Doctor – Patient Communication: Part II
I apologize to my readership for the delay of this blog posting. I have been under the weather recently, but the new-year has brought vigor and good health.
There is so much to say about doctor/patient communication that even an overview of my thoughts is more realistic in serial form; hence, this sequel, Doctor/Patient Communication, Part II. In my previous blog, Part I, I laid out general thoughts about what I think actually defines communication. Specifically and most importantly, its basic ingredient is a two-way exchange - transmission and comprehension - and it is intuitive to me that the gold standard ought to be patient comprehension. Anything short of that is not really communication. Put another way, without comprehension, the conversation is really only doctor’s monolog. Also I firmly believe that the ultimate responsibility for achieving this standard belongs to the doctor, rather than the patient. Bottom line, a physician should have the “people skills” and the concern to recognize when he/she is not making contact at the comprehension level. In that same blog, I used as a problematic example the Informed Consent that all patients must sign prior to undergoing technical procedures. In this document, the potential ramifications even though written, are often not read comprehensively by the patient.
In addition to these basic ingredients of communication (transmission and comprehension), it is critical for the physician to be a good listener. Over time, I have become convinced that patients often have an instinctive sense of their own bodies, and on many occasions they feel something is wrong well before telltale symptoms or signs cause concern for their physician. I vividly remember that while studying physical diagnosis in medical school, we were admonished to listen to what your patient was saying; “they will often give you valuable information that you aren’t even seeking”, we were told. “Learn to read between the lines”. So when a patient says “something is wrong,” the wise doctor takes heed. I speak of medicine in general, but this is no less true in oncology. I realize that this medical school admonition was meant to apply to diagnostic problems; however, the statement also applies to the routines of medical practice, such as during the referral process from one doctor to another. For example, when a patient relates what has transpired with other physicians or other treatments, the cancer specialist must keep a non-judgmental and open mind. Not infrequently, patients come from a referring doctor confused and ill informed about their condition (in the case of the oncologist, a tumor) and its potential treatment. Initially, one is tempted to fault the referring doctor, but in truth, the explanation for this state is often complicated. First, some doctors are simply not good at teaching or explaining, and even when time permits, the communication is ineffective. Additionally, patient misunderstanding, misperception, and superstition can result from fear of the most dreaded word in language—cancer - or as it is euphemistically known, the “Big C.” So even when the referring doctor does a good job of explaining the issues of concern, patients not infrequently fail to understand, and because of either embarrassment or out of consideration for the doctor’s hectic schedule, they are reluctant to ask for further explanation. It is worth noting that medical information – especially that relating to cancer – is not usually well retained by patients. No doubt, the efficiency of retention goes up each time the information is repeated, but in the real world of a busy referring doctor’s office, this is hardly practical. The brain is an excellent filter for unpleasant information, and when added to the normal human tendency for denial, as well as those factors already mentioned – embarrassment, busy office, etc., - the stage is set for misinformation. Cancer patients often leave the primary physician with a referral slip in hand but confused and/or with marginal knowledge of why they are referred in the first place. Truth be known, it is the oncologist’s job not only to diagnose the problem and to formulate the treatment plan, but also to establish and implement real communication; after all, they are the experts, and the referring doctor should not be faulted. In point of fact, the contemporary world of cancer management rarely has primary physicians in charge, and referral to an oncologist is the norm. The reader is referred to my June 2012 blog in which I discuss the contemporary cancer team approach.
In my next blog, Doctor/Patient Communication: Part III, I’ll begin to discuss the interactions between oncologists and cancer patients; and in that piece and others related to this general subject, I’ll attempt to make the doctor’s communicative skills the common denominator that most facilitates the process of diagnosis, evaluation, decision making, and treatment. I refer the reader to the introductory paragraph of today’s writing, in which I unequivocally make it the doctor’s responsibility, rather than that of the patient, to achieve the gold standard of patient comprehension.
In closing today’s blog, I submit for your consideration the concept of “overall process”, rather than only referral and treatment. In reality, there are three phases to this: the initial cancer suspicion and the referral from the primary care doctor; the interval between the referral and the first visit to the oncologist; and the third phase during which the oncologist takes charge of the workup (evaluation and staging), discussions (consultations, tumor boards), treatment options, actual treatment, and the essential follow-up care. The reader justifiably might question the importance of phase two - the period between referral and the actual visit to the oncologist. In point of fact, it is significant because to a great extent, that interval affects the patient’s state of mind when they first encounter the cancer doctor. Allow me to explain what I mean.
This rarely discussed interval between phase one and phase three of “the process” is the dreaded waiting period, during which extraneous influences can magnify anxiety and uncertainty. Obviously, the potentially gravity of the problem dictates one’s level of concern e.g. a lung or breast mass compared to a skin lesion – but I think it safe to say that with some exceptions, patients with a potential cancer are frightened, and their state of mind upon arrival to the oncologist is often influenced by various extraneous matters that pop up during the wait. It is intuitive to me that the longer the wait, the more vulnerable the patient to counter-productive forces. This whole subject of waiting is so importance that in my recently published book, The Cancer Experience: the doctor, the patient, the journey, I devote a full chapter to it (1).
There is so much data readily available today that very little information is or even should be proprietary. With that said, delving into the cancer literature without direction can be counterproductive, and can be scary for many patients. So while it is better for a patient to be informed, the degree of that state is nebulous. Another extraneous factor entering the picture is that during this time, patients and their families often cloud an already emotional situation by talking to other patients or friends of patients who are quick to give unsolicited advice, much of which might be inaccurate and overly dramatized, and for many reasons, the recipient forgets to factor in the commonsense axiom that what applies to one patient does not necessarily apply to another. Even though most cancer patients intuitively know that it’s unwise to listen to nonmedical advisors, especially the self-appointed ones, in the real world of cancer hysteria, they often do just that. However, human nature and unchecked verbosity have probably trumped common sense for as long as people have interacted. Basically, such opinions should be avoided, and my advice is to keep one’s situation confined to a close support circle, and count on your oncologist for the details of the discussion. Once things are more defined, support groups and the related advice acquired from them is an entirely appropriate and helpful resource for cancer patients.
In summation regarding Phase II, be prepared with questions that are based on reasonable literature search and your own common sense, take a friend or family member with you to the oncologist’s office, and avoid inviting random comments from lay people before you get there.
Clearly, process expediency is the responsibility of the medical team, and the longer the wait, the more problematic the issues. Unnecessary delays and cumbersome scheduling mechanisms should be minimized, therefore. In the hectic day- to -day of medical practice, such delays are often not recognized for what they are – misery, uncertainty, and fear along the way. Insensitivity to casual delays of such tests results as a biopsy or a mammogram is inhumane. By the way, the need for process expediency has little to do with cancer growth – this is only rarely an urgent matter – but is more a matter of psychological kindness.
P.S. Intellectual exchange is useful to the educational process – both for reader and author. In that spirit, I welcome your questions and comments.
Roy B. Sessions, MD, FACS
The Cancer Experience: the doctor, the patient, the journey, by Roy B. Sessions, MD, Chapter 18