AA: I'm Avi Arditti with Rosanne Skirble, and this week on Wordmaster: giving doctors better skills to communicate bad news.
RS: Anthony Back [pronounced like Bach] is a medical oncologist at the University of Washington and the Fred Hutchinson Cancer Research Center in Seattle. He and four colleagues are in the fifth year leading a program funded with one and one-half million dollars from the National Cancer Institute.
AA: Doctor Back says specially trained actors play cancer patients to help oncologists learn how to avoid sounding insensitive when the prognosis is grim.
ANTHONY BACK: "Probably the biggest misconception I face is that you're either born with this or you're not. In fact, what the research shows is that people learn to do this over time. And the way they learn to do it is they see good role models, they practice, they get specific feedback on what they're doing, they try out new things, they innovate and develop new conversational practices for themselves."
AA: "Can you give us some examples of those conversational practices -- what are some ways to impart bad news?
ANTHONY BACK: "Here's an example: The patient has had cancer in the past, has been doing well and is coming in for some routine follow-up tests. The routine follow-up tests unexpectedly show the cancer has started to come back.
"The doctor will typically go in and say to the patient, 'Guess what, your cancer's back.' And the patient will be just blown away, right? There are a couple of practices there that doctors can do that can help. One is to start with -- especially if you don't know the patient -- asking what the patient expected, what did they understand about their cancer, what were they expecting with this test.
"Because if the patient says to you 'You know, they didn't tell me anything. I'm just here because I got this appointment in the mail,' that's one whole kind of comprehension level. Whereas if the patient says 'I had a t-one-n-one-m-zero lung cancer and they told me I had a fifty-five percent chance of disease recurrence in the next two years,' that's a whole different story, right?
"The second thing is that after you give this difficult news, then I think it's really important to address both the cognitive reaction and also the kind of the emotional side of it."
RS: "What are some of the phrases or the ways in which you can couch this news?"
ANTHONY BACK: "You know, the way to make it easier is to make sure that you are going from the context the patient drew for you. So you go from what the patient understands and you try to use their words as much as possible. And then, when you get to the really bad part of the news, I think it's actually important to be direct and concrete and not to couch the news.
"It's better to say 'The cancer has come back' than to say 'There are hypo-densities in your liver on the CT' [or] 'You have a malignancy.' All those euphemisms force patients to struggle to understand what's happening to them, and it adds to their confusion and distress."
RS: "Well, should they say things like 'I wish things were different' or 'I hope for the best,' or should a doctor kind of maintain a distance?"
ANTHONY BACK: "You know, my thought about that actually is that the more skilled the physician, the less they have to distance themselves. There are some phrases that we use, and the most important ones are really the ones that are about empathy for the patient. You know, 'I see this is a difficult situation, I see this is not what you expected, I'm hoping for the best.' And I think it's fine for doctors to talk about hope, and I think it's important actually."
AA: "Let me ask you, have you seen any cultural differences come up in the training programs as you've had doctors go through?"
ANTHONY BACK: "You know, we have actually a very multicultural group of physicians who come, and they all bring in all their own different values about how frank should people be. Because the American standard, of course, is that patients themselves get all the information, they make the decision themselves, and there's this very strong emphasis on autonomy. And in a lot of other cultures that's really not the case."
RS: "And what got you started in the first place?"
ANTHONY BACK: "What got me started was, when I was an oncology trainee, and this was after a personal experience -- my mother had died of a pre-leukemia kind of thing -- I remember walking around in the bone-marrow transplant wards with this experienced -- it was this other, older senior physician -- going around having these life-and-death conversations with patients and thinking, 'God, there has got to be a better way to do this."
AA: The result, says Doctor Tony Back in Seattle, is a program that has now trained about one hundred-eighty oncologists at retreats held twice a year. The program Web site is oncotalk.info -- that's o-n-c-o-t-a-l-k dot i-n-f-o. |