Editor’s note: The following column was originally published online in The ASCO Post, March 25, 2019. It is reprinted with permission from The ASCO Post © 2019, Harborside Press.
You cannot write about caring; you must practice it. None of us went to medical school thinking we would be an oncologist, a neurosurgeon, or a stem cell biologist. But we did have vague aspirations of wanting to help others—to be involved in other lives. It was an altruistic avocation; how could it ever be lost? Don’t we all want to return to that initial avocation? But how and why not? What a privilege it is to participate in the care and well-being of another human being. We all wanted to make a difference. When we acknowledge and support human frailty, we receive as much as we give.
When a patient is confronted with a diagnosis or potential diagnosis of cancer, the anger, the fear, the injustice of it all can never be underestimated. We should start by caring for the emotional pain of the presumed diagnosis.
How then to teach caring? You have to teach from the patient’s point of view. When a patient is confronted with a diagnosis or potential diagnosis of cancer, the anger, the fear, the injustice of it all can never be underestimated. We should start by caring for the emotional pain of the presumed diagnosis. Imagine the missing life of your patient—the man who cares for a disabled spouse or the mother of an autistic child. Who will walk the dog?
Delivering information to patients: More art than science
Your office and office assistants define who you are. How easy is it to ask someone else to deliver the information a patient needs? We must be aware that good news can be presented by almost anybody. However, bad news, troubling news of life-impacting diagnostic information, should always be delivered by the responsible physician. That begins caring.
A successful procedure without complications can be communicated to family and friends by any member of the team. A problematic outcome, the inability to perform a procedure, an intraoperative complication, or an untoward outcome must be presented by the person ultimately responsible—you! The delivery of good news by a member of the team can never obviate the need for the responsible physician to communicate a full description of the events that took place.
Setting patient expectations
Many of the problems of delivering unexpected bad news can be tempered by setting expectations. For the surgeon, it’s helpful to inform the patient and family that a brief procedure may well mean that the tumor was not removed. A prolonged procedure may mean the problem is more difficult than expected. But a long procedure does not necessarily mean a problem. Taking the time and setting the stage make so much difference. The expected, no matter how unpleasant, can be handled readily—the unexpected, not so much. The caring physician must own the good and the bad.
The most unethical, unkind communication to the patient is to promise what you cannot deliver, or even worse, promising what your colleagues cannot deliver. “Operation was not possible; you will need chemotherapy.” “We think you have a bowel obstruction, so the surgeons will come and deal with it.” “Radiation will take care of it.”
Sensitivity and empathy
And what about the inpatient? How do you convey caring when you make rounds with a team, some active participants, some observers, some redundancies? How do you change the dynamic from your power, your omnipotence, to an example of caring to the rest of the team? How easy is it to convey your power and dominance by standing, looking down at the patient, or worse, looking not at the patient but at the chart or your colleagues, or even worse, wheeling in the portable iPad? How much better to convey sensitivity and empathy by sitting on the edge of the bed, having conveyed respect by asking permission. The gentle touch of the back of the hand is often responded to by a grasp of your full hand—a grasp of fear, gratitude, desperation, or simply warmth. You care.
“I do not have time for such things,” I hear you say. “How can I make this efficient?” It cannot be done with an erudite discussion of the latest computed tomography findings, but with a simple question: “How can I help?”
“What are your concerns?” “How much do you understand?” These questions are so rarely asked that the patient often does not have time to respond. How much more rewarding it is to set the scenario and turn this into a caring but efficient process. I recommend asking, “Do you have questions? If so, write them down, and we will discuss them tomorrow.”
For that one visit with a patient, however brief, time must stand still. But for the next patient, it will be a different piece of time that stops. Time was left behind with the last patient, as he or she absorbs and reflects on what was said. The time you spent will be expanded tenfold, as patients dissect your words, your touch, and that becomes distilled into what they will ask the next day. I often tell the family to come at the time that I will make rounds; meeting at the bedside embraces the family and ensures the message received by everybody—staff, patient, and family—is the same. Mixed messages breed confusion, angst, and anger. Alignment of the patient’s, the family’s, and your expectations says you care.
What is the value of the first postoperative visit to explain the pathology? Reading the full text of any report means little, if anything. Setting the expectations, explaining the meaning of the findings, and explaining the anticipated future—all say you care.
What if there is to be no more surgery, no more chemotherapy? What does that mean? Certainly, it is not a dismissive referral to palliative care or hospice. This is the time for you to explain why there is no active anticancer treatment, but more importantly, the patient needs to hear why you embrace palliation while still caring and taking care.
Caring begins at the beginning and ends at the end and should never be far from every encounter. Take time to care: it is why you went to medical school.