Robert A. Buckman, M.D., Ph.D.
Adjunct professor, Behavioral Science
The University of Texas M. D. Anderson Cancer Center
Doctor:
May be it would help if I just went ahead and just talked about the plan for the treatment. Would that be a good thing to do?
Mrs. Simpson:
You can cure this right? I mean,
even if the treatment is really nasty, like before, I mean, you're
going to be able to take care of this right?
Doctor:
I wish I could say that we could cure it
in a sense that you're using the word. This is, this is all so very
difficult to hear. We can't cure it in the sense of abolishment...
Mrs. Simpson:
What do you mean you can't cure it?
Doctor:
Unfortunately that's not possible.
Mrs. Simpson:
You can't, you can't cure this? In this day and age you can't cure this! Oh, my God!
Dr. Buckman:
So here's another
critical moment. The patient expresses a big emotion. Again there are
several options available to you and I'm sure you're aware of them and
probably were even thinking about them. Let's start again with a direct
response, one responding factually, to what the patient said. Lets see
how that direct or factual response might affect the way the interview
goes.
Mrs. Simpson:
Are you telling me that in this day and age you can't cure this?
Doctor:
Well, nobody can. Even in this day and
age. It's not actually possible to cure the situation. What we can do
is control it. We may do that for a good long time.
Mrs. Simpson:
Well that's going to do me a lot of good, now isn't it?
Doctor:
It is going to do you good actually.
Mrs. Simpson:
How?
Doctor:
The hormone treatment will allow you to live with it and people do live with it for a, a... reasonable amount of time.
Mrs. Simpson:
Oh, live with it. Yes. That's easy for you, it's not your life now is it?
Dr. Buckman:
Now what you saw
there shows how readily things can escalate if the emotion that the
patient's experiencing is not acknowledged. She might well have thought
of that doctor as cold and insensitive, almost legalistic responding to
the word incurable and not the emotion that she was experiencing
contained in that - I was afraid or something like that. Now let's see
what happens with something worse, the escalationary response.
Mrs. Simpson:
Are you telling me that in this day and age you can't cure this?
Doctor:
Look you have to be optimistic. Look at the positive side...
Mrs. Simpson:
About what?
Doctor:
Well about the positive side of this...
Mrs. Simpson:
Positive side of what?
Doctor:
Well with additional treatment we can
get control of this disease for a good long time and that's positive.
You have to... again you need...
Mrs. Simpson:
It's very easy for you to say
because you're not the one who has to go through additional treatment.
You're not the one who has to worry about whether or not you're going
to live or die.
Dr. Buckman:
Well, I'll bet
nobody felt good after that exchange. An escalationary response is
always tempting really when you feel that you simply can't take any
more. But as we're saying in this series of options, there are other
choices open to you that you may or may not have been aware of. Let's
have a look at an example of the ever trustworthy open question.
Mrs. Simpson:
Are you telling me that in this day and age you can't cure this?
Doctor:
Why don't you tell me just what's going through your mind right now?
Mrs. Simpson:
Going through my mind right now?
It's pretty obvious isn't it? I'm worried that I'm going to go down the
same road as my grandmother.
Doctor:
Well, I wish I could guarantee that we
could cure the situation. That's not possible. But... obviously I don't
know exactly how your grandmother was treated, but even in the last few
years, there are very many options that simply weren't available even
back then. And I know that's not a great deal but its something.
Mrs. Simpson:
I know it's something but even that something doesn't sound so good right now.
Doctor:
Why don't you tell me a little bit more about your concerns and what you're really worried about?
Mrs. Simpson:
I'm scared of the pain.
Dr. Buckman:
So that was an
open-ended question and it gave you and the patient a bit of time and a
bit of space to define the real center, the real focus of the main
issue. And also, I hope you noticed, in that exchange, I used a wish
statement. "I really wish I could..." Now a wish statement is a
response that is not only permissible but it's actually very helpful
and there are papers written on that in the world of literature. Wish
statements, I'm not making this up. So, that's how you can respond to a
strong emotion, with an open- ended question. It may feel a little bit
awkward at times, until you're used to it. Or even as if you're prying
or perhaps you're worried about opening a Pandora's box of emotions.
That's actually very rare. Open-ended questions allow the patient to
get her real concerns out on to the table. So now let's look at how an
empathic response might work.
Mrs. Simpson:
You can't cure this?
Doctor:
It's very difficult...
Mrs. Simpson:
In this day and age you can't cure this. Oh my God!
Doctor:
I know that sounds awful and it feels
terrible to you, I realize its very disappointing and overwhelming and
all of those things. But actually it isn't anywhere possible to cure
this kind of a situation, control is what we can do. But it is, it's
not actually possible...
Mrs. Simpson:
...I'm just trying to get a grip on what you're telling me.
Doctor:
And that's very difficult isn't it?
Mrs. Simpson:
Yes.
Doctor:
Not easy.
Mrs. Simpson:
Yes. And then there's, these, this same thought that's going over and over in my mind.
Doctor:
Go ahead. Tell me. Tell me what's going through your mind.
Dr. Buckman:
There the empathic
response again simply acknowledges the emotion. No promises. You don't
have to promise to cure metastatic breast cancer because of course
that's impossible, nobody can do it. All the empathic response does is
to acknowledge that the patient's feelings have been noted by you. In
other words, she has been heard. It's very often relatively simple and
relatively straightforward.
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