My patient came into the clinic simply to get my opinion on the most suitable secondary prevention for his condition. But we got talking, and again, the magic interchange occurred. He got a sympathetic listener, and I got a memorable story and a lesson for life.
His story was simple enough. He was a lawyer with a busy practice. One morning, he woke up with a sudden, devastating stroke that left him hemiplegic and hardly able to talk. He was admitted to a first-class academic hospital and was seen by one of the top neurologists. After a few days, the neurologist showed him the imaging of his brain—an alarming and unasked-for experience—and went on to pronounce a devastating verdict—a large and critical area of the brain was lost, so my patient “could expect a life of lying in bed, uttering barely understandable gibberish.” He was overcome by grief and dark depression.
A few days later, my patient was discharged from the hospital to a rehabilitation center. There, he was cared for by a team of young, dedicated, and energetic physiotherapists who really cared about him. An entirely new attitude emerged. Instead of looking at the reality, they believed in the outlook, the vision. Instead of seeing a patient with a gloomy prognosis, they saw the glass half full—my patient was able to understand them and he was willing to cooperate. They concentrated not on the bleak imaging or his current severe deficits but, rather, on the future, on what he could achieve, infusing him with their wholehearted belief about what could be done. Their energy, fighting spirit and optimism, and their confidence, openly expressed from the very start, were contagious.
First, my patient’s mood improved. Then, tangible performance results started to materialize. The team’s pride and obvious enjoyment at my patient’s every achievement drove him forward. It was a long and slow journey, almost five months. Today, although he uses a cane, my patient can walk alone. Gradually, he is resuming his work as a lawyer.
Contemplating this story on a quiet evening at home, I thought I understood it. My patient was fortunate, no doubt. His neurologist’s expertise was unquestionable. However, this expert provided too much bleak information but failed to acknowledge the immense value of hope, trust, and encouragement, and that sometimes even the best of us can only predict clinical outcomes to a limited extent.
Can we as physicians not lie or withhold information from our patients and their family while also giving them a sense of hope? A letter I read in the Lancet years ago came back to me. It did not deal with a randomized controlled trial or even with a cohort study. Rather, it dealt with that unseen, often neglected element—the potent effects of emotions on biological illness. Two surgeons reported their experience with seven patients, who all had incurable cancer but were able to enjoy and lead a rather normal life. The patients had something else in common too—once their physicians had discussed their illness with them in great detail, clarified their prognosis, and stressed the incurable nature of their cancer, they deteriorated suddenly and died within 48 hours.
In Proverbs, King Solomon notes that “Death and life are in the power of the tongue” (Proverbs 18:21). Certainly, we must never lie to our patients. But need we really cross all the T’s and dot all the I’s? Some patients demand to be told everything. They insist on learning all the details of their prognosis, every figure and statistics. Others, however, do not want to be exposed to such an abundance of alarming data.
As a rule, I do not show my patients their imaging, unless they specifically ask to see it. I try to avoid citing statistics, knowing how wide confidence intervals can be and that the course of an individual’s disease can be unpredictable. Most of all, though, and especially after my patient’s remarkable story, I remember to look at the glass as half full, stressing courage, action, and hope, which sometimes can transform a patient’s fate.
Ami Schattner, MD
A. Schattner is professor of medicine, Faculty of Medicine, Hebrew University and Hadassah Medical School, Jerusalem, Israel; e-mail: firstname.lastname@example.org.