HOW TO BETTER COMMUNICATE DIAGNOSIS AND PROGNOSTIC INFORMATION WITH OUR PATIENTS
You are listening to ReachMD, The Channel for Medical Professionals. All the technology and advances in medical science hasn't changed, the most difficult thing we do as physician that is to relay emotionally charged diagnostic and prognostic information to our patients. How can we do a better job? Our guest today states the communication skills do not automatically improve with increasing physician experience. Welcome to The Clinician's Roundtable. I am Dr. Leslie Lundt, and with me today is oncologist, Dr. Alan Astrow. Dr. Astrow is the Director of the Division of Hematology and Medical Oncology at Maimonides Cancer Center in New York City. He has a special interest in the treatment of breast cancer, GYN cancer, and Hodgkin's and non-Hodgkin lymphoma. He has conducted research on how to help physicians understand the patient's wishes, values, and needs as well as how to improve communication between doc and their patient.
DR. LESLIE LUNDT:
Welcome to ReachMD, Dr. Astrow.
DR. ALAN B. ASTROW:
DR. LESLIE LUNDT:
Dr. Astrow, how much training and communicating complex and difficult information does the typical oncologist receive?
DR. ALAN B. ASTROW:
Unfortunately, not very much.
DR. LESLIE LUNDT:
So what do you do? You know you are obviously very interested in this. Tell us about what's been happening out there in the real world to try to help us do a better job.
DR. ALAN B. ASTROW:
Well, there are oncologists out there who had been aware that this is a major need in the Oncology Community to learn how to deliver emotionally charged information to a patient, specifically how to give bad news and so there have been workshops, I have attended one myself that was run by the American Society of Clinical Oncology. There are CD-ROMS. There have been books written and there are articles in the literature. There are curricular for fellows. So, there are things that are happening that are going in the right direction, but there is still a lot to do in this area.
DR. LESLIE LUNDT:
Tell us about the SPIKES program.
DR. ALAN B. ASTROW:
Okay, SPIKES is an acronym for a specific protocol for giving bad news to patients. It was devised by Dr. Robert Buckman from the University of Toronto and SPIKES stands for setting, perception, invitation, knowledge, evaluate emotion, and summary/strategy, and so what I do is when I am about to give bad news, I often think about this acronym, and it helps me quite a bit.
DR. LESLIE LUNDT:
Okay, what through it so S is for setting.
DR. ALAN B. ASTROW:
Okay, the first thing you want to do if you have to give bad news to a patient. If you want to make sure that you are in a comfortable setting, you want to be sure that there are no distractions that is possible for a busy doctor, you want to make sure that you are sitting at eye level with the patient, you want to make sure that everyone is comfortable. So, giving bad news in a hallway, standing up not a good idea.
DR. LESLIE LUNDT:
So, even standing up at the bedside is not really the best way.
DR. ALAN B. ASTROW:
No, if you are really giving emotionally charged information, you should be seated, even if it's going to be a brief period of time. The patient appreciates it when you show that's a bad period of time, you have their undivided attention. You don't have 1 foot out of the door that you are there to speak to the patient and answer that patient's question.
DR. LESLIE LUNDT:
Which is easier said than done, right?
DR. ALAN B. ASTROW:
That's right it is easier said than done. First you make sure you are in a comfortable setting, it should be a private setting, then P - perception, then ask the patient what's your understanding of what's going wrong now, what if you've been already told because you will often be surprised about how much the patient misunderstands or you will be surprised that the patient really hasn't been told very much. I, myself, am amazed that how many patients come to me from other doctors and they really haven't even been told that they have cancer. So, you really need to find out from the patient what do they know. I – invitation. Before you start blurting out information to a patient. Wanna to ask the patient, do they want to know the information. You don't want to force information on an unwilling recipient of that information. So, you ask the patient, would you like to know what the diagnosis is? Would you like to know the test result? Are you the sort of person who likes to hear the bad news himself, or herself or would you prefer that I relate to someone else in your family or to a friend. You always need to ask. Then, once you have gone through those preliminaries again - setting, perception, invitation. Then, you get to the K, the knowledge part, which is the center of the bad news discussion, and there you try to speak in common sense, nontechnical language and you give the information slowly in small chunks. Often it's useful to give what is called a warning shock or an opening shot to make sure the patient is prepared. You say something like, I am about to give you some pretty tough news, just see the patient is ready and then you want to go slowly. It should be a dialogue, not a monologue. So, you want to always be checking - do you understand what I am telling you? I am going too fast? Am I am giving you too much information? You want to be sure that the patient is with you each step of the way. Then, after you have done that part, which is the center of the discussion, you want to evaluate emotion, that's E. Now, one of the major mistake that doctors and nurses often make in delivering emotionally charged information is to prematurely reassure the patient. Before you reassure, you want to let that patient express what is on his or her mind. What they are feeling about what they just heard. Then, you might want to say, this is some pretty tough news I just gave you or how does it make you feel here or I bet you weren't expecting to hear this or you look troubled. Someway that you are showing that you acknowledge the human emotions at stake, that you are not acknowledging that person as a human being, that you are there as a human being and there is a doctor for that patient. So, you give the patient a chance to express what it is that they are going through. Then, it is often useful after the patient has expressed that they are truly upset with the trouble. They hadn't expected to hear this. They thought everything was going well. Often they will start to cry. Many times patients have started to cry in my office when I have had to give them news that they didn't expect. You want to offer an empathic statement. You might say something like yes; anyone else would feel the same way as you feel right now. Just to make sure that that patient consents that you are with them that you understand how they feel, that they have a partner to go through this with them. So, after you have explored their emotions, offered them empathic statement of support then you want to end with a summary and a strategy. So, you say yes Mr. Jones clearly this is not what you expected to hear, yes this was not the sort of discussion you wanted to be having today, but we know what's going on and I have a clear plan for you about what the next steps are. We are going to do this additional x-ray, I am going to be contacting some additional physicians for some additional information and this is the plan I have to treat the problem. So, you always want to leave the patient with some clear summary and strategy.
