“I do not know . . .”

I’ve been on spring break this week, so instead of writing my own post, I’ve decided to share another excerpt from one of my favorite authors, Dr. Atul Gawande. Gawande discusses the difficulty—and the inevitability—of uncertainty in medicine, something for which both doctors and patients have not been well socialized to handle . . .

“Seeing patients with one of the surgery professors in his clinic one afternoon, I was struck by how often he had to answer his patients’ questions, “I do not know.” These are four little words a doctor tends to be reluctant to utter. We’re supposed to have the answers. We want to have the answers. But there was not a single person he did not have to say those little words to that day.

There was the patient who had come in two weeks after an abdominal hernia repair: “What’s this pain I feel next to the wound?”

There was the patient one month after a gastric-bypass operation: “Why haven’t I lost weight?”

There was the patient with a large pancreatic cancer: “Can you get it out?”

And to all, the attending gave the same reply: “I do not know.”

A doctor still must have a plan, though. So to the hernia patient, he said, “Come back in a week and let’s see how the pain’s doing.” To the gastric-bypass patient, “It’ll be all right,” and asked her to come back in a month. To the cancer patient, “We can try to get it out”—and although another surgeon thought he shouldn’t . . , and he himself thought the odds of success were slim at best, he and the patient . . . decided to go ahead.

The core predicament of medicine—the thing that makes being a patient so wrenching, being a doctor so difficult, and being a part of a society that pays the bills they run up so vexing—is uncertainty. With all that we know nowadays about people and diseases and how to diagnose and treat them, it can be hard to see this, hard to grasp how deeply the uncertainty runs. As a doctor, you come to find, however, that the struggle in caring for people is more often with what you do not know than what you do. Medicine’s ground state is uncertainty. And wisdom—for both patients and doctors—is defined by how one copes with it.”

Gawande, A. (2002). Complications: A surgeon’s notes on an imperfect science. New York: Picador.

Less Time For Those at the End of the Line

Patients at the end of ICU rounds typically get less time with the physician than those who were seen at the beginning. At least that’s what Laura Jones (from Emory University) and colleagues report. Conducted within a 12-bed ICU, their study revealed that time decreased about one minute per patient, each of whom had undergone coronary bypass surgery. But the statistically significant difference was found when comparing the first four and last four visits.

These results, presented at the annual meeting of the Society of Critical Care Medicine, should be interpreted with caution as they have not yet been peer-reviewed. Also, it’s hard to tell what impact time spent with the patient will have on treatment outcomes. Nevertheless, the interaction taking place during a patient visit—as well as time spent with the patient—likely sets the tone for the level of ownership a patient can take in his or her care, as well as help patients adopt the short- and long-term objectives established by the physician.                                                                                                               

The Society of Critical Care Medicine (SCCM) can be found at www.sccm.org.

What do you think? . . . Health care and the State of the Union

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Objectivity

Here is some more wisdom from Dr. Rachel Naomi Remen:

People who are physicians have been trained to believe that it is a scientific objectivity that makes them most effective in their efforts to understand and resolve the pain others bring them, and a mental distance that protects them from becoming wounded by this difficult work. It is an extremely demanding training. Yet objectivity makes us far more vulnerable emotionally than compassion or a simple humanity. Objectivity separates us from the life around us and within us. We are wounded by that life just the same; it is only the healing which cannot reach us. Physicians pay a terrible personal price for their hard-won objectivity. Objectivity is not whole. In the objective stance no one can draw on their own human strengths, no one can cry, or accept comfort, or find meaning, or pray. No one who is untouched by it can really understand the life around them either.

from Kitchen Table Wisdom: Stories That Heal. Riverhead Books

Overcoming cultural barriers to breaking bad news

Despite how educated and well-informed I am, there are times when I think I unintentionally project my ethnic and cultural values onto some of my blog topics. In other words, there might be values and beliefs that I don’t take into account when I give advice on the best communicative practices. This possibility came to mind when I found the article by Anna Costantini and colleagues’ article on overcoming cultural barriers. Having said that, I felt it necessary to add an addendum to the previous post on breaking bad news.

In many medical settings outside the US, withholding bad news from cancer patients is common. Instead, the bad news is often delivered to a spouse or close family members, with loved ones telling the doctor that the patient mustn’t know about his or her prognosis. Within many Mediterranean cultures—as well as Japan—the decision to withhold information is often based on such values as keeping the patient free from anxiety about her or his condition, building hope through suppression of information, and abdicating control to the family whose responsibility it is to protect the patient from the psychological distress of cancer.

Costantini and colleagues offer that the lack of communication skills and familial pressures might be fueling these cultural practices. To address what the researchers call cultural barriers, they examined the effectiveness of training programs to assist Italian doctors to confront the aforementioned cultural pressures in order to be able to disclose more information to the patient. Furthermore, they wanted to find out whether communication training done in countries where full disclosure is practiced could be adapted to other cultures. Their findings suggest that the optimal communication intervention involves overcoming surface-level barriers to change (low self-efficacy, one’s own attitudes about disclosure to patients), role-play situations that allow doctors to practice their skills, and patients’ active involvement in the simulations.

