Responding empathically to patients: a communication skills training module to reduce lung cancer stigma

Abstract

Most lung cancer patients report perceiving stigma surrounding their diagnosis, and routine clinical interactions with their health care providers (HCPs) are reported as a common source. The adverse effects of lung cancer stigma are associated with several adverse psychosocial and behavioral outcomes. One potential clinician-level intervention target is empathic communication because of its association with higher rates of patients’ satisfaction, treatment adherence, and lower levels of psychological distress. This study describes the conceptual model and evaluation of clinician-targeted empathic communication skills training to reduce lung cancer patients’ experience of stigma. The goal of the training module is to enhance clinician recognition and responsiveness to lung cancer patients’ empathic opportunities by communicating understanding, reducing stigma and distress, and providing support. Thirty multidisciplinary HCPs working in thoracic oncology, thoracic surgery, or pulmonary medicine participated in 2.25 hr of didactic and experiential training on responding empathically to patients with lung cancer. Overall, participants reported highly favorable evaluations of the training, with at least 90% of participants agreeing or strongly agreeing to 11 of the 12 items assessing clinical relevance, novelty, clarity, and facilitator effectiveness. Participants’ self-efficacy to communicate empathically with lung cancer patients increased significantly from pretraining to posttraining, t(29) = −4.58, p < .001. The empathic communication skills training module was feasible and well received by thoracic and pulmonary medicine HCPs and demonstrated improvements in self-efficacy in empathic communication from pretraining to posttraining. The examination of patient outcomes is warranted.

Implications.

Practice: Communication skills training module that teaches health care providers (HCPs) to respond empathically to patients is feasible and acceptable and can be applied to/rolled out into clinical settings to ensure its translational potential.

Policy: Communication skills training module that teaches HCPs to respond empathically to patients should be offered to HCPs treating lung cancer patients to reduce the stigma associated with lung cancer.

Research: Future research should examine the impact of HCP-focused empathic communication skills training on lung cancer patients’ perception of stigma from HCPs.

Introduction

Nearly all (95%) patients diagnosed with lung cancer report perceiving stigma, defined as a perception and internalization of negative appraisal and devaluation by self and others attributable to a lung cancer diagnosis [1]. The deleterious effects of lung cancer stigma on patient outcomes include negative psychological outcomes [2–10], including depression and withdrawal [3,10]. The three main sources of perceived stigma are from family and friends, medical providers, and the general public [2,4]. Prior research indicates that 48% of patients with lung cancer report experiencing stigma from their health care providers (HCPs) [2]. Perceived stigma may be triggered and/or exacerbated by providers’ routine assessment of smoking history, or insinuation that patients are to be blamed for their cancer [2]. Perceived stigma from medical providers has been associated with patients’ delaying [11] and underreporting [12,13] their symptoms, misreporting smoking behaviors [4], and avoiding help seeking, such as smoking cessation counseling. Thus, prior research indicates that perceived stigma within medical encounters may be prevalent and problematic for patients’ well-being and quality of cancer care.

When patients express negative emotions (e.g., guilt, shame, or regret) about their smoking history, there is an opportunity for HCPs to respond empathically. Although empathic opportunities (EOs) occur frequently in clinical encounters, prior research indicates that physicians rarely recognize EOs [14]. One observational study found that as many as 90% of EOs were missed during routine clinical encounters with lung cancer patients [15] and 40% of physicians responded to patient disclosures of smoking history with responses such as “your smoking has done a number on your lungs,” [15] which may be readily inferred by patients as judgmental and blaming. Similarly, research indicates that nurses also miss out on EOs that occur during nurse–patient interactions [16]. HCPs’ empathic communication is associated with higher rates of patients’ satisfaction [17] and lower levels of psychological distress [18]. One small study indicated that physicians who use an empathic, caring approach (e.g., encouragement and sincerity) may be more effective at promoting smoking cessation [19]. Given these positive effects of empathic communication, it could be a potentially effective intervention target to help reduce patients’ perceptions of stigma within clinical encounters.

Empathic communication

Although many definitions exist for the term “empathic communication,” we favor the definition proposed by Pehrson et al. [20] because it is grounded in the empathic opportunity–response conceptual model of empathy [21]. Empathic communication, therefore, is the recognition or elicitation and response to patients’ EOs to communicate understanding, alleviate distress and provide support [20]. EOs describe an occurrence within a clinician–patient encounter in which the patient makes a “direct or indirect comment that provides information about any aspect of a patient’s life circumstances or feelings” [22, p. 1021].

