This is part of a series of columns on the doctor/cancer patient relationship by Seabrook resident Dr. Roy Sessions, MD, and Fellow of the American Council of Surgeons.
More on Doctor / Cancer Patient Interaction
As I did in my April blog, I have devoted the first paragraph of this writing to summarizing where we are and what we have covered in the recent series that contains the common theme of the interaction between cancer doctor and patients.
As a means of paraphrasing my previous writings, certain patients require more explanatory effort by the treating doctor. That this is so relates to several factors – some have extraordinary emotional needs – others simply have difficulty comprehending the sometimes complex and often scary process that consists of workup, staging, treatment, and recovery. The referring doctor should, therefore, attempt to select a cancer specialist (oncologist) with good teaching and communicative skills. I say attempt, because the emotional component of the paradigm is a priority only in the presence of educational and therapeutic competence; obviously, those assets trump others. I have also previously stated that as it pertains to the referral selection, certain doctor and patient personalities simply don’t mesh, and often a flawed relationship leads to disharmony that can compromise the overall functionality of the cancer team. Both of these are important during the endurance test euphemistically referred to as the cancer experience. Finally, the linkage of trust to communication between the doctor and patient is predicated on the notion that the doctor who is able to communicate and teach effectively was more likely to develop an ideal relationship with patient and family, both of whom are usually under considerable stress. In the event of “problems” – complications or even failure of treatment – good intrapersonal chemistry can be essential.
Today, I want to explore certain factors that influence the development of a doctor’s psychosocial abilities. Communication (or a lack of) between doctor and patient often results from the physician’s ability or inability to explain; that is to say, his/her teaching skills. Most teachers have pet methods of making certain points – that’s usually a learned skill. Spontaneous conversational fluency that educates, on the other hand, is rooted in “people skills”. This poses a problem, because in large part, much of this talent is learned during one’s upbringing, that is, through observation of one’s environment. It follows, then that teaching young doctors the art of communication is difficult when the basic familial foundation is not in place, and make no mistake, preople skills and communicative effectiveness are inextricably linked. Truth be known, this issue is not unique to medicine. It’s is my belief that a large proportion of societal success stories that involve management or leadership – no matter the particular endeavor – have as a common denominator, the communicative skill of those seeking to lead. And to repeat what I have said over and over in this series, whether in medicine or otherwise, communication is not only about telling, but also about being understood. No matter how loquacious the wording, patient comprehension is the gold standard.
Both the powers of observation and the ability to listen are fundamental to the process. My suggestion to young doctors is to observe their various mentors and take from them what seems effective. They should never be condescending about learning from everyone, no matter how humble the person’s relative station in the medical system. Many physicians in small-town America, for example, have considerable skill and common sense regarding the art of medicine. All through the mentorship experience, the young doctor should add to the repertoire whatever personal methods that suit their individual style. Throughout the years, doctors also learn what not to do by watching the interpersonal ineptness of some of their colleagues, and even their mentors. Building on this method, an eclectic style of practicing and communicating is eventually developed. This represents the American system of medical education, which has an advantage over the traditional European method, in which one professor is the filter of most information, and the eclectic style has historically been discouraged.
Aside from those methods over which a physician has control, good fundamental doctor/patient chemistry helps greatly—and when it is present, patients are more willing to interact in dialogue and ask questions that lead to comprehension. As in all walks of life, people who like each other have an easier time with such things, and to restate the obvious – sometimes people just don’t like each other. That being said, it is important to note that familiarity does not necessarily lead to good personal chemistry; that is to say, being an informal “good ole’ boy” is not what patients seek in their cancer physician. Instead, a lack of arrogance, an honest directness, an ability to listen, respect for the patient, and other factors all play a role.
