5
Models for Teaching Communication and Attitudes JAMES J. STRAIN, MD HIS OVERVIEW describes the current knowledge of T models for teaching the biopsychosocial aspects of cancer patients, with special emphasis on ways to en- hance communication and influence attitudes. It is es- sential in reviewing this area to address three important questions: 1. What current models are used to teach the bio- psychosocial aspects of cancer care at the level of patient, public, the allied health professional, the physician, and the psychiatrist who is a teacher-re- searcher? 2. What are the critical variables needed to evaluate the effectiveness of teaching programs? 3. Based on the awareness of the critical variables and the teaching models, what is needed to develop long-range evaluation methods to assess the effec- tiveness of cancer detection and cancer care training programs on patient outcome? Despite the fact that most psychosocial care of the cancer patient is rendered by the physician and other professionals, many questions remain about how this type of support can and should be done. Few data exist which demonstrate a systematic evaluation of how ef- fective psychosocial training programs in cancer care have been. This is probably the result of the inability to reliably define the nature and extent of psychosocial needs, i.e., the patients’ psychosocial personality traits, interpersonal relationships, that occurs in medical set- tings, including ~ a n c e r . ~ . ~ ’ Most data have been obtained from epidemiologic surveys, interviews, questionnaires, and clinician’s reports. Even when psychosocial needs are clearly established, such as in patients with depres- sion, anxiety or poor adaptation to illness, the role of oncologists and primary care physicians is unclear, rec- ognizing the constraints of their training, individual ap- titudes, and diverse medical settings. The critique presented here is the result primarily of review of teaching models for primary care physicians and medical students. Nurses, social workers, clergy, volunteers and patient representatives, while not directly addressed, share common problems. Some of the generic Supported in part by NIMH Training Grant MH 16438. Professor and Director, Psychiatric Liaison Service, Mount Sinai School of Medicine, New York, New York 10029. concepts, problems, and research strategies encountered with the psychosocial training of the primary care physi- cian are applicable to other disciplines as well. At the outset, some major questions must be asked. It has not been established, for example, who should treat the patient with psychosocial dysfunction (includ- ing adjustment reactions), what management techniques are appropriate for the primary care physician and allied health professional to use, or what organized structures are best suited to the management of patients with psy- chosocial di~ability.~~,~’ Applied to cancer patient care, it is not clear in what situations the staff member work- ing with a cancer patient should be expected to detect, diagnose, manage, or refer patients with psychosocial morbidity. Should they ideally work in a multidisciplin- ary team, ideally be taught by a psychiatrist, function primarily autonomously, or are all three viable alter- native~?’~,~~ These gaps in knowledge have complicated the ability to establish appropriate goals and objectives for psycho- social teaching in the general medical and oncologic areas. Not surprisingly, studies reported seldom contain goals or objectives for specific knowledge, skills and at- titudes in the psychosocial area that should be expected in the oncology training programs. When goals are given, it is not specified whether they are derived from a needs assessment of the patient. In addition, usually neither a curriculum nor teaching format for psycho- logical care are specified. The orientation of the psy- chological teaching is important, since it may be biased toward a biological, behavioral, psychodynamic, sys- tems, or eclectic approach. The curriculum may include humanistic concerns, interview techniques, interper- sonal relationships and/or information about classic psy- chiatric entities seen in medical patients, particularly depression and anxiety. The teaching format should ide- ally also include stepwise progression of increasingly more complex blocks of information. It is also important to know how a particular kind of information will be taught, by lecture, reading assignment, or videotapes. Finally, it is important that programs can outline the competencies expected to be developed in any psycho- social training program, for which discipline, their level, and when each should be taught. Most studies review a single program in which the charisma of a given 0008-543)</82/1101/1974 $1.05 0 American Cancer Society 1974

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Page 1: Models for teaching communication and attitudes

Models for Teaching Communication and Attitudes

JAMES J. STRAIN, MD

HIS OVERVIEW describes the current knowledge of T models for teaching the biopsychosocial aspects of cancer patients, with special emphasis on ways to en- hance communication and influence attitudes. It is es- sential in reviewing this area to address three important questions:

1. What current models are used to teach the bio- psychosocial aspects of cancer care at the level of patient, public, the allied health professional, the physician, and the psychiatrist who is a teacher-re- searcher? 2. What are the critical variables needed to evaluate the effectiveness of teaching programs? 3. Based on the awareness of the critical variables and the teaching models, what is needed to develop long-range evaluation methods to assess the effec- tiveness of cancer detection and cancer care training programs on patient outcome?

