PracticeUpdate: Why is effective communication so critical in healthcare practice?
Dr. Schwartzberg: Effective communication is perhaps the most important task that a doctor has when she's interacting with patients. Cancer care, in particular, is so complex now that straightforward communication with the patient in a way that the patient can understand without the use of jargon is really critical to having shared decision–making. It's well-known from studies that, once you tell patients that they have cancer, they don’t hear 90% of what comes afterwards. And, so, part of effective communication with patients is making sure that critical aspects are repeated at regular intervals, and that patients understand what you are telling them.
One method that works well to see if a patient understands you is teach-back, which means that you pause after giving a segment of information related to the patient's cancer treatment or diagnosis, and ask the patient to tell you, in her own words, what she heard. It is also important to stop at times and simply ask, "Am I making sense to you?" Because, although it may make sense to the provider, we all lapse into using technical terms and talking with a fair amount of complexity. The information needs to be broken down in ways that the patient understands it. Otherwise, the communication isn’t meaningful.
Lillie Shockney: Nurses are taught the teach-back method that Lee mentions. But patients don't want to say to their physician, "No, I didn't get it." They are embarrassed, and it’s unfortunate that they actually feel that way—because then the patient is just going to leave the physician in charge. And I want that patient to engage and participate actively and confidently in the decision-making about her care, including to the point of deciding to stop treatment and enrolling in hospice.
If we are not making sure that the patient understands what the deal is, then we could end up taking that patient down the wrong road, down a road that she doesn’t want to go.
When it comes to family members, I do not want an adult child pushing her mother or father, "Oh, come on, Mom, do one more treatment for us." That's very unfair. This is her life, and she needs to spend it as she wishes, and, if she wants to stop treatment or embark on a different treatment or whatever, that is her choice. I don't want children being selfish, because it is being selfish, whether they realize it or not. Or saying, "No, no; I don't want her in hospice yet." They are not making her feel any more well or have any more joys in her life by forcing her to exist, and we need to be respectful of her. I will tell adult children, "Don't you be in charge or think you're going to be. She's going to be in charge… she is in control, and you need to respect that. One day you'll have a crisis and you'll get to make your own decisions; but, right now, you need to respect your mother's decisions."
PracticeUpdate: What are some techniques you have found to be helpful in these conversations?
Dr. Schwartzberg: One important aspect of effective communication that's worth getting right on the front end—and it's really critical—is to get a feel for the patient’s education level. Your approach to a patient who didn't finish high school as opposed to someone with a graduate degree might be different. In addition, some patients are now highly educated, sometimes incorrectly, though, because of the use of Google and the Internet in general. So, it's good to ask everyone, "What have you looked up? What have you read about your condition?” And to dispel any misconceptions that may have come about.
PracticeUpdate: What are some of the most challenging conversations to have with patients and families?
Dr. Schwartzberg: In cancer, there are a lot of points at which the conversation becomes very challenging. Simply hearing a diagnosis is challenging for patients. We don't tend to deliver the diagnosis for the most part as medical oncologists; the patients usually come to us with a diagnosis. However, we certainly get that opportunity now and again, depending on the way the workup was conducted. That's number one. The biggest issue isn’t so much the emotional support, I think, than making sure that the patient understands what is said after he receives the diagnosis, because of the shock factor and not hearing you after you give him the diagnosis. The other potentially more emotionally laden point is when cancer comes back, particularly after treatment. That's a very difficult conversation to have with patients. There tends to be guilt. There tends to be recrimination and going through the stages of grief.
And the most difficult conversation is when you discuss with the patient that more specific therapy will not be beneficial and that it’s time to focus on palliative care only. Hopefully, the patient's been prepared for that conversation because palliative care should be part of the conversation from day one. But there is that moment when cancer-specific therapy stops and palliative care continues. In my experience, interestingly, both the time of relapse or recurrence and the end of active treatment are worse for patients who have done well beforehand, who are many years out from cancer. As a breast medical oncologist, just this week, I had a recurrence 14 years after successful treatment and another 8 years after successful treatment.
Those are very difficult conversations to have because many of these patients don't feel that their cancer is going to come back. And, then, there are those who have done well with continuous therapy in the advanced cancer setting; they’ve gone through several lines of therapy and have responded at least to some of them. It is really, in my experience, very hard to say to them that we're going to stop, because they've already seen that they can do better. And so how could it be that there are no more medicines that can help?
PracticeUpdate: Do you have advice for new healthcare professionals on how to give bad news?
Dr. Schwartzberg: I think giving bad news is always a challenge, and it doesn't necessarily get easier, but you do learn techniques of how to do it. Earlier on in my own career, I tended to beat around the bush a little more than I do now. And I think patients really understand a lot more than you think they know so I tend not to coat the news in euphemisms. But, on the other hand, there is always hope associated with any specific condition. So, even when a patient is not getting active therapy, her biggest fear is abandonment. So, saying to her, "I am still going to be your doctor. I'm still going to be with you. I'm still going to be helping you feel as well as you can for as long as you can," is very reassuring.
This is the kind of thing you should learn as a resident and a fellow. You should observe attendings; that's how I picked up a lot of the social cues and the interactions, which I then made my own, based on my own personality and my own style of communication. But, it's hard to do unless you've watched an expert do it a few times. And then you should practice giving the bad news with an expert around. I’m of the opinion that postgraduate training is when that should be a focus. It's really about watching someone else, someone with expertise, talking with the patient, and learning it and doing it.
Lillie Shockney: For reasons I may never know, I have always felt comfortable giving bad news.
People have a tendency to try to whitewash it, and I don't think that's fair because it's a sign that we're not really giving all of the truth. "You have stage-four metastatic breast cancer, but you're going to be fine." She might be fine today, this month, or maybe even for the next couple years; but, then she’s not going to be fine. I like to give the news in pieces, and, right then and there, have the patient say back to me her understanding of what I just said.
Then I want to be able to discuss what the milestones the patient has coming up. Again, I want to help preserve them for her because this is even more important than it was before. I can't have her think that she'll still be here to meet her life goals necessarily, but I can help her figure out how to fulfill those goals in alternative ways. And I've been trying to teach providers and nurses and nurse navigators the importance of moving the patient through phases of hope. We were taught in nursing school and in medical school to take the patient through the phases of dealing with her cancer. First, there's shock, then there's denial, then there's anger, then there's depression, and then there's maybe acceptance. I don't do that at all. I don't. I say, “Let's look at the phases of hope.” And that first phase of hope is—this is shocking—but I'm going to hope for a miracle. And we can hop on that bandwagon with the patient for 3 or 4 weeks. She has the right to have that hope, and there's no need for us to burst the bubble. I have seen a couple miracles in my 47-year career.
Our next hope is that the patient will have normal longevity and live in harmony with this cancer and live out her life. Then, as the patient is starting to blow through more lines of therapy, and that therapy is working for a shorter period of time and it's more toxic, I have a very different discussion saying, "Your life is definitely going to be shorter than what you had hoped and what we had hoped for you. We want to make sure you have good quality of life for this remaining time, and we don't want you to postpone joy."
I am a strong believer in being honest. If we are not being honest and if we are sugarcoating something, then we're doing it for ourselves because we don't think we're ready to talk about the tough stuff. We chose this career knowing that there would be tough stuff.
And that is something that patients have said to me, particularly when they're very ill, "Thank you for always being honest with me. Thank you for always leveling with me. I could always count on you to do that for me."