Because there are often treatment options that must be discussed, patient comprehension early on is especially important in cancer victims. The wise oncologist engages the patient in making that discussion logical and understandable, but in the final analysis, that doctor should take leadership by offering a definitive recommendation. In doing this, I have always started with the statement, “If you were a member of my own family, I would do the following —-”. This is important, but only helpful to a point. Steadiness and firmness, rather than indecisiveness is needed in the recommended game plan. Physician indecision can be unnerving. One must always remember, whether true or not, the stakes are perceived to be higher in cancer than with other maladies, and physician leadership is paramount.
The psychologically tuned in oncologist should always remember that a cancer patient’s life is never quite the same —even after being cured. Although they might be well adjusted to it, fear lurks just below the surface in most patients who have endured a major cancer, and not infrequently, they will attribute all lumps, bumps, and other things to that dark memory. Since the fear is so quick to spring up, I’ve always advocated a long-term follow-up by the oncologist – even life long in some types of malignancy. The relationship and the trust in one’s doctor that I’ve talked about so much ought to permanently be a reliable source of comfort for a patient, and to a great extent, the whole scenario is predicated on patient education and good communication early on. Even during medical school, I felt that an informed patient was an asset to the care administered, and perhaps as a result of having grown up in a home in which my parents were skilled communicators, I have always had an ease with transference of information. This head start was very useful, but even so, over the years I continued to work on my skills at getting the message across to patients.
Even when teaching comes easily and naturally, the cancer physician should continue to work at becoming a more effective communicator with both patients and their families. This vastly under rated standard adds immeasurably to the patient’s overall tolerability of the cancer experience. As it pertains to the honing of one’s effectiveness, being attentive to the patient’s response to various communicative techniques is critical to a physician learning what works best. As an academic, I have spent my life attempting to teach—not pontificate without concern for comprehension—but teach in a manner that led to understanding. Whether with young doctors or patients, the gold standard ought to be clarity. It is my contention that despite the anxiety of knowing scary information, not knowing can be even more problematic. Throughout my career of dealing with cancer patients, two axioms have remained practical from the patient’s perspective: ignorance is not bliss, and knowledge is comforting, even when frightening.
It’s actually easier to teach young physicians than patients because in the former, the teacher generally is not allowed to escape until the matter is clear. Patients are less inclined to self-advocacy; therein is the reason for being perceptive to a patient’s countenance and body language – listen and observe, being the admonition. Since this blog concerns doctor patient communication rather than doctor – student communications, I won’t pursue that comparison except to again emphasize that the ability to achieve clarity is the basis of teaching, whether it be with a cancer patient or otherwise.
Another physician-controlled enhancement to communication with cancer patients is a state of doctor relaxation that allows the patient not to feel rushed and to feel that they have the physician’s full attention; that is to say, without the sense that he/she is trying to get out the door. If a patient doesn’t get that feeling, a comfort zone is unachievable and they feel the need to hurriedly make important points- not infrequently, forgetting to ask pressing questions. A great technique for accomplishing this state of relaxation is for the physician to sit down—in an exam room sitting on a nearby chair, or if in the hospital a chair or even on the edge of the patient’s bed. This might only be for a minute or two, but doing so indicates a relaxed focus on what the patient is saying. Obviously, the conversation has to be governed by the physician, because some patients have difficulty staying on track. With some effort, however, this is usually easy to accomplish.
In this day of computer note taking, I have noticed less emphasis on eye contact with patients during conversation. This invaluable technique adds a level of personalization not achieved if the doctor is staring at a laptop screen. Call me old fashioned, but I place great value on eye contact!
An aura of physician self-confidence is also important to effective communication. This is derived from strength of personality and the self-assurance that allows patients to ask penetrating questions and expect real answers. This sense of self is totally different from cockiness or arrogance, neither of which should have a home in dealing with cancer patients and their families. Reaching this state of mind is easier for the physician with age, experience, and a record of achievement. However, such a state is not limited to older physicians. Many young and recently trained oncologists have that intangible quality, which is immediately obvious to colleagues and patients alike. Could this be people skills?
Roy B. Sessions, MD, FACS