November 11, 2002
Your Patient Is A Person Too
M.J. McKeown, MD, FACOG, FACS
It was a tough night on call, your stomach is irritated from too much coffee, and now the final blow; 30 patients to see today and this first one needs to be counseled about evidence of metastatic malignant disease.
You are a professional, you have spent years in training how to diagnose and treat some very bad diseases, you keep up with the very latest knowledge in your field but no one ever included a course in how to be gentle with, be empathetic with and to communicate with your patients.
The beginning of any such communication is simple. You are a person with likes and dislikes and irritable times and happy times and so are your patients. If the patients are persons too then they likely have personality assets and defects just as you do.
Now how about something unique? How about recognizing that the patient in front of you is not just the one with metastatic cancer but that they are a person undergoing a terrible emotional reaction to information they may consider a death sentence. How about simply treating him/her as a child you are being gentle with and want to help through facing difficult information. How about a simple approach, " I know this information is difficult and that you may think of it as a death sentence. However let's see if we can sit down and discuss what this really means in terms of what can be done and then discuss how I and my staff can help you get through this."
If you can open a dialogue with your patient in that fashion then you can proceed to function as the informative and supportive professional. You can become a partner with your patient in the solution to this problem in a way not otherwise possible. Once you are a partner with your patient in the solution of a clinical problem then you can open and maintain a true communication with your patient and not just lecture to this upset person who, in turn, is upsetting you on this day of too much to do with a coffee stomach and perhaps a headache. Once you become a partnering person with your patient you will be amazed at how much easier it is to get through a course of treatment.
Are there guidelines for this? I am sure there is a great deal written on this subject but I have not read it. Like many things the guidelines are simple and don't need a degree in psychology or other social sciences discipline to understand and implement. The basic principle is simple. The patient is a person not a diagnosis.
You must remember Learning Theory. If your patient can not repeat back to you what you just told him/her in such a fashion that you can understand it is what you thought you told them then you have not communicated with the patient but have simply talked at the patient. If simple questioning of your patient shows that communication did not occur then it is your job to slow down, reflect on possible barriers to communication and plan how to get through the barriers.
In these days of increased electronic communication and immense amounts of information, good and bad, available on the internet it is likely that this patient, this person, will arrive in front of you with a handful of printouts containing information on his/her problem found through an internet search. If you react with irritation at this intrusion on your domain of supplying the information then communication will be lost. Your patient is grasping at any and all information in the face of an immense problem. View it as a help by your patient in supplying you with all this information and thank them for the help. Then explain that one must be careful to evaluate the truth of internet information and that you will be glad to help them with that. If your reading of their information leads you to review scientific information in order to evaluate the internet viewpoint then so much the better.
The future and the uncertainty of it are the major basis of your patient's uneasiness. A quick dismissal with cold statistics leading to a small percentage of survival is not kind and not what this patient, this person, needs to hear in this difficult time.
"Men are only great as they are kind."
Even if the rock bottom truth is the certainty of death it is kind to explain that the outlook is grim but that new information is available every day. Thank them again for their information search before coming to you, or if they did not do one suggest they do so. It might even be a kindness and an advantage to a medical practice to supply an internet connection and a helper to the patient in their search for information. Guide the patient to well reviewed and factual sites on the internet that will help the patient inform themselves about their problem. Excellent guidelines can be found on www.cancerlynx.com.
It could also be helpful to have an introductory talk with the patient about the possible impediments to their therapy by the health plan they belong to if such are known. It may be good practice to then have an employee who specializes in knowing how to help the patient navigate the sometimes rough seas of Managed Care. It might be helpful to develop a compact explanation, in your own words, of what evidence based medicine, outcome analysis, and quality of life years mean and how they are applied by managed care organizations and proponents to support their rationing of care. In particular it is important to help the patient to understand the limited availability of clinical trials and alternative therapies. Clinical trials are likely limited by financial constraints and alternative therapies are likely limited by evidence based medicine and outcome analysis.
The concepts of alternative healthcare approaches to such a life threatening illness are sometimes difficult to listen to with aplomb and then to gently evaluate them to your patient. My approach was to tell the patient that I realized I could never know everything and that I would evaluate whatever therapy they were proposing with an open mind and let them know my opinion. If the therapy did not appear to be effective however did not appear to conflict with more traditional therapy and did not appear dangerous to the patient I would tell them that and ask them to tell me how things came out. If the therapy appeared to conflict with traditional therapy or to be dangerous to the patient I would tell them so and advise them I did not think the therapy would be wise. However I would attempt to do all this in a kindly, partnering approach and not from an academic tower of pronouncement. It was not unusual that I would learn something that could be carried on to other patients.
Remember, listen, comment, instruct and advise. If your patient does not seem to get the message you thought you sent, then try again. Do not erect walls of superior training and knowledge since that is too easy and definitely not helpful.
If you treat my prickly nature with your prickly nature we will both bleed.