Smoking assessment, empathic communication, and lung cancer stigma

Recognizing the deleterious consequences of persistent smoking for lung and all other cancer patients, the National Comprehensive Cancer Network has established clinical guidelines for promoting smoking cessation in the context of cancer care [23]. Adherence to these guidelines requires periodic assessment of current tobacco use and brief cessation counseling for current smokers. Although tobacco use assessment and cessation counseling are widely considered a standard of high-quality cancer care [24], it is apparent that some patients find having smoking-related discussions with their oncologists to be uncomfortable. Considering the highly prevalent clinical problem of persistent smoking following cancer diagnosis [25] and the potential for assessment of smoking status to be awkward and distressing, improving empathic communication in the context of lung cancer patients’ expressions of guilt and blame may improve patient–physician communication, reduce perceived stigma and psychological distress, and increase patients’ acceptance of smoking cessation advice and assistance [26].

To address this key need, we modified an empathic communication skills module that had been developed for oncology nurses [20]. For this adapted empathic communication module, we focused on the communication challenges inherent in HCPs’ discussions of smoking behavior and history with lung cancer patients. The primary aim of this article is to discuss the content and adaptation of the empathic communication module for reducing lung cancer stigma. Guided by the Kirkpatrick Model [27], the secondary aim of this article is to demonstrate initial support for the effectiveness of the module as evidenced by HCPs’ reported confidence in communicating empathically, their intention to use the skills they learned in training, and their overall satisfaction with the module.

Methods

The Communication Skills Training and Research Lab (Comskil) in the Department of Psychiatry and Behavioral Sciences at Memorial Sloan Kettering Cancer Center originally developed an empathic communication module to improve the communication between oncology nurses and their patients [19]. The goal of the module was to recognize, elicit, and respond to patients’ EOs in order to communicate understanding, alleviate distress, and provide support [20, p. 611]. To tailor this module for the current project, we identified specific common challenges experienced by lung cancer patients through focus groups with lung cancer survivors [28].

Participants and procedures

Thirty HCPs working in thoracic oncology, thoracic surgery, or pulmonary medicine at MSK participated in a 2.25 hr Comskil training on Responding Empathically to Patients: A Communication Skills Training Module to Reduce Lung Cancer Stigma from December 2017 to April 2019. The multidisciplinary participants included 11 clinical nurses (36.7%), 8 physicians (26.7%), 7 physician assistants (23.3%), and 4 nurse practitioners (13.3%); a majority were female (n = 25, 83.3%). The participants worked in various cancer care settings, including thoracic surgery (n = 19, 63.3%), thoracic oncology (n = 3, 10.0%), radiation oncology (n = 3, 10.0%), pulmonary service (n = 3; 10.0%), and thoracic survivorship (n = 2, 6.7%).

Participation was voluntary. Participating HCPs were eligible based on two criteria. First, they needed to be a member of the MSK Thoracic Disease Management Team currently treating thoracic patients (per HCP self-report). We included any of the following types of HCPs: attending physicians (radiologist, medical oncologist, or thoracic surgeon); advanced practice providers (APPs, i.e., nurse practitioner [NP] or physician assistant [PA]); medical trainees (fellow or resident); and other clinical nurses (i.e., clinical nurse specialist [CNS], or registered nurse [RN]). Second, the clinician had to conduct routinely individual clinic consultations during which assessment of smoking history was conducted with the target patient population of English-speaking, adult patients (at least 18 years of age) who had a suspicious lung mass or confirmed lung cancer diagnosis, were a former or current smoker, and had no more than three visits with the clinician or diagnosed within the past 6 months. This study was reviewed and approved by the MSK Institutional Review Board.

Recruitment

In order to recruit HCPs, the lead study investigators (S.B. and J.O.) contacted service chiefs, attending physicians, and other HCPs in supervisory roles, followed by a presentation of the rationale, procedures, benefits, and risks of the study at Thoracic Disease Management Team and Pulmonary Service meetings. Eligible HCPs were emailed a study invitation with a participant information sheet providing details on study procedures and, then, the research study assistant met with the HCPs that expressed an interest in participation to consent them.