If you are just joining us, you are listening to The Clinicians Roundtable on ReachMD, The Channel for Medical Professionals. I am Dr. Leslie Lundt, your host, and with me today is Dr. Alan Astrow. We are discussing strategies to help us better communicate potentially bad news to our patient.
DR. LESLIE LUNDT:
What's the outcome Alan of using program such as SPIKES in practice?
DR. ALAN B. ASTROW:
Well, there is some data out there that physicians, who have taken workshops in which they have been taught the SPIKES protocol, feel much more confident giving bad news and they feel much less stress at the prospect of giving bad news. Because they had a strategy themselves before they start. So, there is data out there that this is helpful tool for physicians.
DR. LESLIE LUNDT:
So, I would hope then may be it might lessen the chance of burnout in challenging professions like Oncology.
DR. ALAN B. ASTROW:
Yes, burnout is a major problem for oncologist. By burnout, I mean emotional exhaustion. A loss of the ability to care for patients, which can happen to oncologists who have been in practice for many years. One study has shown that over 60% of oncologists experienced emotional burnout after being in practice for many years. So, there are, you know, various tools that can help lessen the risk of burnout. One tool as it has been shown that physicians who get to take more vacation time have less burnout. You can try that with the hospital administration.
DR. LESLIE LUNDT:
You know, I would go like with that.
DR. ALAN B. ASTROW:
But in addition, it looks like physicians who have better relationships with their patient feel less stressed overall, get more satisfaction from their work, and also are less likely to burnout.
DR. LESLIE LUNDT:
Now Alan, you just wrote a paper in primary psychiatry on this topic and you mentioned this and I think this is an important thing for us to talk about, what do you do with the patient who does not want to hear any bad news?
DR. ALAN B. ASTROW:
Yes, that happens not infrequently. So, the first thing is you don't want to force information on a patient, who doesn't want an information, but I would like to explore with the patient why it is they would prefer not to be given the information. I will say something like, what is that they are worried about, what is that you are afraid about. Because often I find that the actual news is not as bad as the patient had been fearing, so, I ask what is that you are worried about and if the patient is really pretty firm that they would prefer not to have the information given directly to them, then I would ask well who would you prefer that I share the information with, might be a family member, might be a friend.
DR. LESLIE LUNDT:
Are there gender or age differences that play here? Can you generalize it all about that?
DR. ALAN B. ASTROW:
You have to be careful, you know, with stereotypes, but there is actually some data that will address this question. There was 1 study done from the MD Anderson Cancer Center with over 300 cancer patients, found that women wanted more information than men want it in this study. They also were more interested receiving emotional support from their physician, but it has been my experience that women ask more questions than men. I mean, the study does bear out that at least in this 1 study women and more highly educated individuals wanted more specific information, wanted more content.
DR. LESLIE LUNDT:
Nothing we can say about age differences.
DR. ALAN B. ASTROW:
Younger patients also seem to want more content, but in addition for younger patients the setting was more important. For younger patients, it was very important that the information be given to them directly by the physician that it be given in person by the physician and if the physician devote sufficient time, then the patient didn’t feel rushed. So, yes, younger patients the felicitation skill is the most important thing on the patient.
DR. LESLIE LUNDT:
Are there any good resources out there for our listeners, who may be interested in this topic and want to learn more?
DR. ALAN B. ASTROW:
Yes, I find that anything written by Robert Buckman is extremely helpful to me in practice and I would recommend anything by Dr. Buckman highly. He has written a book about how to give bad news and Dr. Buckman along with Dr. Walter Baile from the MD Anderson Cancer Institute had made a CD-ROM, 4-disc CD-ROM that presents strategies about how to give emotionally charged information to patients with a whole curriculum on communication skills and I have it and I recommend it very highly and it's at the google Robert Buckman and you will find on the web.
DR. LESLIE LUNDT:
I would like to thank our guest today, Dr. Alan Astrow, for being on the show. We have been discussing how to better communicate diagnosis and prognostic information with our patients.
I am Dr. Leslie Lundt. You are listening to ReachMD, The Channel for Medical Professionals. For a complete program guide and downloadable podcasts, visit our website at www.reachmd.com. For comments and questions, please call us toll free at (888 MD-XM157). Thank you for listening.
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