What If Docs Focused on the Person Instead of the Disease?
The results could be less pain, lower medical costs, and more trust in doctors
Posted Feb 19, 2018
Imagine you get the worst news possible: You have late stage cancer. Your doctor lays out the treatment options: chemo, radiation, surgery. You hear lots of numbers, some of them probably related to your prognosis, but you’ve just been told you have cancer. They make no sense. You trust the doc, as do many patients, so you do what the doc tells you. It’s all about a cure.
What if, instead of burying you with data, the doctor instead sat down, looked you in the eye, and clearly and honestly explained your prognosis, then began talking about making you comfortable and giving you the best quality of life possible, but did not promise a cure.
Which doctor would you trust most?
A study in the Journal of Clinical Oncology shows that the second approach builds a far better doctor-patient relationship. Patients appreciate having information that can help them make end-of life-decisions.
But doctors are often more comfortable with the first approach. They want to succeed, and success means beating this disease for you. Even when the odds are against success.
“Prognosis discussions don’t happen early and often, and, as a result, it’s been clearly documented that many patients often completely misunderstand their prognosis so treatment decisions made near the end of life might not be totally aligned with the patients’ and caregivers’ priorities,” said lead author Joshua Fenton, a professor of family and community medicine at UC Davis. “Discussing prognosis doesn’t undermine trust, and informing patients may have large benefits in terms of future quality of life.”
Researchers studied 238 adult patients with advanced cancer in cancer clinics in Western New York and Northern California, including at the UC Davis Comprehensive Cancer Center. Visits with oncologists were audiotaped and then analyzed for prognosis discussions. Patients were surveyed 2-7 days after their visit and again at three months.
Doctors still are underprepared for these difficult discussions, Fenton says. They tend to focus on the disease and not the patient, emphasizing treatment options, spending little time discussing prognosis or end-of-life options such as palliative care and hospice. This can be an expensive approach, economically, physically and psychologically, resulting in greater use of intensive, hospital-based services, higher health care costs, lower quality of life for patients, more difficulties for caregivers, and even shortened survival.
For How To Have These Discussions: Atul Gawande's Being Mortal is one of the best books available on facing death.
Impact of Prognostic Discussions on the Patient-Physician Relationship: Prospective Cohort Study Joshua J. Fenton, Paul R. Duberstein, Richard L. Kravitz, Guibo Xing, Daniel J. Tancredi, Kevin Fiscella, Supriya Mohile, and Ronald M. Epstein Journal of Clinical Oncology 2018 36:3, 225-230