Modular content and format

The training goal of this 2.25 hr communication skills module was to enhance clinician recognition and responsiveness to lung cancer patients’ EOs by communicating understanding, alleviating stigma and distress, and providing support. Consistent with the Comskil Conceptual Model [29], we presented seven recommended communication strategies (a priori plans) to achieve the communication goal: agenda setting, history taking, recognizing or eliciting a patient’s empathic opportunity, shared understanding of the patient’s emotion/experience, empathic responding, coping and connection to social support, and closing the conversation. The strategies can be accomplished through the use of communication skills (standalone verbal utterances) and process tasks (set of verbal and nonverbal behaviors that create a conducive environment for effective communication; see Table 1). The didactic modular content was followed by experiential role-play exercises with standardized patients (additional details about the intervention are provided in the Supplementary Material).

Table 1.

Modular blueprint for responding empathically to patients: a communication skills training module to reduce lung cancer stigma

Strategies	Skills	Process tasks
1. Agenda setting	- Declare agenda - Normalize - Provide clinical rationale (for asking about smoking history) - Invite agenda - Negotiate agenda, if appropriate	- Greet patient appropriately - Make introductions - Ensure patient is clothed - Sit at eye-level
2. Questioning and history taking	- Ask open questions - Clarify - Restate	- Follow the list of questions for taking smoking history
3. Recognize or elicit a patient’s empathic opportunity	- Ask open questions (about smoking) - Acknowledge - Encourage expression of feelings	- Notice patient’s nonverbal communication
4. Work toward a shared understanding of the patient’s emotion/experience	- Ask open questions - Check patient understanding - Clarify - Restate	- Avoid leading questions/blaming statements - Avoid giving premature reassurance
5. Empathically respond to the emotion or experience	- Acknowledge - Validate patient struggle with tobacco dependence (will vary by smoking status) - Normalize nicotine addiction - Praise patient efforts	- Identify patient’s strengths and sources of support - Provide clear physician recommendation for quitting - Emphasize benefits of quitting
6. Facilitate coping and connect to social support	- Prepare patient for recurring smoking assessment - Suggest counterarguments (will vary by smoking status) - Invite questions	- Make referrals - Express a willingness to help - Make partnership statements
7. Close the conversation	- Praise patient efforts - Endorse question asking - Review next steps	- Reinforce joint decision-making

Goal: to enhance clinician recognition and responsiveness to lung cancer patients’ empathic opportunities by communicating understanding, alleviating stigma and distress, and providing support.

Evaluation of empathic communication training module

Consistent with the Kirkpatrick Model [27], training was evaluated in several ways, including module evaluations to elicit participants’ perceptions about the module and their self-efficacy before and after training to ascertain the change in confidence in the use of communication skills learned to reduce lung cancer patients’ experience of stigma.

Module evaluations

Immediately following the module, participants were given an evaluation form, modeled after prior Comskil evaluation measure [29] that contained 12 statements using a five-point Likert scale with anchors of (1) “strongly disagree” to (5) “strongly agree.” The statements measured posttraining attitudes, including the skills learned (e.g., “The skills I learned in this module will allow me to provide better patient care”), relevance of the content of the module (e.g., “The information in the module related closely to me”), novelty of the training (e.g., “The module taught me something new about discussing smoking with my patients with empathy and sensitivity”), clarity of presentation (e.g., “The didactic was easy to follow”), and facilitator effectiveness (e.g., “The small group facilitators were effective”). In addition, participants were asked to rate three curricular activities (didactic teaching, exemplary video, and role-play experience) using a three-point Likert scale with anchors of (1) “did not aid my learning at all” to (3) “aided my learning a lot.”

Self-efficacy

Self-efficacy was assessed using a retrospective pre–post methodology [30] in which participants were presented with the following two items rated on a five-point Likert scale with anchors of (1) “strongly disagree” to (5) “strongly agree: “Before this module, I felt confident communicating empathically with my patients” and “Now that I have attended this module, I feel confident in my ability to communicate empathically with my patients.”

Data analysis

For module evaluation, a rating of “agree” or “strongly agree” was considered to be an indicator of satisfaction with the module and was analyzed descriptively. For assessing improvements in self-efficacy, paired t-tests were used to assess significant pretraining and posttraining differences. In addition, we computed a change score for self-efficacy (posttraining self-efficacy score minus pretraining self-efficacy score) and used independent sample t-tests to analyze subsample differences based on clinician sex (male vs. female), clinician role (MD vs. APP [NPs and PAs combined] vs. RNs), and clinician service (thoracic service vs. other services).

