because they're coming on our turf, they're in our offices, they're under our time constraints. And so they're very conscious of how limited our availability is and how much they need to say the things that are going to get them what they think they need from us, which are the best treatments, the best care the right referrals, right? All that stuff. I think most patients are very aware of that and very conscious of how they take up the time when they're in the office.

 

So my number one recommendation is to pay attention to that emotion channel and acknowledge it explicitly. I mean, you can be very a very nice person and very warm, but it turns out that explicit verbal acknowledgment takes the conversation to another level.

 

ASCO Daily News: Absolutely. Well, Tony, we're now living in a COVID-19 world, and we've seen a sharp increase in telehealth-based palliative care during the COVID-19 pandemic. Telehealth based care will likely continue for some time in the future because of the pandemic. Can you tell us a little about telehealth-based palliative care and how the pandemic will impact palliative care in the future?

 

Dr. Anthony Back: Sure. Well, I would say that we've entered an era of telehealth oncology care, right? It's not just the palliative part of the care, it's all-- it's many aspects of oncology care aside from a few infusions or surgery or radiation treatments. But I think COVID has actually accelerated something that was happening very slowly that actually really benefits patients, which is the ability to talk to their doctors and nurses and nutritionists and social workers without having to come into the cancer center or clinic, and I think that access, I think it has the potential to really improve palliative care, because both the clinicians and the patients won't be thinking, ooh, this issue isn't big enough for me to bother to come in; oh, this issue isn't big enough for me to come in and deal with the traffic and find parking and all that sort of stuff.

 

So I actually think that care that addresses quality of life for patients with cancer, that a good deal of it can be done over a good telehealth encounter, and that overall, that will really benefit patients in the short run and the long run. And I think it will actually benefit clinicians, too, because I think they'll be able to feel like they're doing the right thing and it'll-- and it's easy-- in some ways, it's easier.

 

Now it doesn't replace face-to-face encounter, there is still a place for the face-to-face encounter, but there is a lot you can do in telehealth. And so I feel kind of excited about this, actually. I am not that worried about it, except that I want to make sure that some of the policy issues that have made telehealth more accessible now are continued permanently.

 

ASCO Daily News: So let's focus on community-based palliative care for a moment. In your article published in ASCO's Educational Book, you reported an improvement in care quality, patient-centeredness, and cost reduction. Can you tell us more about the benefits of community-based palliative care for patients, caregivers, and clinicians?

 

Dr. Anthony Back: Yeah. Well, now there are a number of studies that show that for patients with advanced cancer, that having concurrent palliative care improves a number of outcomes.

 

It improves symptom outcomes like pain, it improves mood outcomes like depression, and in some circumstances, that even improves survival, and the reason for that is probably that it decreases the amount of chemotherapy at the very end of life that probably shortens your life, it doesn't lengthen it, right? Because if you're really weak, having more chemotherapy may do more harm than good, and I think that's been made very clear by the research that's out there, and it's very high-quality research, and it's more than one study, it's now a whole bunch of studies.

 

And so I think what that means for us as oncologists is figuring out, how do we enable patients to access that kind of care in a way that dovetails with what we do in our oncology practices? Because some of that palliative care will happen in our practice, some of that palliative care may happen outside the practice.

 

And I think there are pros and cons to both things. For patients who often see their primary oncologist as a person-- the captain of the ship, right? The person who's making the big decisions, having that person include palliative care in the treatment plan is like a huge sign to the patient that this is really important, and it enables patients to act and work on those things because they see that the oncologist values them, too.

 

On the other hand, I think there are times when it is valuable for a patient to see a palliative care clinician who isn't their oncologist because I think some patients find it easier to talk to other clinicians about some really sensitive topics, because those patients, they worry about disappointing their oncologist, they worry that their oncologist will feel unwanted or feel like the patient has been disloyal.

 

And of course, I think many of those feelings are much more in the patient's hearts than in the oncologists' hearts, but it turns out to be a little bit of a barrier, and there now is a great deal of on-the-ground clinical experience that shows that having another person to talk to that you come to trust is incredibly valuable in helping enabling somebody to navigate this complicated journey.

 

ASCO Daily News: Right. So let's talk about oncology practices. In its 2017 guideline, ASCO recommended integrating palliative care into standard oncology care for patients with advanced cancer, but it's proving to be quite a challenge to increase primary palliative care. Why is it so difficult?

 

Dr. Anthony Back: Yeah. Well, I think one of the reasons has to do with how oncology care is funded, right? So if oncology care continues to be funded as a kind of a procedure-driven thing, that actually makes it harder to create palliative care capacity within oncology practices, because it's much easier to fund palliative care if a practice is being funded kind of on a value-based scheme rather than on a procedure-based scheme.

 

I also think that there is this sense among oncologists that palliative care clinicians are horning into something that was kind of their domain. Like they were the ones who did everything, they're responsible for everything. And when I was trained as an oncology fellow, that's how I was trained, like I was-- the buck stopped with me and I was responsible for everything. And I came to own that and take pride in that and feel responsible for it.

 

And now this is much more of a team sport where we have to acknowledge and find colleagues that we really enjoy sharing patients with. And so I think building those kinds of relationships among our colleagues who are palliative care clinicians and finding the ways to fund those people so that they're available enough in a practice to make a difference, I think those are some of the barriers we're still working on.

 

We've made a lot of progress on this, and I think the fact that ASCO endorsed this is a huge step in the direction of policy that will make this sustainable and robust. And we still have a ways to go.

 

ASCO Daily News: Well Tony, this has been such a fascinating conversation. Any tips you'd like to share with oncologists before we wrap this up? Anything else you'd like to add?

 

Dr. Anthony Back: Yeah. Well, my big tip is that what this is about is investing a little bit of time upfront for a payoff that comes again and again and again in your work with patients. Because basically, good communication is about building trust, and if there is one thing that you need as an oncologist when it comes to making difficult and tough decisions, you need to have earned that patient's trust, right? It's not going to happen in one conversation. It really is the beauty of the continuity that you get with a career in oncology, and it's an incredibly satisfying way to practice. So that's my last tip.

 

ASCO Daily News: Absolutely. And I'd like to just remind our listeners about the article that you've published along with your co-authors, Dr. Tara Friedman and Dr. Janet Abrahm in the ASCO Educational Book on "Palliative Care Skills and New Resources for Oncology Practices-- Meeting the Palliative Needs of Patients with Cancer and Their Families." Thank you, Tony.

 

Dr. Anthony Back: Thank you.

 

ASCO Daily News: And thank you to our listeners for joining us today. If you're enjoying the content on the podcast, please take a moment to rate and review us on Apple Podcasts.

 

The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.