This article is more than 5 years old. Information may no longer be current.
How to treat the whole patient with a therapeutic approach
Click Here to Manage Email Alerts
In a recent e-mail to the National Public Radio blog “My Cancer,” a physician finishing her radiation oncology residency wrote the following:
“I am finishing my training in radiation oncology in three to four more months. My question to you is: What advice do you have for me, as an up and coming cancer specialist? More specifically, what did you like/dislike about your physicians, what could we do to be better? I know everyone has differing sets of opinions on the matter, but I would appreciate any input.”
The blog received many passionate postings with advice to the doctor. Almost all of the comments focused on lessons learned during individuals’ experiences as cancer patients and caregivers.
Most urged the young doctor to focus on becoming an effective communicator and developing her interpersonal skills in caring for patients. Concepts such as respect for the patient, providing hope and reassurance, honesty, determining each individual’s information needs and how to encourage the patient were frequently mentioned. Several respondents acknowledged how hard it is for doctors to give bad news and take care of seriously ill patients and admonished the writer to engage in activities to promote her own psychological well being.
It is important to note that most of the responses to the physician’s request were thoughtful and did not seem to come from patients who were angry or disappointed because their treatment had not gone well.
|
|
Many had obviously received excellent medical care, but their letters revealed a deeper appreciation of what was and was not “therapeutic” about their relationship with their caregivers. Actions and behaviors on the part of their medical team that gave them courage and comfort but were not related to their medical treatment dominated almost all of the discussion.
The need to connect
The comments of the patients to the young radiation oncologist’s query underscore the importance of interpersonal and communication skills in the eyes of the patient. They remind me of some basic psychological principles that underlie many helping relationships, and explain why physician attitudes and verbal and nonverbal behaviors can influence patients to the extent that many important outcomes of medical care such as patient satisfaction, compliance with treatment and even malpractice suits are linked to communication and the doctor–patient relationship.
Despite recent advances in cancer treatments, which in some cases have made it less arduous for the patient, many patients are still frightened by the disease and its treatment. They often experience a significant crisis around diagnosis, and fear of dying, treatment adverse effects and life changes raise significant anxiety about the future.
Because of this uncertainty, patients can be observed forming strong relationships with their caregivers as they reach out for help and may even regard their oncologist as the most important source of psychological support, as Molleman et al reported in Social Science and Medicine.
Patients are mostly quite grateful for their care, and want to get better not only for themselves and their families but also for their treatment team. However, they can also suffer a loss of self-esteem because of their illness as they are often taken out of their usual roles as parents and providers for their families and deprived of normal sources of gratification that we all may take for granted. These factors all serve to intensify the relationship between patients and their medical caregivers, and make patients more vulnerable to the words, actions and attitudes of their oncologist and members of the oncology team.
How can communication be therapeutic for the patient?
As Novack reported, our words and actions can have an important psychological benefit. Given the patient’s need for not only good medical care but also for a “guiding hand,” a “therapeutic alliance” with the patient would emphasize the following: Most impressions are made in the first minute or two after we meet someone.
Invest in the beginning; a friendly handshake, smile and eye contact go a long way to an initial establishment of trust and rapport; careful listening to the patient’s concerns without interrupting can help them feel regarded and take up only a fraction more time; appropriate reassurance can decrease anxiety; encouragement in the face of setbacks can bolster optimism; empathy can reduce emotional tension; praising the patient can acknowledge effort; providing a plan can reduce uncertainty; discussing treatment choices communicates respect.
Important words
Our words especially represent an important source of hope for the patient. Many patients in the response to the young doctor complained that, “[Doctors] are so afraid to give false hope that they have nothing positive to offer.”
Comments such as “you have nothing going for you” were reported as “devastating.” Certainly balancing honesty and optimism can be challenging, but as one patient put it, “we are each a study of one and statistics are just plain wrong sometimes.” The technique of “hoping for the best while preparing for the worst” is one useful way of couching hope in a positive framework. As one patient suggested, “if [the doctor] will just say to me there are people out there working on cancer treatments and cures every day and that they will help to keep me living as long as possible it would be priceless to my psyche.”
Are these above competencies within the reach of every oncologist? Some require nothing more than reflection on the part of the physician and a bit of “putting oneself in the shoes of the patient.” It is useful to ask in this vein “what are the behaviors I’d like to see in my cancer doctor if I became ill?” Others require more skill training and coaching, which ideally should be part of every oncology fellowship program.
Lastly as one respondent put it, “compassion fatigue is real … you must develop a kindness and compassion that doesn’t drown you in its weight, but allows you to express sincere feeling … find what you need to do to de-stress, unwind and recharge your spirit after days filled with giving.”
During a presentation on “Stress and Burnout in Oncology” at the 2007 Society of Surgical Oncology Cancer Symposium, it was remarked by one surgeon in the audience how not only keeping up with new knowledge but also struggles with increased paperwork and diminished time for patients now make the job of patient care much more challenging and often frustrating. Indeed ways to balance one’s life in practice of oncology has been addressed by Shanafelt et al.
However, another important way is to make the relationship with the patient as rewarding as possible. Patients who feel connected to us are grateful for their care, which makes our reward that much greater.
For more information:
- National Public Radio. www.npr.org/blogs/mycancer. Accessed March 22, 2007.
- Molleman E, Krabbendam PJ, Annyas AA, et al. The significance of the doctor–patient relationship in cancer. Soc Sci Med. 1984;18: 475-480.
- Bedell SE, Graboys TB, Bedell E, et al. Words that harm, words that heal. Arch Intern Med. 2004;164:1365-1368.
- Novack DH. Therapeutic aspects of the clinical encounter. J Gen Intern Med. 1987;2:346-355.
- Back Al, Arnold RM. Hope for the best, and prepare for the worst. Ann Intern Med. 2003;138:439-443.
- Back Al, Arnold RM, Baile WF, et al. Efficacy of communication skills training for giving bad news and discussing transitions to palliative care. Arch Intern Med. 2007;167:453-460.
- Shanafelt T, Chung H, White H, et al. Shaping your career to maximize personal satisfaction in the practice of oncology. J Clin Oncol. 2006;24:4020-4026.