Walther Program director driven to improve physician-patient communication

November 6, 2014

For anyone, the loss of a parent is a devastating experience. For Richard Frankel, Ph.D., it was also a call to action.

After an error in communication during a routine hospitalization hastened the death of his mother in the 1970s, IU research sociologist Dr. Frankel began to engage more deeply in questions about how doctors communicate, with a particular interest in physician-patient communications related to care at the end of life.

Richard Frankel, Ph.D.,  director of the Mary Margaret Walther Palliative Care Research and Education Program.

"How we die is a lifelong question that everybody asks themselves from time to time," Dr. Frankel said. "As a social scientist, I think end-of-life and palliative care decisions are some of the most difficult to face and to research. My mother's story has given me passion and energy to do this work of improving physicians’ communication skills in areas such as delivering bad news and talking about death and dying -- skills that they were likely never taught in medical school or residency."

Dr. Frankel joined IU in 2002 as a professor of medicine at the IU School of Medicine, a senior scientist at the Regenstrief Institute and an associate director of the Center for Healthcare Information and Communication at the Richard L. Roudebush VA Medical Center. In 2010, the IU Simon Cancer Center received a $3.4 million grant from the Walther Cancer Foundation to establish the Mary Margaret Walther Palliative Care Research and Education Program. Following a national search, Dr. Frankel was selected as the program’s first director in late 2012.

On Nov. 17 and 18, the program will host its first major event, "Passages and Promises: Innovations in Palliative Care Research, Education and Communication." On the first day, best-selling author Gail Sheehy and poet and philosopher Mark Nepo will join national palliative care experts Robert M. Arnold, M.D.; Amber E. Barnato, M.D.; Vicki Jackson, M.D.; Timothy E. Quill, M.D.; and local presenters, for a series of talks, workshops and small-group discussions exploring the latest innovations in research, communication and care for people with serious illness. 

Sheehy, Nepo and Dr. Quill will also headline the public conversation capping the 19th annual Spirit & Place Festival at Christian Theological Seminary on Nov. 16. This year’s event theme, “Journey,” includes the role of dignified death as part of end-of-life care.

In addition to being a national expert, Dr. Quill is a past co-director, along with Dr. Frankel, of the program for biopsychosocial studies at the University of Rochester. Frankel was also co-director of the internal medicine residency program at Highland Hospital, an affiliate of the University of Rochester Medical Center, from 1990 to 2001, where a strong emphasis was placed on integrating psychological and social aspect of care into the training program. It was also during this period that Dr. Frankel and a colleague from Kaiser Permanente, the country's largest nonprofit health care organization, developed a model of teaching physician communication skills called "The Four Habits of Highly Effective Clinicians."

The Four Habits are "Invest in the Beginning," "Elicit the Patient's Perspective," "Demonstrate Empathy" and "Invest in the End." The approach has now been used to train thousands of physicians at Kaiser and across the country, including recently at the Cleveland Clinic, where more than 1,000 physicians were trained using the approach.

"This is a highly evidence-based system," Dr. Frankel said. "There now are a number of studies and systematic reviews that show the positive effects of improved communication on patients' biomedical as well as psychosocial health outcomes. For patients with life-limiting conditions who may be facing difficult decisions about treatment, pain management and uncertainty about their future, a well-trained physician with outstanding communication skills can be a godsend and help with choices that align with, and respect, their goals and wishes."

This has not always been the case. In one well-known study, Dr. Frankel and a colleague found that 70 percent of the time, physicians interrupted patients, on average, 18 seconds after asking them why they had come to see the doctor. Once interrupted, these patients almost never raised additional concerns at the beginning of the visit.

In another study, when older adult patients were asked to prioritize their reasons for seeking care, the third item on their list turned out to be most important. Since most patients were interrupted after their first stated concern, many physicians may never actually learn what is most important from the patient’s perspective.

"The beginning of the visit is also the first opportunity for shared decision-making, which can affect the course, direction and outcome of a visit," Dr. Frankel added. "It goes without saying that this is especially important in palliative care and end-of-life discussions."

Although the importance of good communication is increasingly recognized in the medical community, Dr. Frankel acknowledges that it wasn’t on the top of everyone’s list of topics to teach medical students or residents in the early 1990s.

"Typically residents, and many faculty, considered communication 'fluff,' a skill you either have or don’t but not something that requires the same type of training as a medical procedure, such as reading an EKG,” he said.

That attitude has largely disappeared, he added, and most physicians are eager for expert advice on how to negotiate the often difficult and emotionally fraught topics they're required to broach with patients and families.

“Overwhelmingly, I think physicians are highly invested in doing the right thing and avoiding unnecessarily harming their patients with pain and suffering," he said. "There’s actually a body of literature that shows physicians who make mistakes suffer disproportionately from the mistakes they make; they're often much harder on themselves than the harms they may have caused."

As director of the Walter Palliative Care Research and Education Program, Dr. Frankel said his next goal is raising the program's profile on campus and beyond -- in part through the ideas expected to grow out of the "think tank" session comprising the second day of the Nov. 17-18 symposium. During the event, Drs. Arnold, Barnato, Jackson and Quill will partner with local investigators to develop proposals for pilot palliative care research projects, several of which will be funded up to $50,000.

"These four individuals are not only top-notch researchers, they’re generous and generative people who have agreed to play a mentoring role with our faculty," Dr. Frankel said. "I think that the ideas that will come out of the symposium are really going to give us a lot more visibility and a more substantial footprint within the national research community."

Registration for the symposium closes Nov. 7. To sign up, visit the event website.