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Cross‐cultural communication in pediatric oncology: Catch them when they're young

It is with great interest that we read the recent article by Ilowite et al reporting the racial and ethnic disparities in communication regarding prognosis by pediatric oncologists. Their study highlights the implicit racial and ethnic biases that physicians have when communicating unpleasant and upsetting news to the parents of children with cancer. Although the need for cultural competency and sensitivity training in medical education is mentioned briefly, the authors do not delve into details regarding how such a training program might be designed or implemented for pediatric oncologists and whether the surveyed pediatric oncologists received prior training in crosscultural communication (CCC). Educational organizations such as the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education have emphasized the need to incorporate CCC training into medical education. Accordingly, CCC training exists in various curricula for medical students and residents; however, these programs may not address the challenges faced by pediatric oncologists in their day-to-day practice. Frequently, pediatric oncologists are faced with emotionally charged discussions with parents such as communicating the dismal prognosis for their child, including impending death. We believe that CCC training should be incorporated in fellowship programs to empower budding pediatric oncologists to recognize potential racial and ethnic biases and provide culturally competent care while addressing the challenges inherent to the field such as breaking bad news and discussions regarding treatment and clinical trials and end-oflife/hospice care. To assess the current environment for CCC training in the United States, we conducted a nationwide survey of pediatric hematology/oncology (PDHO) trainees. Of the 111 responders (31.2%), only 10.8% of the fellows reported that the majority of their CCC training occurred during fellowship. In addition, there was a modest correlation noted between level of agreement of the fellows having received comprehensive CCC training and their comfort level in handling complex clinical situations, with a significant improvement noted with each year of training in most clinical aspects. As an extension, we implemented a CCC training curriculum for our PDHO fellows with the goal of preparing them to handle complex clinical situations while navigating through different social and cultural belief systems as well as language barriers. This curriculum followed the framework of experiential learning, in which fellows participated in role-playing with standardized patients using simulated case scenarios based on real-life aspects of PDHO care such as discussing a new cancer diagnosis, treatment decision making, communicating an adverse prognosis, and end-of-life discussions. Fellows also submitted preand postcourse (at 1-month and 3month intervals) reflections. Postcourse feedback reflected increased levels of confidence, awareness, and respect for other cultures, beliefs, and value systems. This curriculum has been published in its entirety elsewhere and can be readily adapted into PDHO fellowship programs. Having discussions regarding prognosis with oncology patients is difficult. This challenge is compounded when such discussions involve emotionally distressed parents. Therefore, establishing a relationship based on trust between parents and physicians is fundamental because it can affect long-term care of the child. Recognizing the intellectual and emotional needs of parents as well as honest communication conveying clear, direct, and comprehensive information are key factors. However, cultural differences including race, ethnicity, and language proficiency as well as limited literacy can be significant barriers. Furthermore, Ilowite et al have reported the lack of physician selfawareness in identifying one’s own biases against racial and ethnic minorities, thereby highlighting the need for systematic changes in PDHO fellowship training curricula. Preparing future generations of pediatric oncologists through rigorous and well-rounded training in CCC will help them to become better caregivers to diverse populations.