Walter F Baile, M.D.
Professor, Behavioral
Science
The University of Texas M. D. Anderson Cancer
Center
Dr. Baile:
This is, undoubtedly, not the
physician's last interaction with Mrs. Anderson, but in many ways, it's a
"saying goodbye." She's making an important transition in care and he offers her
closure on the relationship. Here we saw, yet again, the importance of checking
the patient's perception before proceeding. In this case, it allows the doctor
to acknowledge the gravity of the situation.
Dr. Buckman:
Not really. It's okay. Is it okay if we have
a talk about how things are at the moment? Yeah? How do you think you're doing
at the moment?
Mrs. Anderson:
I don't think that it's going very
well.
Dr. Buckman:
No. No, it isn't. I'm sorry to say that it
isn't going well.
Dr. Baile:
The doctor also uses the
"Narrative Approach" successfully here. In essence, he tells the story of Mrs.
Anderson's illness. This allows him to ease her into the news he has to impart:
that no further treatment is available. And it also gives him the opportunity to
approach the situation gradually to the point where he can tell her that any
further anti-cancer treatment would be futile. And as you saw, this led to the
question about prognosis. It would be tempting to avoid this conversation
altogether. In doing so, the physician, however, would have missed the
opportunity to find out something more he could do for this patient, and would
have missed the therapeutic intervention. One way physicians, at times, avoid
this kind of encounter is to continue futile therapy or to promise a clinical
trial and both of these are, sort of, really pitfalls. Finally, telling a very
ill patient that there's no treatment available that will arrest their cancer
can be very painful and stressful for the physician and even evoke a sense of
sadness or guilt or failure. So reflecting on and acknowledging our own distress
can allow us to separate the message from the messenger, in a sense, so we can
be supportive to the patient. This physician also did that by focusing on the
behavior of the cancer.
Dr. Buckman:
This - I've said this many times over the
years - this breast cancer was, um, behaved aggressively from the very
beginning. It did nasty things and you have always been, and you are now, a
remarkable and brave lady. I'm sorry. I want you to know that.
Mrs. Anderson:
Thank you.
Dr. Buckman:
I'm going to come see you tomorrow
morning.
Mrs. Anderson:
Okay.
Dr. Buckman:
I'll let you sleep. Bye-bye for now Mrs.
Anderson.
Mrs. Anderson:
Thank you.
Dr. Baile:
A final comment: this doctor
took the opportunity to tell Mrs. Anderson that she was a remarkable lady,
actually, to compliment her. I have no doubt it was a very emotional encounter
for the doctor, but it was also a therapeutic one for his patient. I think it's
helpful to think of encounters - conversations with patients - as potential
therapeutic interventions. This helps us as physicians to take the time and
effort to do them right.
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