Psychologist Chris MacKinnon and Palliative Care Physician Stefanie Gingras have been working together for almost 8 years delivering a novel psychosocial training program to oncology fellow-physicians at the McGill University Health Centre (MUHC). Dr. Gingras is an attending physician at the MUHC and Dr. MacKinnon is director of a private clinic in Montreal.
This program was developed in response to a request from the Palliative Care McGill Education Committee for greater psychosocial training in helping fellows advance their practice. The program was originally adapted from Dr. Robert Lambert’s longstanding model used in spiritual care training at the MUHC called “verbatim case reporting.” At this time, the application of this model to the field of palliative medicine remains unique.
According to Dr. MacKinnon, circumstances at the end of life are often charged with complex emotions and interactions for patients and their families, as well as for the accompanying physician. The focus in this training is for fellows to develop enhanced communication skills by identifying and increasing awareness of the fellow’s own feelings and how to work with those feelings. The primary goal is to foster constructive outcomes with patients and families in the difficult and often traumatic situations at the end of life.
“Fellows work on developing their own sense of physicianship through their relationship skills. How do they form a relationship with the patients and families in front of them? How do they use their feelings to guide them in these interactions? This is the most important thing that happens - putting physicians in touch with their own feelings and using those feelings to guide them. We are often talking about themes such as powerlessness, being overwhelmed, feeling stuck, dealing with anger, dealing with immense sadness because of the tragedy of end of life… It’s like a laboratory of learning the human skills of palliative medicine.” – Dr. MacKinnon
In addition to promoting concrete skills such as active listening and asking open questions, fellows make valuable contributions to the group by bringing their own insights and interpretations regarding issues such as cultural awareness.
“The diversity of perspectives and the ways in which people ascribe meaning to circumstances in different ways is so important. Some of the richest moments come from the various ways we can see from what can happen in a situation. A student might say,“Hold on, in my culture that would be heard in an entirely different way.” We see together that words matter a lot - your choice of words and how you ask questions. All these microskills are about really listening. This does not just happen… but it can happen with practice.” – Dr. MacKinnon
While Drs. MacKinnon and Gingras occasionally teach students about specific topics such as psychological assessment or family dynamics, the educational model is experiential and is based on the fellows taking turns choosing and preparing a case script from memory, and then as a group, re-enacting the case. Each cohort of 6 to 8 fellows attends bi-monthly sessions of 90 minutes that take place for the duration of one fellowship year.
The combined expertise of a psychologist and physician is crucial to the program’s success. Dr. MacKinnon, having previously undergone a year-long training in verbatim case reporting at the MUHC supervised by Dr. Lambert, brings intimate knowledge of how the model functions. Dr. Gingras having lived through medical training, understands the demands and pressures on the fellows. As co-facilitator, she serves not only as a role model, but actively demonstrates through her many years of experience the importance of self-reflection and excellent communication skills for physicians.
Dr. Gingras believes that this training not only improves communication skills and helps develop confidence and maturity, but also protects fellows from stress-related problems that might arise from unarticulated or unresolved feelings and fears. For example, many fellows often grapple with unstated feelings of failure, inadequacy, and shame. During the training, fellows have the opportunity to talk through challenging cases and their response to them in an environment built on trust where the common goal is to be a better physician for their patients.
“There are several main benefits to this training. One of them is developing good communication skills with families and patients. Another is developing maturity. A third is developing confidence in trusting their feelings. The one that I think is really important is to improve the psychological states of the fellows. Our experience suggests that this training prevents burnout. When a fellow believes they have failed in a certain case, they can bring it to our group and we debrief it. It’s extremely helpful to dissipate the negative emotions.” – Dr. Gingras
Dr. Sonia Skamene, who completed two years in the program now works as a radiation oncologist. She claims her awareness about her own feelings and how to communicate with patients was greatly sensitized regarding common and highly challenging issues such as breaking bad news, confirming a patient’s understanding of their situation, managing questions about prognosis, and facing the unknown.
“It was an incredible experience for me. I was invited by Dr. MacKinnon who knew I had an interest in palliative care. Our group of fellows met to discuss cases and it was the only type of training I had ever had that focused on the analysis of communication that we have with patients while looking at it through a psychological lens. I remember being very honest with my colleagues. What I learned I now apply all the time in my practice.” - Dr. Skamene
This training continues and may even expand. Drs. MacKinnon and Gingras have recently been approached by other palliative care training centers outside of Montreal who are interested in this program.