Sunday, August 09, 2009

No Easy Way

This has been bothering me a great deal lately:

How do doctors learn to deliver bad news?

I know, I know. Doctors don't necessarily have to get tied to their patients. My current doctor could probably care less about me, but he has a very blunt approach in delivering news. I also know that modern doctors are taught how to deliver news, whereas the doctors of my parents would have to learn and figure out their patients. Is teaching our modern doctors how to deliver bad news a good idea? I believe the answer is no, but it is because it allows them to ignore the human element.

One of the most important aspects of life is learning how to read a person. The body language, the facial expressions, the tone of voice, and the speed of words all allow you to know what they are thinking. When a person is angry, for example, he or she will lean forward, even hunch, and will probably have closed fists. The face will be tinged red, and the words will be clipped regardless of speed. Again, it varies from person to person, but being able to read it is important.
The more you get to know a person, the more you understand them and can read them. Talking becomes less important. For example, the second my wife steps out of her car, I know how her day has gone. And yet, doctors are losing this skill.

The best doctor I ever had was Gerald Spielman. He was an old school pediatrician. Used to smoke, ate horribly, and could make me and my sisters feel better quickly. He had warmth, but also could speak in a serious tone. Dr. Spielman never had a course on how to deliver bad news, but learned how to read people and how to talk to people. Once upon a time, my mother was desperately worried that I didn't eat enough vegetables. Dr. Spielman looked at her and said, "It's ok. I hate vegetables too, and I'm old now." She was shocked, but she laughed and realized she was being silly. Why? Because of his tone and his words. Ironically, Dr. Spielman would die of a heart attack because he ate horribly and smoked. Still, he knew how to get a message across to his patients.

Since Dr. Spielman, I have not had a doctor that I trust or who gets how to deliver news. In watching them try, it's almost like they watched a video with various forms of delivery:

The patient has an aggressive form of Cancer. There are varying ways to deliver the news. Let's watch Dr. Demonstration as he attempts to tell Patient Peter he has Colon Cancer.

I. Direct. The doctor will not attempt to console the patient at first. Much like ripping off a band-aid, the doctor will immediately get to what is ailing the patient.

"Peter, there is no easy way to say this. You have Colon Cancer. Here is what you can do now."

Do you see what the doctor did there? He told the patient the problem in a matter-of-fact manner, but made sure to include something to show his empathy. "There's no easy way," is, in fact, a simple way to show that you are upset about the news as well, but must be professional.

II. Empathetic. The doctor will attempt to show a connection to the patient, usually through touch and tone of voice. He or she should begin with an apology.

"I'm sorry, Peter. I wish the news was better." (Doctor will put hand on Peter now.) "You have Colon Cancer. I'll give you a minute to let that sink in, and then we will discuss what you can do now."

Unlike our first situation, the doctor here tried to make a human connection with touch and tone. Peter will be upset, but will also feel that his doctor cares about him.

III. Nurturing. The doctor will deliver the news and offer to console the patient.

"Peter, I'm so sorry to tell you this. You have Colon Cancer, but we can fight this. We can beat this. Is there anything I can do before we discuss what you can do now? Questions? Do you need a minute?"

Here, the doctor acts almost like a family member. As if Peter and the doctor will attack this Cancer together.

Now, I don't believe doctors watch a video like this, but I'm curious how the classes work. Working with an actor is not the same thing as telling a parent of two he or she is going to die. And how do you prepare for all situations?

My neighbors down the street had a horrible experience a few weeks ago. After being pregnant for all nine months, (we'll call her) S started her contractions and was taken to the hospital to give birth. The baby did not survive. She came out and never cried. S and her husband H were devestated. To compound the problem, the doctor delivered the news using the first approach above. Direct, to the point, and with no...warmth.

S and H found this doctor to be unappealing in helping them deal with the situation. They were given directions on how to find a grief counselor, how to tell their almost three year old the news, and how soon to try again, but none of it was comforting. And while they have been seeing the counselor, they also have been talking to me a great deal. I'm the human element. Someone who has been through experiences and can talk to them about it without using large clinical words. The only problem for me is trying to hide the guilt I feel over having two healthy children when they do not. They have not noticed so far.

I, however, have dealt with all three types of doctors in my life. When I was in college, I was told I had Cancer by the on-campus medical staff. The joke about the nurse's office there was that everyone was either pregnant, had Cancer, or both. After my car accident, I went to the nurse's office because I was not feeling well and had a pain in my chest. They took an x-ray, and put me in a room by myself. After thirty minutes, a doctor appeared looking solemn.

"There's no easy way to tell you this," he sighed.

As a side note, I really hate when doctors say that. We know there's no easy way to tell someone they are sick. It's like trying to tell a kid that his or her mother is dead. There is no easy way to do it. That's why a class was created back in 1987 to help doctors learn how to deliver news. Yes, I get that starting with the phrase allows doctors time to formulate their words, but come on... wait outside and compose the idea before entering then. That phrase is almost a slap to the patient. Back to my point.

"There's no easy way to tell you this," he sighed, "but you have Cancer." With that, he held up the x-ray and pointed to spot on my lung. While my mind rushed to WTF speed trying to figure out how, the doctor put his hand on my shoulder and said, "This is not the end. We can fight this, and you can live a long life. Don't give up."

Now, I would go to the hospital the next day and get another x-ray with an Oncologist. When I first met him, (we'll call him) Dr. R was very much like approach II. "My wife had Cancer," he would tell me, "but she fought it back and won. There's hope." I would later find out that his wife's Cancer was skin cancer, and her "fighting back" was having it cut off. Still...points for trying.

And here is where it was fun to watch Dr. R. They did the x-ray, and it turned out there was nothing there. The first x-ray had a smudge or something on it that was regarded as Cancer. As he was told this, his face and body changed. It was like watching Dr. Jekyll turn into Mr. Hyde. He had shared with me this story only to have it turn out I was not dying. Now Dr. R used the first approach. "You're fine. Live a long life. Goodbye, sir," and he headed out of the room to go find the next person.

While the class may be useful, I fear that as we become more and more technology centered, that it will be necessary. Tone, body language, and speed cannot be read over the internet. The more we lose the human element, the harder it will be for doctors to learn how to talk to them. I know that S thought the delivery of the bad news would be like on a medical show. The doctor would look sad, would deliver the news, leave the room, the music would swell, and the doctor would collapse much like Willem Dafoe in Platoon while sobbing about the death of a child. It was not that way. Nor was there a lesson learned.

While I am not a doctor, my advice to all of them is learn how to talk to people by actually talking to people. Don't bank on a class to teach you how. I'm a teacher. I learned how to interact with students by doing it, not by sitting in a classroom practicing it. The real world application is never the same as the simulation no matter how well-trained the actor is. Even Sir Laurence Olivier cannot match the real pain people feel when a baby dies. Just talk to us.

Of course what do I know? I never sugarcoat. I could be wrong.


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