Four core communication skills are “Ask-tell-ask”, recognize and respond to emotion, ask permission to move forward, and “Tell me more…” “Ask-tell-ask” is asking what the patient or surrogate knows about the medical situation, telling them the headline (information and meaning), and asking what they are taking away from your conversation. Recognizing and responding to emotion, both verbal and nonverbal, can allow patients to discuss additional medical information, builds connection between clinician and patient, and can clarify what is important to the patient. Responding to emotion may be nonverbal or verbal (e.g., NURSE statements), and may include simple or complex reflections or “wish statements”. Asking permission to move the conversation forward signposts that there is a transition, allows patients control, and helps you judge if they are ready. Finally, “Tell me more…” helps clarify informational needs or allow a deeper view into a patient’s reasoning or emotional space, giving the clinician guidance on where to direct the conversation. In telemedicine, communication skills need to be adapted as some of the in-person nonverbal skills are less effective or impossible.

While most clinicians have experience discussing resuscitation, talking about dying requires the patient and family be willing to think about the medical treatment not working. Clinicians hesitate to bring up dying because they worry it will raise strong emotions, and they’re not sure what to do. Like REMAP, discussing code status requires a shared understanding of the “big picture”, responding to emotions, eliciting values, and making a recommendation about code status based on the medical reality and the individual patient’s values even if they differ from our own. The frame of “hope for the best, prepare for the worst” may help with the discussion. As people near the end of life, there are often questions that are hard for patients and families to ask, like what dying looks like, issues brought up by trauma or stigma, spiritual or existential concerns, or when the dying process is longer than anticipated. When clinicians create space for these sorts of concerns, we can address uncertainty and suffering that would have otherwise gone unspoken. Finally, being able to say goodbye to a patient requires insight and skill, but can be deeply meaningful for all involved.

The VitalTalk roadmap for talking about serious news is GUIDE (Get ready, Understand, Inform, Demonstrate empathy, and Equip patient for next steps). Getting ready includes planning the details of the meeting, including why and how the information is to be shared. The next step is understanding what the patient expects from the visit and what they have been told so far. Prior to giving information, the clinician should ask permission to share what they know. The news should be shared using a headline containing both data and what it means for the patient’s life. Afterwards, the clinician should demonstrate empathy by recognizing and responding to emotion. Equipping the patient includes discussing next steps, summarizing, and checking for shared understanding. There may also be challenges of patients receiving potentially too little or too much information when families say “don’t tell” or due to asynchronous electronic results delivery respectively. How much patients want to know and how and when they get information can be clarified through preparatory discussions. Finally, medical errors are another form of serious news that require an apology along with the headline.

The times in between significant medical events allow for different conversations with patients about living with uncertainty, the effects of their disease and its treatment, the fear of the next crisis, or figuring out who they are now and what they might hope for their future. Sometimes worry about becoming more ill or dying shows up in conversations in disguise, like being fixated on a particular test that a clinician might consider medically less important or even unnecessary. Sometimes completing cancer therapy brings a mix of emotion, relief that it is done and worry that it may not really be. Other times patients who have recovered from an exacerbation, like in heart failure, realize how much they have changed due to the disease and its treatment, and while glad they survived are simultaneously unhappy about how their life has changed. The roadmap for clinicians in these more calm but uncertain times is to ask your patient’s perspective, respond to their emotion (often exploring to create a deeper understanding), and offer your clinical experience of other patients which might apply to help clarify the issues at hand, provide different perspective, and offer support.

Discussing serious news can be difficult and a skilled clinician can improve their patient’s care and feeling of being cared for. Communication is central to the effective medical practice, and the data shows that clinicians can learn to improve their skills. This book will focus on the broad domains of communication skills and cognitive roadmaps. Through personal reflection as well as honing communication skills and using roadmaps, clinicians can cultivate internal psychological capacities that lead to more skillful and authentic conversations. Our basic principles at VitalTalk are to start with the patient’s agenda, track emotional and cognitive data, stay at the patient’s pace, express empathy explicitly, discuss what can be done before the things that can’t, cover big picture goals before specific interventions, pay true attention, and ask for the patient’s take away. In addition to reading about serious illness communication, these skills are best learned through observation, practice, and feedback.

