Introduction: Teaching how to effectively lead serious illness conversations in real-time clinical encounters (e.g., clinic, inpatient rounds, telehealth encounters, family meetings) is vital for clinicians of a variety of disciplines including physicians, social workers, and advanced practice providers. It is also challenging to do well. Teachers are tasked with balancing the needs of the learner and the needs of the patient, while managing time constraints. Learners may not be accustomed to being critiqued on their communication effectiveness. Still, real-time clinical encounters offer irreplaceable learning opportunities where previously taught communication skills can be applied in relevant situations and specific and timely feedback can be offered. In this Fast Fact we present a framework for teaching how to lead serious illness discussions in real-time clinical settings. The goal with this framework is to maximize educational efficiency and effectiveness by utilizing skills practice, direct observation, and feedback, three teaching strategies with proven effectiveness in communication skills building (1).
Step 1: Pre-Encounter Preparation A brief pre-encounter huddle between teacher and learner can foster learning engagement. The teacher should provide clear expectations for the encounter to help the learner feel safe, supported, and open to learning new skills (3). Expectations may include: 1) determining who will lead each part of the conversation; 2) notifying the learner you will be taking notes 3) providing words the learner can use if they become stuck (see Step 2); 4) informing the learner the process will include self-feedback and formative feedback from the faculty after the encounter (see Step 3). See Fast Fact #421 for more guidance on providing formative feedback.
| What you say… | Why this works… |
| What will be challenging for you? | Self-identifies a challenge to enhance learner engagement |
| What communication skills could you utilize in this encounter? | Introduces previously taught communication skills as “tools” to address specific communication challenges (2) |
Step 2: The encounter Learners of all skills level can become stuck during a serious illness conversation. Learners and teachers should have specific words they can use to signal for help. Occasionally, it may be appropriate for the teacher to pass the conversation back to the learner after the teacher has intervened: “(Dr., Mr., Ms.) Jones, would you like to talk about what tests we will do next?” The teacher should take notes on specific words and behaviors of both the learner and the patient. This will enable specific and timely feedback during the post-encounter debrief (Step 3).
| What you say… | Why this works… | |
| Learner | [Teacher], do you have anything to add? | Signals for help while remaining actively engaged. |
| Teacher | May I add something? | Intervenes without diminishing learner contributions |
Step 3: Post-Encounter Debrief Feedback is essential to learning from a clinical encounter (4). Start with prompting the learner to self-examine the experienced successes and challenges.
| What you say… | Why this works… |
| How did that go? | Acknowledging emotions connected to the encounter helps focus on learning |
| What went well? | Reinforces behaviors that were successful |
| What would you have done differently? | Allows the learner to identify a specific skill they can further refine |
When addressing challenges, many learners focus on the teacher’s specific intervention(s) during the clinical encounter. By utilizing open-ended questions to address these moments, learners can identify improvement opportunities in a non-threatening way.
| What you say… | Why this works… |
| How did the patient respond after I stepped in? | Focuses on the patient’s change in behavior |
| What did I do to make that happen? | Connects the intervention to that behavior change. |
The teacher may also want to highlight a salient learning opportunity that the learner was not able to recognize. This formative feedback is most effective when the teacher uses their written notes to help the learner recall the specific moment in the encounter.
| What you say… | Why this works… |
| Did you notice how the patient was responding before I stepped in? | Directs the learner back to a specific challenge |
| Here is what I saw or heard… | If the leaner can’t remember, describe it for them. |
Consolidate the learning: At the end, identify one concise learning point that can be adapted to future situations. Help the learner connect a specific communication skill when addressing a specific communication challenge: “When I responded with empathy, the patient become less emotional”. Encourage the learner to create an action plan for using this skill in the future – “What will you do differently next time?”
Conclusion A structured approach to teaching communication skills in real time provides an impactful and efficient educational experience for learners of different levels and disciplines (5).
References
- de Sousa Mata ÁN, de Azevedo KPM, Braga LP, et al. Training in communication skills for self-efficacy of health professionals: a systematic review. Hum Resour Health. 2021;19:30. doi:10.1186/s12960-021-00574-3
- Childers, Julie W., et al. “REMAP: a framework for goals of care conversations.” Journal of oncology practice 13.10 (2017): e844-e850.
- Johnson CE, Keating JL, Molloy EK. Psychological safety in feedback: What does it look like and how can educators work with learners to foster it? Medical Education. 2020;54(6):559-570. doi:10.1111/medu.14154
- Boud, David, Rosemary Keogh, and David Walker, eds. Reflection: Turning experience into learning. Routledge, 2013.
- Back AL, Arnold RM, Tulsky JA, Baile WF, Fryer-Edwards K. “Could I add something?”Teaching communication by intervening in real time during a clinical encounter. Acad Med. 2010;85(6):1048-1051. doi:10.1097/ACM.0b013e3181dbac6f
Author Affiliations: 1University of Pittsburgh Medical Center, Pittsburgh PA; 2Oregon Health Sciences University, Portland OR.
Attribution: This content is adapted with permission from the Real Time Facilitation Map created by VitalTalk. Visit VitalTalk.org for more information on teaching communication skills in real time. With special thanks to Robert Arnold and Tony Back for content development and editing.
Version History: Originally edited by Sean Marks MD; first electronically published in February 2022
Fast Facts and Concepts are edited by Sean Marks MD (Medical College of Wisconsin) and associate editor Drew A Rosielle MD (University of Minnesota Medical School), with the generous support of a volunteer peer-review editorial board, and are made available online by the Palliative Care Network of Wisconsin (PCNOW); the authors of each individual Fast Fact are solely responsible for that Fast Fact’s content. The full set of Fast Facts are available at Palliative Care Network of Wisconsin with contact information, and how to reference Fast Facts.
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