Walter F Baile, M.D.
Professor, Behavioral
Science
The University of Texas M. D. Anderson Cancer
Center
Dr. Baile:
When you're discussing any new
information that adversely affects the patient's view of his or her future, it's
basically a breaking bad news interview. So after you've got the setting right,
you can start with a very simple assessment of the patient's perception, asking
before telling. In this interview, the physician did just that and found that a
gap existed between the patient's perception and the medical reality.
Dr. Buckman:
So I want you to start if you wouldn't mind,
tell me what you know about it so far: what everyone else has told you; family
doctor and Dr. Miller.
Mrs. Anderson:
Well, Dr. Miller told me that the
operation was a success...
Dr. Buckman:
Yeah.
Mrs. Anderson:
...and that he got everything he believed
that was involved...
Dr. Buckman:
Yes.
Mrs. Anderson:
...in the cancer. And then he just asked
me to set up an appointment with you.
Dr. Baile:
Now here's something important
that may not come naturally and that is to acknowledge what the patient has
heard as their perception of the situation even though it may not actually be
true in medical terms. So at this point, it's really not helpful to contradict
the patient directly or to try to set the record straight. You'd basically be
arguing with the referring doctor using the patient as a messenger. In any
event, that would also distract from the real issue which is to really get the
right treatment for the patient. It might even create an emotional state that
would interfere with her getting treatment. I mean, for example, supposing she
stormed out in anger. So once you've acknowledged what she's heard, you can go
on to describe your role in the patient's management.
When you're delivering medical information, 3 basic points are really valuable. One, use plain language. It's really an effort to translate jargon into plain words, but the effort really pays off. Secondly, check that the patient actually understands the message. And third, as you talk about the disease, giving the news as it were, always emphasize what is known about the biology of the tumor: what we know about the particular way this cancer is likely to behave so that you're actually telling it the way it is. And, this also involves the patient directly and may create the motivation for her to consider additional treatment. So that's a really useful and helpful approach and it's worth concentrating on and remembering to really use plain, everyday language in your explanations. So, let's see this scenario.
Dr. Buckman:
But this is the important point I want to
make, Mrs. Anderson. The fact that this cancer had spread to a large number of
lymph nodes, is a sign of how aggressive it is: of its tendency to recur, to
spread elsewhere in the body.
Mrs. Anderson:
Even though it's gone, including the lymph
nodes that were on the outside?
Dr. Buckman:
Exactly right. Even though the breast cancer
itself and all the lymph nodes have gone...
Mrs. Anderson:
Right.
Dr. Buckman:
...there is still - and this is an important
point - there is still a chance of the cancer recurring elsewhere in the body:
in distant parts of the body. And that's a very important thing. In fact, right
now at this moment, that's the most important thing about your future. Even
though there's no cancer left...
Mrs. Anderson:
Right.
Dr. Baile:
When the physician here said,
"This is an important point," he provided a sign post for Mrs. Anderson: a way
of underlying a very important point he wanted to make. When Mrs. Anderson
asked, "Even though it's gone," and the physician replied, "Yes, even though..."
he used another very effective technique that's so simple it's often overlooked
and that's repetition of the patient's own words. By using her own words, he did
3 things. First he acknowledged that he'd heard her. Second, he made her an
active participant. And third, he validated her. Also, throughout this
discussion the physician made an effort to acknowledge how Mrs. Anderson was
reacting and so that's the objective of the empathic response: indicating that
you've noted how the patient is feeling.
Mrs. Anderson:
I didn't realize it was going to be such a
long road.
Dr. Buckman:
I know. I know. I understand what you're
saying. When you found that lump in the breast -- I've got some Kleenex here.
Here you go Mrs. Anderson.
Mrs. Anderson:
Thank you.
Dr. Buckman:
When you found that lump in the breast,
nobody knew including...
Dr. Baile:
And that's another pearl: if at
any point the patient cries, it's really important to offer a tissue and move
closer while breaking eye contact for a moment. And this gives the patient
permission to cry and shows you won't abandon them. And catharsis or emotional
release can really be important in allowing the patient to regroup. If you feel
comfortable doing so, you can also touch the patient lightly on the forearm at
that moment. These are all ways of providing acknowledgement and this is about
building rapport and the value of acknowledgement really can't be overstated.
Acknowledge you hear her. Acknowledge her emotion.
Now recall that the physician's real agenda here was to get into the discussion of treatment, yet all of the first part of this interview was taken up with gently and you might think painstakingly dealing with perception and emotion. So, one might really feel anxious to get on with it, so to speak. But to rush the agenda would be a mistake here since anyone who is emotional is not likely to really absorb much information. For some doctors, discussing clinical trials really is a trial. It can feel laborious and time consuming and sometimes we might even be tempted to hand the patient a pamphlet so we can get on with it. But studies have shown that this conversation really can affect accrual to clinical trials and also the patient's ongoing attitude about treatment.
So it's really useful to think about education as a dialog and as a therapeutic intervention in itself, and it requires rapport. And once there's rapport, there are some things you can do to really make teaching more effective. For example, using sign posts. An example was when the doctor said, "Now this next part is important Mrs. Anderson." Another was when he said things like, "Now what I'm going to tell you next." Rather than one long monologue, he gave the information in chunks and before moving on he checked for understanding. At the end of the discussion, it really helps to ask if there are any other major issues that minute. If there are, you don't have to address them right then and there. You can just indicate to the patient that they are top items on the agenda for the next visit. But always ask, because important questions often emerge at the end of the interview.
Dr. Buckman:
You can take that little piece of jotting
which at least reminds you of our conversation.
Mrs. Anderson:
Yes, no that's good to take.
Dr. Buckman:
And we'll meet again in a week. Bring your
husband or a friend or both...
Mrs. Anderson:
Okay.
Dr. Buckman:
...and we'll go over every single question
that you have. Oh one point that I didn't say. By the time you get home, you'll
have 70 questions in your mind.
Mrs. Anderson:
I'm sure I will.
Dr. Baile:
And finally, it was important
that the physician let Mrs. Anderson know that even though even if she rejected
or dropped out of the trial, he would still be her doctor and this not only
gives the patient a real choice, but avoids any pressure or fear of rejection on
her part. This interview could have gone very differently. There were quite a
few communication landmines or potential pitfalls for this physician. Right at
the start it might have been tempting to engage in blaming Mrs. Anderson's
surgeon for what he said or didn't say. But the doctor here opted instead to
discuss the cancer and stay on topic.
Second, had he forged ahead with discussion of the clinical trial before Mrs. Anderson was ready, I think that the information may have simply gone right over her head. Finally, when we're explaining clinical trials, it's tempting but important not to exaggerate the benefits or underplay the differences and side effects of the treatment choices. So that's it: a very significant discussion for the patient and for her entire attitude to the treatment and actually to her medical care and the treatment team. I hope that you've seen how the SPIKES protocol and the use of simple techniques like acknowledgement, repetition, empathic responses can help in a major task such as discussing a clinical trial.
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Center
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