I often advocate for full disclosure to the patient when I talk to providers about their medical interactions. Despite what Costantini and colleagues add to the body of literature, there is a larger issue that goes unaddressed, which is the assumption that the patient must be given the information, or that the provider always knows what’s best for the patient. Given that patients in the US generally want to be told the truth about their illness, it’s hard for some of us to imagine that there is an alternative point of view. But then again, the notion of “overcoming” cultural barriers might seem culturally myopic ethnocentric to others. Perhaps the real issue is whether patients themselves want to know the bad news, or instead be shielded from the potential trauma and distress of a bleak outcome. If we truly believe that full disclosure is crucial, then we must rethink what we mean when we say we’re culturally sensitive or relative. In other words, sometimes well-meaning providers must act in ways that might look ethnocentric after all.

Costantini, A., Baile, W., Lenzi, R., Costantini, M., Ziparo, V., Marchetti, P., Grassi, L. (2009). Overcoming cultural barriers to giving bad news: Feasibility of training to promote truth-telling to cancer patients, Journal of Cancer Education, 24, 180-185. doi: 10.1080/08858190902876262.

Breaking bad news

Providers should never underestimate the impact of delivering bad news. Telling a patient she has late-stage cervical cancer, or informing a woman that her husband suffered a stroke are extremely difficult for the recipients and require sensitivity from the messenger. For definitional purposes, bad news is any information that alters for the worse a patient’s view of his or her future. Providers’ handling of bad news will influence patients’ level of anxiety, uncertainty, and ability to cope. Unfortunately, delivering bad news is not taught routinely or consistently; this reality is evident in that many medical students and residents feel unprepared to engage in this sensitive and difficult task.

Early disclosure of the bad news is almost always advisable. The provider should also keep patients and families up-to-date and discuss the situation as much as the patient needs. Kaplan (2010) and others propose a framework—SPIKES—that can help facilitate this difficult discussion. It’s an acronym for a series of steps designed to reduce uncertainty and ease the inevitable pain of bad news.

The first step is setting; find a quiet and private setting in which to have the conversation. If feasible and appropriate, choose a setting that can accommodate a few close family members. Second is perception. Establish that the patient understands the situation before breaking the news. This is also a good time to clear up misconceptions. This step might require a few discussions before you deliver the actual news. You then should plan the invitation. What kinds of information would be helpful to the patient? If possible, determine the patient’s preferred learning style. For example, is a verbal description the best approach, or will the patient want some things written down? When reaching the knowledge step, it’s best to warn the patient before you hit him or her with the news. Ease up on the medical jargon; breaking it down in lay language is best. Also, give the patient some time to absorb news. Once the news is delivered, it’s important to show empathy. Acknowledge the patient’s emotions and respond to emotional expressions appropriately. Finally, summarize or strategize. Make sure the patient understands the information and allow for questions. You might have to explain something more than once.

Breaking bad news is never an easy task, and it’s important to do what one can to reduce stress for all parties involved. Whether you use SPIKES or any other framework, have a structured plan before you commence the discussion. Hopefully we can draw attention to the need for more focused efforts to train medical students—not just teaching the skill sets but placing them in simulated practice contexts.

Harrison, M. E., & Walling, A. (2010). What do we know about giving bad news? A review. Clinical Pediatrics, 49(7), 619-626.

Kaplan, M. (2010). SPIKES: A framework for breaking bad news to patients with cancer. Clinical Journal of Oncology Nursing, 14(4), 514-516.

Lienard, A., Merckeart, I., Libert, Y., Bragard, I., Delvaux, N., Etienne, A-M., Marchal, S., Meunier, J., Reyneart, C., Slachmuylder, J-L., Razavi, D. (2010). Is it possible to improve residents breaking bad news? A randomized study assessing the efficacy of a communication skills training program. British Journal of Cancer, 103, 171-177. doi: 10.1038/sj.bjc.6605749.

You know how to get to Carnegie Hall, right?

I’m currently reading Dr. Atul Gawande’s Complications: A Surgeon’s Notes on an Imperfect Science (He’s also the author of The Checklist Manifesto.). While I’m finding the whole book to be a compelling read, a particular section gave me pause:

Surgeons, as a group, adhere to a curious egalitarianism. They believe in practice, not talent. People often assume that you have to have great hands to become a surgeon, but it’s not true. When I interviewed to get into surgery programs, no one made me sew or take a dexterity test or checked if my hands were steady. You do not even need all ten fingers to be accepted. To be sure talent helps . . . Nonetheless, attending surgeons say that what’s most important to them is finding people who are conscientious, industrious, and boneheaded enough to stick at practicing this one difficult thing day and night for years on end . . . Skill, surgeons believe, can be taught; tenacity cannot.

Dr. Gawande argues that practice and tenacity—more so than raw talent—are what’s crucial to make it as a surgeon. His words instantly reminded me of what I say most often about communication: Everyone does it, but few of us do it well. When I teach health professionals how to interact with their patients and with each other, I point out that virtually anyone can learn to be an outstanding communicator, even if it feels like one lacks the raw ability. Positive health interactions aren’t just limited to a few gifted individuals who know how to “connect.” Borrowing Gawande’s point, it takes practice, and that’s how we need to approach teaching communication in the healing professions.

Gawande, A. (2002). Complications: A surgeon’s notes on an imperfect science. New York: Picador.