Is the best medicine in the doctor-patient relationship?
February 5, 2008
By Eve Savory
"And he said to him, 'what do you expect? You're an old man!'"
My mother's voice on the phone cracked with anger. My father, old in nothing but years, had abruptly and dramatically begun losing weight. Nothing could persuade his body to absorb calories.
The internist trying to diagnose the problem was stymied — and no doubt frustrated. In the end, even the autopsy could not explain my dad's sudden decline.
But with the internist's words that day, my father stopped being the doctor's patient and became his failure. The man he hoped would save him had as good as said, "Yours is not a life that matters."
My mother said my dad seemed to shrivel in front of her. He had been written off.
That was almost 25 years ago. So it was discouraging to read of a recent study at North Carolina's Duke University. It seems some doctors still don't realize the power of words.
Researchers taped 398 conversations between 51 oncologists and 270 patients, all with advanced cancer. Ninety per cent of the patients had visited the oncologist more than twice over at least six months. There was, presumably, a relationship.
The researchers were looking for empathy. If a patient said something that showed they were sad or scared or uncertain, would doctors ignore the comment or shut it down — using what the researchers call a "terminator"? Or would they offer an empathetic response — a "continuer" — and thus encourage the patient to open up?
"The patient says 'I'm really depressed,' and the doctor says 'Are you still smoking?'"
— Kathryn Pollak, Duke University Comprehensive Cancer Centre
The terminators triumphed. Oncologists responded empathetically to their patients' expressions of negative emotions only 22 per cent of the time. In fact, 41 per cent of the doctors being recorded never used a continuer.
In other words, if the patient was going to be depressed, he better do it somewhere else.
So? Well, Kathryn Pollak, the lead author on the study, told me when our doctors respond to our anxiety and sadness with empathy, we cope better. And we're better patients.
So empathy is good medicine for patients.
But perhaps medicine isn't good for oncologists. As Pollak listened to all those recordings, she realized how hard it is to be a cancer doctor. They give bad news all day.
And their patients cry.
"You see 20 patients a day and you walk in and every one of them is doing this. This job is hard. It's hard," she said.
Maybe the oncologists thought showing empathy would make it harder.
Dr. Terri Paul, who teaches first and second year medical students at the University of Western Ontario's medical school, thinks so. In a telephone interview, she said the lack of empathy could be a survival mechanism, "so they can get through each day without having to emotionally drain themselves."
Not that patients always make it easy. In only a third of the conversations in the Duke University study did they say something that called for an empathetic response.
Perhaps they knew they weren't likely to get one. But sometimes, Pollak said, a patient would ask if the tumours were getting bigger, meaning "Am I going to die?" The oncologist would tell the patient to a millimeter how much it had grown.
Pollak suggests patients need to learn to ask for exactly what they really want from the doctor.
Nonetheless, some of the oncologists did understand what the patient was saying, responding, for example: "It makes sense that you feel this way" or "I will be with you until the end."
Why can't they all?
"As medicine has become more and more science oriented, we began to just look at the disease. And the patient became the disease …"
— Dr. Terri Paul, Clinical Methods coordinator, UWO
Medical schools know it's a problem. Thousands of academic articles have been written about doctor-patient communication.
Back in 1971, McMaster University in Hamilton led the world in using actors — playing patients — as part of the curriculum in medical school. Now, every school in North America teaches communication skills in first and second year.
And younger doctors were more likely to respond empathetically than older ones.
Perhaps then the courses work. Perhaps not. Pollak's study also found no relationship between the amount of communication training an oncologist had and his or her expressions of empathy.
One has to wonder if the lessons are sinking in, when almost everyone I talked to while researching this column had an anecdote about a health care worker who did emotional harm to a patient.
"He was getting changed in the room when the urologist walked through and said, 'Oh you can put your pants back on, it's cancer. Come on in my office.' And just shut the door again … He hadn't even met this man."
— Dr. Romayne Gallagher, Physician Program Director for Palliative Care, Providence Health Care
So in recent years, attention has turned to the residents, the newly graduated MDs training in their chosen specialty.
For several years now, Dr. Romayne Gallagher has arranged for oncologists-in-training at Providence Health Care in Vancouver to meet and learn from cancer survivors.
"Our best teachers are our patients," she told me.
The patients tell the young doctors what they did that worked. And what hurt. The doctors hear what Gallagher calls "horror stories," like that of the patient with prostate cancer above.
"Something disconnects between that early training and what they do in practice," says Dr. Betty Calam of St. Paul's Hospital in Vancouver.
Well over a third of Canadians will get cancer. So a lot of us are going to get to know an oncologist. But almost all of us will have a relationship with a family physician — the ones to whom we first take our lumps and bumps and fears.
Calam, the director of the Family Practice Residency Program, told me even the future family docs resist the "touchie- feelie stuff."
"The realities of training are such that they are so exhausted, or starving, or overwhelmed with the amount of responsibilities," she said in an interview. "It's not out of negativity, it's out of 'I need to know what to do not to kill anyone!' more than they need to know how to break bad news."
Dr.Calam and a team at B.C.'s Centre for Practitioner Renewal tell the residents it's part of their job to learn how to talk and how to listen; that learning those skills is just as important as learning how to use their scalpels and their stethoscopes.
This isn't just about making a happier patient. It's about making a happier doctor.
Physician burnout — and dropout — is a big and scary problem. A study of cancer care workers in Ontario found about one-third have considered getting out of the field. Cancer physicians had by far the highest level of "emotional exhaustion" — the first stage of burnout.
So how could listening and responding empathetically to a patient make for a happier doctor?
Terri Paul of UWO told me a colleague rediscovered his love of medicine while working with students on communication skills. Perhaps, she said, what is best in medicine for both of us is the relationship. Perhaps making the journey together enriches both our lives.
"In learning to talk to his patients, the doctor may talk himself back into loving his work. He has little to lose and much to gain by letting the sick man into his heart."
— Anatole Broyard, NYT, 1990
Twenty years after my father died, my mother was diagnosed with cancer. In those first ghastly days, the phrase "palliative care only" was whispered. After all, she was 91.
But in our first and subsequent meetings with the charming, funny, listening radiation oncologist she was treated as if she had as much to offer the world as a young mother of 30. Every health worker and cancer agency volunteer she encountered treated her as tenderly as if she was someone's mother. As, indeed, she was.
In their presence, she bloomed and joked and laughed. She wasn't a disease, but a person, with a life that mattered. And that was the best medicine.
- Patient monitoring
- Doctor recruitment
- Is the best medicine in the doctor-patient relationship?
- Health records
- Modern care
- Palliative care
- PET Scanning: Medical science's underused super tool?
- Public vs. private health care
- Waiting for access
- Anatole Broyard's Doctor Talk to Me, New York Times in Aug. 26, 1990
- Diagnosing Suffering: a Perspective, by Dr.Eric J. Cassell
- The Oncologist, A six-step Protocol for Delivering Bad News: Application to the Patient with Cancer, 2000
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