Despite the fact that most psychosocial care of the cancer patient is rendered by the physician and other professionals, many questions remain about how this type of support can and should be done. Few data exist which demonstrate a systematic evaluation of how ef- fective psychosocial training programs in cancer care have been. This is probably the result of the inability to reliably define the nature and extent of psychosocial needs, i.e., the patients’ psychosocial personality traits, interpersonal relationships, that occurs in medical set- tings, including ~ a n c e r . ~ . ~ ’ Most data have been obtained from epidemiologic surveys, interviews, questionnaires, and clinician’s reports. Even when psychosocial needs are clearly established, such as in patients with depres- sion, anxiety or poor adaptation to illness, the role of oncologists and primary care physicians is unclear, rec- ognizing the constraints of their training, individual ap- titudes, and diverse medical settings.

The critique presented here is the result primarily of review of teaching models for primary care physicians and medical students. Nurses, social workers, clergy, volunteers and patient representatives, while not directly addressed, share common problems. Some of the generic

Supported in part by NIMH Training Grant MH 16438. Professor and Director, Psychiatric Liaison Service, Mount Sinai

School of Medicine, New York, New York 10029.

concepts, problems, and research strategies encountered with the psychosocial training of the primary care physi- cian are applicable to other disciplines as well.

At the outset, some major questions must be asked. It has not been established, for example, who should treat the patient with psychosocial dysfunction (includ- ing adjustment reactions), what management techniques are appropriate for the primary care physician and allied health professional to use, or what organized structures are best suited to the management of patients with psy- chosocial di~abili ty.~~,~’ Applied to cancer patient care, it is not clear in what situations the staff member work- ing with a cancer patient should be expected to detect, diagnose, manage, or refer patients with psychosocial morbidity. Should they ideally work in a multidisciplin- ary team, ideally be taught by a psychiatrist, function primarily autonomously, or are all three viable alter- n a t i v e ~ ? ’ ~ , ~ ~

These gaps in knowledge have complicated the ability to establish appropriate goals and objectives for psycho- social teaching in the general medical and oncologic areas. Not surprisingly, studies reported seldom contain goals or objectives for specific knowledge, skills and at- titudes in the psychosocial area that should be expected in the oncology training programs. When goals are given, it is not specified whether they are derived from a needs assessment of the patient. In addition, usually neither a curriculum nor teaching format for psycho- logical care are specified. The orientation of the psy- chological teaching is important, since it may be biased toward a biological, behavioral, psychodynamic, sys- tems, or eclectic approach. The curriculum may include humanistic concerns, interview techniques, interper- sonal relationships and/or information about classic psy- chiatric entities seen in medical patients, particularly depression and anxiety. The teaching format should ide- ally also include stepwise progression of increasingly more complex blocks of information. It is also important to know how a particular kind of information will be taught, by lecture, reading assignment, or videotapes. Finally, it is important that programs can outline the competencies expected to be developed in any psycho- social training program, for which discipline, their level, and when each should be taught. Most studies review a single program in which the charisma of a given

0008-543)</82/1101/1974 $1.05 0 American Cancer Society

1974

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teacher and self-selection of students may be important factors.

These studies are characterized by rudimentary pos- itive evaluations, while the exhortation is given that pri- mary care physicians and allied health professionals can and should provide the psychological care of their pa- t i e n t ~ . ~ ~ ~ ’ Evaluation instruments tend to be imprecise and often rely on subjective impiressions. In the actual context of patient care, including oncology, outcome studies to date have found only little or partial success from training in the psychosocial aspects of medical practice.

Trent, Houpt, and Eaton have compiled a set of eval- uation instruments for the teaching of psychological medicine employed by various consultation/liaison training programs;@‘ five kinds of evaluation have been commonly reported in training grants.52 Many of the reports up to the present do not identify evaluation as having an impact on the program, nor do they attempt to differentiate process from outcome or the effects of the teaching on the subsequent behavior (performance) of students, on patients, or on the cornm~nity;’~ eval- uation must be related to

