Map of life expectancy at birth from Global Education Project.

Friday, June 11, 2010

The Doctor is In the Moment?

Physicians are trained to be biological technicians; they learn how to be healers of humans -- or not -- more or less by accident, by observing their preceptors in their clinical rotations and residencies. The idea of trying to systematically equip them with communication skills, and an understanding of how people are likely to respond to everything they say, is really quite novel.

One of the hardest things for anybody to do is to deliver bad news. Doctors often have to do it, so you would think they would be good at it, but many of them are not. It just isn't part of what traditionally goes into assessing clinical competence or conferring professional prestige. Two Italian physicians discuss the problem of bad news thoughtfully, and the journal is kind enough to make the essay available. Their first recommendation seems pretty obvious -- the doctor must look into his or her own psyche and understand how this task creates fear.

It is an extremely difficult task but if done properly it leads the doctor to construct that therapeutic alliance which allows the patient to listen to bad news without being overcome by it; to hear a possible truth, said with delicacy, without being dismissive or brutal and without shame. Life itself can also be perceived as a fatal illness but it is possible to live it serenely tearing away the mask of this obscure illness without being petrified by it.

Then there is simply a right way and a wrong way to proceed.

It is necessary to find a private area where the patient can feel as comfortable as possible without interruptions from colleagues or telephones and dedicate ample time to the conversation (listen and be listened to). Allow the patient to choose if he or she wishes to see the doctor alone or in the company of a family member, a relative or a friend. . . .

Leaving aside for a moment the approaches which clinical and psychological research have identified to help make this task less painful and for which a doctor is never totally prepared, the way to break bad news is never easy. Perhaps individualized disclosure and a shared decision-making process bring the patient to the bad news not in accordance with a pre-fixed standard but in a way which takes into account the patient's history, character, cultural level, capacity to understand and many other variables which can at that moment influence the impact of bad news.

It is extremely difficult to respect all these variables and for this reason the job of the doctor, if he or she has established this objective, is even more delicate because in the end bad new is bad news and whoever has to announce it, share it, help and support it must have or acquire those abilities which allow him or her to communicate confidently and delicately with kindness and honesty.

One of the most difficult tasks all physicians face, one at which many do not succeed, is to feel real caring, empathy and respect for patients; without being overwhelmed or emotionally scarred by all the bad things that happen to them. Some adopt a defense of callousness and indifference; others become over-involved and start to depend on their patients for emotional gratification. There is a place of maturity, compassion and strength which is hard to get to and hard to stay in, but finding it is central accomplishment of a healer.


robin andrea said...

This is what a doctor said to a patient yesterday, a few minutes after a colonoscopy and while the patient was still rather groggy from demerol:

"I did find that you have diverticulosis. We will give you information about that.

I removed five polyps. You will get a handout about that as well.

It is too bad that you did come sooner (I thought he was saying we were late for our appt, that maybe he would have had time to remove even more polyps!) for your colonoscopy because I did find a cancer in your lower colon that's been there a while and needs to be removed, and a second lesion. I biopsied them both. Do you have a surgeon you would like to see, if not I will set up an appt for you.

I will keep you in my prayers."

PRAYERS? That's some scary and inappropriate language.

kathy a. said...

robin, how awful.

kathy a. said...

i mean, nobody can take in the information and make decisions at just that moment. there just HAS to be a more thoughtful followup. gah.

roger said...

the groggy patient did hear "you have cancer" but did not hear the prayer comment, and does not quite remember getting dressed. altho he did arrive home fully clothed.