Results

Module evaluations

Overall, clinician participants rated the training favorably. Specifically, more than 90% of the 30 participants indicated that they “agreed” or “strongly agreed” with 11 of the 12 evaluation items (with 1 item receiving endorsement by 65% participants; see Table 2). In addition, the majority of clinician participants (>90%) rated each individual modular component as aiding in learning (as indicated by cumulative scores for “somewhat aided my learning” or “aided my learning a lot”; see Table 2).

Table 2.

Participant-rated evaluations for responding empathically to patients: a communication skills training module to reduce lung cancer stigma (n = 30)

Items from module evaluation	M (SD)	Endorsement
1. I feel confident that I will use the skills I learned in this module.	4.70 (.47)	100%
2. The skills I learned in this module will allow me to provide better patient care.	4.73 (.45)	100%
3. The module prompted me to critically evaluate my own communication skills.	4.73 (.45)	100%
4. The skills I learned were reinforced through the feedback I received in the small group.	4.77 (.43)	100%
5. The small group facilitators were effective.	4.90 (.31)	100%
6. The information in the module related closely to me.	4.46 (.65)	92.3%
7. I identified with the lung cancer clinician–patient interactions that were discussed in the module.	4.54 (.76)	92.3%
8. The module contained a lot of information about communication skills and empathy that was new to me.	3.81 (.98)	65.4%
9. The module taught me something new about using empathy to reduce lung cancer patients’ experience of stigma.	4.65 (.56)	96.1%
10. The module taught me something new about discussing smoking with my patients with empathy and sensitivity.	4.54 (.58)	96.2%
11. The information in the module was hard to understand. (R)	4.27 (.83)	96.2%
12. The didactic was easy to follow.	4.46 (.58)	96.2%
Items from program evaluations
13. Didactic teaching	2.63 (.56)	96.7%
14. Exemplary video	2.73 (.58)	93.3%
15. Role-play experience	2.87 (.43)	96.7%

Items 1–12 were scored on a five-point Likert scale with anchors at (1) “Strongly Disagree” to (5) “Strongly Agree;” Items 13–15 were scored on a three-point Likert scale with anchors at (1) “Did not aid in my learning at all” to (3) “Aided in my learning a lot.” Endorsement = percentage of participants that endorsed “Agree” or “Strongly Agree” (Items 1–12) or percentage of participants that endorsed “Aided my learning somewhat” or “Aided my learning a lot” (Items 13–15).

Self-efficacy

Paired sample t-tests were performed to assess overall change in self-efficacy in communicating empathically with patients. Overall, results indicated a significant change, t(29) = −4.58, p < .001, in self-efficacy for empathic communication ratings from pretraining (M = 3.70, standard deviation [SD] = 0.70) to posttraining (M = 4.40, SD = 0.50). Additionally, we examined if clinician-specific variables (sex, role, or service) were differentially associated with the change in self-efficacy from pretraining to posttraining. We were likely underpowered for these analyses, but preliminary examination did not show any significant differences in self-efficacy change score by clinician sex, role, or service.

Discussion

This study demonstrated the feasibility and promise of implementing a communication skills training module for thoracic oncology HCPs to respond empathically to patients with the ultimate goal of reducing lung cancer stigma. The potential benefit of the module was evidenced through favorable course evaluations and significant improvement in self-efficacy in communicating empathically with patients. With encouraging favorable evaluation of the training module, the next steps include the assessment of observable change in clinician communication skills and reduction in lung cancer patient reports of perceived stigma during consultations.

The focus of the module was on using empathic communication skills to provide greater understanding and support to lung cancer patients while taking a smoking history during clinical consultations. To the best of our knowledge, this is the first communication skills training module specifically designed to improve clinician empathic communication with the ultimate goal of decreasing lung cancer patients’ perceptions of health care provider-induced stigma. As such, this work contributes to the growing literature on the importance of assessment of smoking behavior and advisement of cessation in cancer care [24] by providing practical guidance on how to best engage and structure smoking-related discussions with lung cancer patients.

