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Talking to a Patient

From the Chao Family Comprehensive Cancer Center, University of California Irvine, Orange, CA; the Finnish Medical Journal, Helsinki, Finland; Princess Margaret Hospital, Toronto, Canada

Address reprint requests to Frank L. Meyskens Jr, Professor of Medicine and Biological Chemistry Director, Chao Family Comprehensive Cancer Center, University of California Irvine, 101 The City Drive, Route 81, Building 56, Room 210, Orange, CA 92868; e-mail: flmeyske{at}uci.edu

Send and Receive

"It’s only a little spot."

I have cancer.

"We can get it all out"

They’re going to crack my chest.

"The radiation only produces a little  sunburn."

My neighbor got fried.

"The chemotherapy isn’t bad"

My mom barfed for days.

"It’s just a small shadow on your spine"

I’m going to be paralyzed,

I’m going to have pain.

"It seems to have spread to your liver

but there is this new drug... .."

I’m going to be a guinea pig,

I’m going to die.

One fact,

one reality.

Two truths.

One sent,

one received.

Frank Meyskens, MD

Commentary

In this simple but poignant poem, the doctor tells the patient bad news using euphemisms, belittling the seriousness of the message. The patient reacts to this by interpreting the words in a most gloomy way. Neither the words of the doctor nor those of the patient represent reality. Those of the doctor reflect the well-intentioned, but misguided, policy of trying to protect patients by describing the effects of cancer and its treatment in gentler terms than are likely to be experienced; the patient responds with an exaggerated response that also misinterprets the effects of the disease and its treatment. Suppose that the words of the doctor and the patient were reversed. The doctor would then be seen as sadistic, because "truth" without empathy is cruel.

Words form a limited part of the communication between doctor and patient. Here the interpretation and reaction of the patient suggest that the doctor’s words are thrown in the air lightly, creating anger in the patient. The content of the words might become more acceptable if qualified by explanation and delivered in a sensitive and serious tone that invited discussion of their meaning. The doctor must encourage rather than block the response of the patient, answer their questions and respond to them in realistic and understandable terms. It is important for the doctor to express feelings and emotions, and also to recognize and acknowledge those of the patient, which may include anxiety, disappointment, grief, and anger.

The patient needs information about their disease but also needs time and space for shaping thoughts about their situation. Per Salander interviewed patients with terminal cancer and, on the basis of his studies, introduced a concept called "creative illusion."^1,2 This means that even patients with incurable disease who are aware of the seriousness of their illness need the possibility of dreaming and fantasizing about their future. This is not denial, but coping with the vicinity of giving up one’s life. It is possible for the doctor to tell the facts in a sensitive way and at the same time leave room for hope and illusion. Patients like doctors who are able to find words of hope in difficult situations. "Your mind and body are so strong despite your illness," said a colleague to a woman with advanced breast cancer and painful bone metastases. The patient always remembered this doctor with warm feelings.

Are the working conditions and education of oncologists good enough for sensitive and truthful communication with patients? Although doctors will differ in their innate communication skills, there is evidence that education is effective in improving these skills for all of us.^3-6 Until recently, little time has been devoted in medical school or in postgraduate training programs to this topic which is surely as important as learning about the pathophysiology of disease. Slowly this is changing, with the recognition that courses in doctor/patient communication form an essential part of medical education. They will not only help to prevent the misinformation and reaction captured in this poem; they will aid also in helping patients to accept the treatment that can most help them to live longer and higher-quality lives, and encourage their participation in clinical trials that ultimately will enhance the quality of cancer treatment for others.

The relationship between physician and patient must be built slowly and on truth and trust: if the physician misrepresents the disease or its treatment, that trust will be lost. With proper education, physicians will not need to cocoon themselves by breaking bad news with euphemisms.

Päivi Hietanen and Ian Tannock

Authors' Disclosures of Potential Conflicts of Interest

The authors indicated no potential conflicts of interest.

NOTES

Authors' disclosures of potential conflicts of interest are found at the end of this article.

REFERENCES

1. Salander P, Bergenheim T, Henriksson R: The creation of protection and hope in patients with malignant brain tumors. Soc Sci Med 42:985-996, 1996

2. Salander P, Windahl G: Does "denial" really cover our everyday experiences in clinical oncology? A critical view from a psychoanalytic perspective on the use of "denial." Br J Med Psychol 72:267-279, 1999

3. Fallowfield L, Jenkins V, Farewell V, et al: Enduring impact of communication skills training: Results of a 12-month follow-up. Br J Cancer 89:1445-1449, 2003[CrossRef][Medline]

4. Razavi D, Merckaert I, Marchal S, et al: How to optimize physicians' communication skills in cancer care: Results of a randomized study assessing the usefulness of posttraining consolidation workshops. J Clin Oncol 21:3141-3149, 2003[Abstract/Free Full Text]

5. Back AL, Arnold RM, Tulsky RA, Baile WF, Fryer-Edwards KA: Teaching Communication Skills to Medical Oncology Fellows. J Clin Oncol 21:2433-2436, 2003[Free Full Text]

6. Armstrong J: Fellow Suffering. J Clin Oncol 22:4425-4427, 2004[Free Full Text]

Submitted October 24, 2004; accepted March 11, 2005.

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