Finally, programs must ideally outline selection of trainees and the nature of the resource allocation and costs as a part of the evaluation. Additional problems in psychosocial training evaluatiion of programs de- signed to teach those involved in cancer care are: ( I ) the need for randomized studies; (2) accurate measurement of knowledge; (3) a common vocabulary, a common data and knowledge base, and common skills for various models; (4) competency-based teaching and evaluation programs which are difficult to ~ndertake;~’-~~ and (5) the difficulty of measuring attitudes cross-sectionally and longitudinally. In addition, criterion referenced measurement in which the subjec1:’s individual status is assessed in respect to a well-defined behavioral domain is insufficiently employed in prefeirence to group assess- ments of trainees; statistical apprctaches do not employ methods more appropriate to bio medical-psychosocial phenomenological processes, i.e. ., Bayesian concepts. Finally, evaluation schema must be tied to patient out- come. More general goals sound better and seem to have greater clinical relevance, but are harder to evaluate. More specific goals sound noncli~~ical and at times ir- relevant, but are easier to evaluate. Many programs take time to develop goals and objectives, but do not spend adequate time on either seeing that the objectives are actually put into practice, let alone evaluate their effec- tiveness. This makes cross comparative effectiveness of various teaching models difficult.

With regard to training in the psychosocial aspects of cancer, Glick and C a ~ s i l e t h ~ ~ described an interdisci-

plinary didactic and clinical elective oncology course whose major goal was to sensitize medical students to patient’s and families emotional need and develop their interpersonal skills to meet the challenge of caring for oncology patients. Their course employed a set curric- ulum, lectures, small group discussions, patient inter- views, and pre- and post-training assessments of the medical students’ response to a patient with regard to the unprompted inclusion of psychosocial factors in their case summaries. Cassileth and Egan” reported on the modification of medical student perception of the cancer experience and found that attitudes toward can- cer patients and oncologists are altered favorably as a result of relevant didactic and clinical experience^.'^ Mays44 described a three and one-half day residency for clergy sponsored by the American Cancer Society with teaching in this area?4

Teaching programs in psychosocial medicine have diverse philosophical and theoretical emphasis. Is their primary emphasis biological, behavioral, psychody- namic, family, social, or eclectic? The second major con- sideration is the teacher. What is the role of the psy- chiatrist versus the role of the physician (the oncologist), versus the role of other professionals (the psychologist, social worker, nurse), any of whom may be teachers? Categorization of the program by the background of the teachers, as well as their relationship with the program, offers one approach to conceptualizing teaching models. Everyone agrees that the masters are effective in teaching their disciples, but the problem is to develop disciples who can teach others.

For example, the teacher of psychological medicine may be: (1) the physician trained in psychological med- icine, exemplified by the model employed at Rochester by Engel;16 (2) board-eligible and/or certified in both psychiatry and a medical specialty, e.g., the approach at the University of West Virginia; (3) the psychiatrist, such as consultation/liaison programs and primary care programs which are extant at several teaching hospitals, i.e., the family practice program at the University of Alabama and the social medicine program at the Albert Einstein College of Medicine. These institutions employ a psychiatrist as a member of their teaching faculty, and he/she functions as an equal member of an interdisci- plinary team.

Major debate continues as to whether the psychiatrist can serve as teacher and role model to the general phy- sician. EngleI6 believes that the psychiatrist cannot fill the role and, thus, that liaison programs are therefore limited; and believes that the “specially trained” ap- proach is the optimal approach. In Engel’s model, the psychiatrist is used as a “primary messenger;” faculty and their fellows are “secondary messengers;” the med-

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1976 CANCER November 1 Supplement 1982 Vol. 50

ical practitioner is the “tertiary messenger.” The latter may diagnose, manage and treat mental health issues or refer to the psychiatrist as needed. It is thought that the medical practitioner may be unenthusiastic about learning primarily from a psychiatrist.

The “double-board method” at the University of West Virginia provides an integrated dual-trained role-model and teacher. The question can be posed, however, as to whether they are sufficiently sophisticated (and re- spected) in each specialty to serve as teachers? Finally, the consultation/liaison approach which is an “alliance model” provides for the development of a medical om- budsmen (medical oncology attendings assigned indef- initely to a ward, clinic, training site) and preceptors (medical attendings) who, after developing skills in the psychosocial aspects of medical care, accomplish much of the psychosocial teaching, eventually using the psy- chiatrist as a resource person.65

What is the make-up of the trainee in the family prac- tice and primary care settings that permits a “primary messenger”-psychiatrist-to act as teacher to the “ter- tiary messenger”-the practioner-without an inter- mediary role model as seen in the Rochester and the West Virginia models? Is there a trainee selection process in operation with these teaching approaches similar to that seen in the B a h t 3 teaching groups in which a psy- chiatrist serves directly as teacher to private-general practioners that allows an enthusiastic and supportive relationship between psychiatrist and physician trainee?