Our data indicate a favorable evaluation of the empathic communication skills module across various domains, including the applicability of skills in learners’ clinical practice, the relevance of the content of the module, clarity of presentation, and facilitator effectiveness. Only one item in the module evaluation received low endorsement (“The module contained a lot of information about communication skills and empathy that was new to me”). This is not all that surprising given the heightened focus on effective communication skills training in medical schools and GME programs [31]. It is possible that the learners were aware of different kinds of communication skills and, therefore, rated the module low on the novelty of communication and empathy skills. However, more than 95% of participants gave a high endorsement to the item about the applicability of empathy skills to reduce lung cancer patient stigma (“The module taught me something new about using empathy to reduce lung cancer patients experience of stigma”). This finding clearly indicates that our empathic skills training module applied communication skills in a novel clinical context.

Implications of the study

Building upon the well-established clinical practice guidelines for assessment and brief treatment of tobacco dependence in health care settings [32], this work contributes to the field by providing guidance on how HCPs can best structure and facilitate nonjudgmental and supportive smoking-related discussions with lung cancer and, perhaps, other patients with smoking-related medical conditions who may be prone to experiencing stigma during routine assessment of smoking history and current status. It is also likely that these empathic communication skills could help to engage smokers and former smokers seeking lung cancer screening in shared decision-making and uptake of cessation support services. Encouraged by the feasibility of conducting this didactic and experiential training with busy cancer care clinicians and the initial favorable participant evaluation of the empathy training module, results clearly indicate that this training can be rolled out into clinical settings to ensure its translational potential. The next steps should assess observable changes in empathic communication skills and, ultimately, reductions in lung cancer patient reports of perceived stigma during clinical consultations.

Limitations

We recognize that this study has some limitations. This study was carried out at a comprehensive cancer center in the northeast USA, which has a well-established communication skills training and research lab dedicated to improving clinical communication. As such, the results may not be generalizable to other cancer centers or hospital settings. Second, our multidisciplinary clinician participants included physicians, APPs (i.e., PAs and NPs), and clinical nurses. With few participants representing each specific clinical care role, we had inadequate power to conduct stratified analyses. Future larger-scale, fully powered trials could assess outcomes by various clinician roles. Third, we only included a two-item participant-report measure of self-efficacy and did not include a behavioral assessment of empathic communication skill use with patients. Although the findings of the current study demonstrate clinician-reported improvements in self-efficacy to communicate empathically with lung cancer patients, it would be helpful to assess clinician use of communication skills objectively with patients before and after training. Finally, the application of training to study patient outcomes, particularly, as they relate to perceptions of stigma from HCPs, is recommended for future research.

Conclusion

This paper presents the development, implementation, and initial evaluation of an empathic communication skills training module for oncology HCPs to reduce lung cancer stigma. Results demonstrate that such training at a major cancer center is feasible and acceptable and has a significant impact on participants’ self-efficacy for empathic communication.

Funding:

Research reported in this paper was supported by a National Cancer Institute grant (R21CA202793: Provider Training in Empathic Communication Skills to Reduce Lung Cancer Stigma; MPIs: J.S.O. and S.C.B.), a K-award (K07CA207580; PI: M.J.S.), and a Cancer Center Support Grant (CCSG-Core Grant; P30 CA008748; PI: Craig B. Thompson, MD). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Compliance with Ethical Standards

Conflicts of Interest: The authors S.C.B., N.H., C.L.B., M.J.S., M.R., H.A.H., P.A.P., and J.S.O. declare that they have no conflicts of interest.

Authors’ Contributions: Conception or design of the work: S.C.B., C.L.B., M.J.S., H.A.H., J.S.O.; Data collection: S.C.B., N.H., M.R., J.S.O.; Data analysis and interpretation: S.C.B., N.H., C.L.B., M.J.S., M.R., H.A.H., P.A.P., J.S.O.; Drafting the article: S.C.B., J.S.O.; Critical revision of the article: S.C.B., N.H., C.L.B., M.J.S., M.R., H.A.H., P.A.P., J.S.O.; Final approval of the version to be published: S.C.B., N.H., C.L.B., M.J.S., M.R., H.A.H., P.A.P., J.S.O.

Ethical Approval: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. For this type of study, formal consent was required. This article does not contain any studies with animals performed by any of the authors.

Informed Consent: Informed consent was obtained from individual clinician participants.