Misinformation and suspicion surrounding sexually transmitted HPV – along with the social implications of administering shots to young girls – significantly hinder worldwide uptake of the vaccine. The 2006 U.S. rollout hit a quagmire of public ignorance, suspicion and paranoia, and by 2020, just 61 percent of eligible U.S. girls had been vaccinated. In Japan, anti-vax sentiment led to an HPV vaccine ban, and in Denmark, the vaccine met similar resistance. Nearly twenty years after its introduction in higher-income countries, the vaccine is vastly behind its prevention potential; in lower-income countries, its trajectory has been abysmal. Hang-ups about sexually transmitted infections and baseless fears about the vaccine have made advocating its use a cause laden with stigma. In male-dominated cultures – and in the absence of an existing delivery system – a girls-only vaccine is often stopped before it can start. And yet, without a worldwide commitment to countering misunderstanding through trust-building, hundreds of thousands of women will miss their critical opportunity to beat this disease.

No parent, partner, or child could quantify the worth of a beloved female family member lost to cervical cancer. And yet, with today’s economic realities – and most particularly in countries that struggle to meet citizens’ basic health needs – quantifying a woman’s financial benefit to her family and community becomes necessary to justify the cost of eradicating this disease. A senior health economist with the World Health Organization estimates that for every dollar spent on cervical cancer prevention, women’s paid and unpaid contributions return $26 USD to an economy: a return rate of twenty-six to one – impressive for any health intervention. Yet for varying political, social, and cultural reasons, most countries are reluctant to spend sufficient funds on female reproductive health care. These financial obstacles to eliminating cervical cancer won’t change until each unique society is willing to question how it values its women. Eliminating death by a preventable cancer makes intuitive sense. But until those sentiments translate into public policy and equitable, affordable health care for all women, lofty ideas are not enough to save lives.

Australia is set to become the world’s first country to eliminate cervical cancer by 2035, shining a light for all to follow. Its government provides nationwide screening, school-wide HPV vaccination, and an equitability program for underresourced communities. Australia’s successes remind us that disease elimination means addressing the needs of all citizens, including those hampered by cultural, geographic, or economic differences. In regions without the capacity or political will to target cervical cancer, grassroots movements and organizations can intervene. Cervical cancer survivors form the backbone of community-based initiatives: holding governments accountable to offer health care access and education. The Zambian-based Teal Sisters is just one of many such organizations offering collective empowerment for its members and advocating for greater support for women’s health. With so much global inequity, so much resistance, and so many women to serve, the hurdles to ending cervical cancer can seem insurmountable. And yet, individuals with passion and commitment – even entire countries – are proving these barriers can be overcome.

Men born male may be immune to cervical cancer, but they play a pivotal role in helping to do away with the disease – with good reason to do so. Men benefit greatly from keeping women alive. But in order to spare persons with cervixes this potent killer, they must put women’s rights at the forefront. The following are among the ways men can demonstrate this alliance: they can lower HPV transmission through condom use and male circumcision, support and advocate for family members and friends fighting cervical cancer, back women in key leadership positions, and empower them to make their own health care decisions. Men can also work to transform patriarchal norms and laws – belief systems often at the root of ignorance, misunderstanding, and stigma about the disease. All of these efforts are instrumental toward the larger goal of reducing cervical cancer rates. As men get involved with cervical cancer elimination in higher- or lower-income countries, their activism alongside or on behalf of women can make an immediate difference. The quest to eliminate this disease simply cannot succeed without the unwavering support, understanding, and commitment of the world’s other half.

Cervical cancer is one of the world’s most preventable cancers. And yet, every year, it continues to kill more than 340,000 women around the globe. Its rampage shows no sign of abating. Recent developments in medical science have given us the means of eliminating this cancer, including an HPV vaccine with a record for preventing up to 90 percent of cervical cancer, increasingly effective screening tests for detecting it as pre-cancer, and – should cervical pre-cancer progress to cancer – sophisticated treatment methods for extending and even sparing lives. But the vast majority of lower-income countries and regions within higher-income countries either know little about this cancer or lack the resources or infrastructure to stop it. Without greater awareness and a global willingness to intervene, hundreds of thousands more persons with cervixes will die. It will require a passionate, sustained, collective effort to save them.

One of the great myths of cervical cancer is that it only strikes women in impoverished countries like Somalia or Sierra Leone – countries that struggle to feed their people, let alone inoculate them against cancer. And to some degree, it’s true: cervical cancer kills more poor women than wealthy ones. Yet, even amid affluence, cervical cancer assails women no matter where they live. Persons with cervixes in the United States and other higher-income countries are routinely denied the means or knowledge for protecting themselves against this disease – even while sharing space with some of the world’s wealthiest inhabitants. In fact, those with female reproductive systems are marginalized everywhere, and thereby receive unequal access to the interventions for preventing this deadly cancer. The sound science for ridding the world of cervical cancer requires universal intolerance of the inequities that flourish in every corner of the globe. The political, social, cultural, and financial obstacles for eliminating this cancer must be addressed and removed, one by one, in order to give all persons with cervixes a fighting chance.