Translating research on communication in the intensive care unit into effective educational strategies.

I n this issue of Critical Care Medicine, the research presented in the article by White et al (1) has given us a revealing window into how physicians communicate with patients and families in the intensive care unit. The next question is, how can we translate these insights into effective educational interventions? Medical educators commonly assume that effective interventions are those that result in observable and reproducible changes in behavior. That is, if certain behaviors are associated with a better outcome, we should develop educational programs that generate those behaviors in clinicians. For example, research has shown that families are more satisfied with family meetings when clinicians talk for a smaller percentage of the time (2). Following this model, an educational strategy would be to teach physicians to talk less during family meetings. Whereas acknowledging that such education might potentially improve the quality of communication in the intensive care unit, I believe that it sets the bar too low in terms of what families need and what we can achieve. To do better, however, we will need to shift from learning paradigms focused on producing specific behaviors to those that target the ability to perceive and respond to the ethical elements that pervade these conversations, something we call “moral imagination. ” This Editorial offers a number of clues about how this approach would differ from the behavioral model of education. For example, standard models of communication favor the “shared decisionmaking” style above those that emphasize patient autonomy or paternalism (3). When the concept of shared decisionmaking is unpacked, it is typically described in terms of the physician providing the medical “facts” and the patient or family providing the “values. ” Based on these separate contributions, “shared” decisions emerge. Hidden within this simplistic model, however, are a myriad of small, or “microethical,” choices. For example, the literature shows that whether the “facts” are presented as the probability of survival vs. the probability of death can have a substantial impact on the decisionmaking process. Even the clinician’s tone of voice can convey a positive or negative bias that will significantly affect decisionmaking (4). In other words, the question is not whether clinicians should introduce values into the conversation; this is inevitable. The question is how clinicians go about making microethical choices, sentence by sentence, as the discussion unfolds. For example, the authors found that approximately half of the physicians who were directly asked to provide a recommendation refused to do so. Most physicians have probably been asked at one time or another, “Doctor, what would you do if you were me? ” (5) These data show that many clinicians are reluctant to respond, and some even outright evade the question. For patients and families, how clinicians respond to this request for help and guidance may be the most critical and formative element of their intensive care unit stay, and our educational methods must be up to the task of preparing clinicians to do this well. Furthermore, the authors note that none of the clinicians in this study ever directly asked the surrogates about their preferences for decisionmaking. These data might suggest that we create an educational strategy that targets this specific behavioral outcome. Again, however, I think the microethical choices here are more complex than this. This study found that many of the clinicians actually used more than one of the models in each of their conversations, generally starting with the informative model and then moving into either the facilitative or collaborative style. One interpretation of this could be that these physicians were, in essence, skillfully “asking” the families about their preferred model by beginning with the least intrusive approach, staying sensitive to the families’ responses and nonverbal cues, and gradually moving in the direction that seemed to be most responsive to the family’s needs. Finally, the authors found that in approximately half of the conversations, the physicians explicitly expressed support for the family’s ultimate decision. Here again, microethical choices were likely at play. Although the physicians may have recognized that several different treatment options were ethically acceptable, they waited until the family showed signs of settling on a choice before expressing their support. In this way, they were able to compassionately take some of the moral burden from the family, making this a “shared” decision in the deepest sense of that word. My message, in short, is that although behavioral approaches to education may be successful in making us better than we currently are, they fall short of making us as good as we could be. The educational strategies we develop in intensive care need to be linked more directly to helping clinicians to critically reflect on their own values and to engage with patients and families with a greater awareness of the microethical choices inherent in these conversations. My colleagues and I have been applying these strategies in our teaching for several years now with some success (6, 7). Many will argue that this is too difficult, that the best we can hope for is behavioral change without directly engaging the relational and microethical dimensions. I would have two responses. First, as this study shows, many intensive care unit clinicians already have these skills and are doing an outstanding job of *See also p. 743.