In addition to the characteristics of the teacher, the desired role qualifications and competencies of the trainee- student preeminently determines the nature and extent of an educational program. If physicians and allied health professionals are expected primarily to develop an aware- ness of psychological issues to expedite triage and make referrals, clearly there is need for less of an educational program than ifthe desired outcome is that the physicians and the allied health professionals will diagnose and treat psychological disruptions and frank mental disorders in the cancer patient and their family.

By determining which caretakers-internist, oncolo- gist, primary care physician, specialty physician, psy- chiatrist, or other professional-are involved in which teaching and practice activities, e.g., case finding, refer- ral, diagnosis, treatment planning, treatment modalities, follow-up, administration and research, one can begin to describe, categorize, and evaluate mental health train- ing programs for general health care personnel with re- gard to cancer care. To more fully differentiate the char- acteristics of training programs, it is necessary to estab- lish the critical independent variables with knowledge of the basic program components: program organiza- tion, discipline of teachers, characteristics of cumculum, nature of teaching vehicles, theoretical emphasis.

I. Background of organization and program: Insti- tutional relationships, administrative arrangements, his- tory (successes/failures).

11. Characteristics of faculty: Number, specific train- ing, length of time with program, involved in year-end evaluation.

111. Characteristics of trainees: Number, source, background, input into curriculum.

IV. Characteristics of other stafl Nurses, social work- ers.

V. Statement of educational design: Statement of general and specific objectives, objectives translated into specific behavioral and observable objectives, sufficient exposure to core areas, description of teaching methods, time in training, clinical setting for training, continuity of care, other specified enabling objectives.

VI. Evaluation of program: Extent to which program has been implemented, availability of evaluation instru- ments constructed with objectives, use of pre- and post- test measures, trainees eventual vocational selection.

VII. Program funding sources: Department budget, hospital budget, government training grant, state county municipal funds, fee for service, endowment.

For optimal program design it is necessary to establish educational goals and objectives for every level of trainee, i.e., public, patient, family health care workers, nurse, social worker, primary care physician, oncologist, psychiatrist. These should be specified in three areas: skills, knowledge, and attitudes. Methods need to be tried to see if these objectives can be reached, e.g., di- dactic sessions, case conferences, precepting, self instruc- tional, faculty supervision, peer supervision, videotape teaching, role modeling. Is there sufficient time in struc- tured psychosocial training, appropriate clinical training settings, a systematized cumculum, e.g., interviewing skills, diagnosis and assessment of depression, anxiety, fear, hypochondriasis, noncompliance, substance abuse, adaptation and maladaptation, psychological reactions to medical illness, and an appropriate faculty to achieve the objectives described?

Not only is it important to establish appropriate goals, critical variables and a taxonomy of training programs, but it is essential that the outcome of the teaching pro- grams be quantified: Are trainees better informed, have their attitudes been affected in a desired direction, do they have the necessary skdls and knowledge? Does the teaching influence patient outcome: compliance, coping, adaptation, decrease use of unnecessary hospitalization and drugs. For example, in the study by Bonadonna and Valagussa, it was determined that patients with breast cancer had to take 85% of their medication to have ap- preciable benefit from the chemotherapy; only 17% of the patients reached this level.* The majority took 60%

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of the prescribed dosage, experienced the side effects, and had enjoyed minimal benefit of treatment of their neoplasm. Is there greater case detection, earlier rec- ognition, and earlier referral as a result of teaching pro- grams? And finally, as a result of the pedagogic effort, is morbidity altered? Ultimately, cost-benefit analysis needs to be conducted to ascertain the outcome of teach- ing programs with regards to cost and savings. Levitan and K ~ r n f e l d ~ ~ have done such a study on an orthopedic ward, showing that for an investment of $10,000 in psy- chosocial teaching and services, $190,000 was saved in additional hospitalization and nursing home costs.

Clearly there are several important research studies which could be undertaken to assess the quality and outcome of training programs in cancer care. The guide- lines of this report point the way for the construction of experimental designs to examhe model teaching par- adigms and outcome effects. Only with carefully con- trolled evaluations can it be determined how much and what kind of resources should be devoted where for the teaching of cancer care.

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