Just three weeks earlier, she had noticed something strange about one of her breasts. An irregular shape. Her daughter brought her to the doctor, and soon the patient, I’ll call her Amanda, was diagnosed with breast cancer, stage “to be determined.” In fact, she was now in an oncologist’s office, learning what tests she would receive to determine the extent of her tumor. And sitting between her and the doctor was a tape recorder, capturing their conversation. A dozen minutes into the appointment, Amanda would break down crying. And the physician’s response, which I will lay out for you in a bit, is unfortunately not uncommon. When patients express negative emotion, many oncologists do not respond with empathy. As I’ll explain later, this is an enormous problem, but also one we can fix. Amanda was 60 years old at the time of the appointment, quite frail for her age, requiring help climbing up onto the exam table because of a recent stroke. She needed to wear adult diapers. She also suffered from diabetes and tremors, although it was unclear whether those non-spontaneous movements were from Parkinson’s or some milder disorder. In other words, her health was already fragile, and a breast cancer diagnosis wasn’t going to make things better. Which may be why she was so distraught about her situation. The oncologist described how he would evaluate her problem: “Now I am going to order a scan, a CT scan. It’s like an x-ray, but she needs to lie down,” he explained to Amanda’s brother. “After that, we will check her blood. After we’ve done the blood test and the scan, I will meet you in one week, and we will discuss this, and I will advise accordingly.” Then, perhaps noticing the look on Amanda’s face, he advised her: “Don’t be scared, please. We will wait for the scan and blood results and see you in one week. So next week, [turning to the brother] please come with your children [one of whom was Amanda’s caregiver] and I can discuss this further.” Amanda’s brother agreed with the plan, but Amanda started crying: “So difficult,” she said. Her brother tried to intervene. “Stop crying,” he said. The oncologist also stepped into the uncomfortable situation: “Amanda, don’t be scared, please. We don’t know for sure [how bad your cancer is], so let us check first. OK?” “I can’t do so many things,” she responded. “This cannot … that cannot …” and she trailed off, crying more. “Don’t worry,” said her brother. “OK, don’t cry,” reaffirmed her doctor. “Doctor will do the best for you,” continued her brother, “so don’t cry. OK?” The physician continued, almost a tag team now with the brother. “Today we can do the blood test. You don’t have to wait after doing that and can go home thereafter.” “You have a lot of work, right?” she said, apologizing for letting her emotions take up so much of the doctor’s time. He tried to ease her mind. “No,” said the doctor, denying that he was too busy to address her concerns. But he immediately muddled his message. “I mean, you can do your blood tests today.” A heartbreaking episode, heartbreaking in large part because of the awful situation poor Amanda was in, with so many things she could no longer do because of health problems and now with advanced cancer. Tragic, truly tragic. But compounding this tragedy was a veritable tragicomedy of miscommunication. Amanda breaks down crying and what message does she hear from her brother and doctor? Stop crying. Neither brother nor doctor acknowledged that, given her situation, she had a right to be scared, that it would, in fact, be abnormal not to be frightened. Neither realized that when people start crying, telling them to “stop crying” can actually make patients feel worse. I am sure I have made this same mistake scores of times in my own clinical practice. When a patient cries, our natural instinct as doctors, as humans, is to relieve their suffering, to say something that will stop their crying. It is perfectly normal, even compassionate, to reach out to soothe someone who is crying, to gently tell them not to cry, that everything will be OK. But that is not necessarily what is best for our patients. What Amanda needed was simple validation of her feelings. She needed her doctor to say something like: “I see you’re frightened, and I can understand that.” And she needed an explicit statement of support: “Whatever we find out in these tests, I want you to know I will do everything I can to help you. Our whole team will be here to support you.” Further adding to the tragedy was Amanda’s interpretation of the oncologist’s efforts to stop her sobbing. When he told her not to cry, he was making an earnest effort to tell her that he didn’t want her to feel overwhelmed by her illness. But she instead assumed the doctor was too busy to attend to her emotional needs. When patients have emotional needs, the last thing physicians should do is make them feel like they don’t have time for them. Sadly, this kind of exchange is not unique to this patient’s story. Dr. James Tulsky, chair of the department of psychosocial oncology and palliative care at Dana-Farber Cancer Institute in Boston, has conducted a series of studies which have shown thatsenior oncologists respond appropriately to patient expressions of negative emotion only slightly more than one in five times, a paltry .220 batting average that ought to send these docs back to the minor leagues to work on their skills but, instead, leaves them practicing medicine at some of the nation’s leading medical centers (where those studies were conducted). Fortunately, there is a way to improve this situation. Dr. Kathryn Pollak, a psychologist who worked with Tulsky, is confident oncologists can respond more appropriately to patient emotions. “Oncologists care deeply about their patients but sometimes struggle showing how they care. Some worry that discussing such emotions would lead them down a rabbit hole and consume huge amounts of their scarce time. What we know, though, is often when they don’t address the emotion, it takes even more time, as patients will continue to bring up their concerns.” In fact, in their research, Tulsky and Pollak gave oncologists some simple suggestions for how to more effectively respond to patients who express negative emotions. They explained that patients often feel vulnerable when expressing negative emotion (who likes to tell people that they are scared?). Oncologists can reduce this sense of vulnerability by naming the emotion for the patient: “I can see that you are scared.” Then they can follow up by praising patients for what they have done: “Given all that you are going through, I’m impressed that you are still able to help out your sister.” They taught oncologists to support patients by letting them know they are with them for the whole journey: “No matter what happens, my team and I will be here with you throughout this whole process.” Finally, they showed oncologists how to explore emotions with their patients by asking them to “tell me more about that.” The results of this communication training were impressive, with large improvements in oncologists’ abilities to both acknowledge and respond when their patients express feelings like pain, fear, and anger. Physicians really do want to help patients out when they are suffering; they just don’t always know what to say when emotions start spinning out of control. This type of communication intervention could become a standard part of medical training. But to date, very few medical schools or residency programs have incorporated this intervention into their training, outside of research contexts. No state licensing board and no sub-specialty society has built a program like this into their certification criteria. And organizations that measure the quality of healthcare don’t include rigorous assessment of physician communication. James Tulsky thinks this needs to change: “No one measures physician communication as an indicator of the quality of medical care. We now have the tools to do so, and such measures could revolutionize the doctor-patient relationship.” Patients deserve to interact with physicians who know how to address their emotional needs. The question remains whether the medical profession will take such communication skills seriously enough to emphasize them in training and licensure. Source
