Communication is the most important component of our work with patients. It is the cornerstone of our interaction with people. A good and an effective exchange between people helps them see what the other person thinks and how he or she feels. It helps people understand each other better and, as a result, it brings them closer to each other.
It used to be believed that a doctor’s job was just to make a correct diagnosis, focusing only on the symptom and trying to eliminate it by giving the correct drug. He had to decide for the treatment by himself without even asking the patient’s opinion because the doctor “knew best”; he was the “specialist.” Generally what he really had to do was just to fix the part of the body that suffers and that’s all. He didn’t have to communicate with the patient, ask her how she was feeling or what she was thinking about the whole procedure. He had the first and the last word.
Fortunately, now we know that things are not so simple. The patient is not a machine that just needs repair. Cancer is a long-term and difficult illness, which affects the person as a whole, and almost always, affects not just the patient but her social environment as well. Cancer is not just a biological disease but a biopsychosocial illness because it affects the 3 main areas of the person-the body, and the psychological and the social status of the patient.1 In the following paragraphs, I will briefly try to explain the term “biopsychosocial.”
To understand the difficulty of being a cancer patient, I believe it is important to try to get a taste of what patients go through. What really are their needs? What do they feel and what goes through their minds? If we know how a cancer patient feels and what her needs are, we will more likely be able to help her out and cover those needs. Of course, we always need to have in mind that each and every person is an individual who has her own special individual needs regarding to the type and stage of cancer, prognosis, age, sex, personality, etc.
As we know, the patient has to go through a physical treatment—either surgery, chemotherapy, radiation, or a combination of the three—and face related negative side effects such as vomiting, nausea, diarrhea, fatigue, weakness, tiredness, etc. Then all those psychological problems begin to develop: guilt, loss of control, anger, anxiety, worry, sadness, confusion, and fear about what may happen, fear of death, concerns about body images, communication and family problems, loss of appetite, sleep problems, sexual problems, loss of dignity, low self-esteem, low confidence, depression, suicidal risk, etc. Last, but not the least, social problems emerge such as financial problems, prejudice, unemployment, cost of healthcare, lack of health insurance, lifestyle changes, inability to fulfill other normative social roles, etc. I wish I could get more in depth about the above problems but unfortunately this would be beyond the scope of this paper.
As mentioned above every patient is an individual who has her own special needs; what is important for one person may be insignificant for another. For instance, for some patients the biggest fear is the chemotherapy itself; for others, fear of the pain from the operation is the strongest. Some other patients may have no fear about pain but about the anesthesia process and some others may be panicked just by looking at a needle or by thinking of a blood transfusion.
Good communication is very important and helps health professionals to identify those individual needs. Fortunately, the modern perspective emphasizes that the doctor (and generally all health professionals) and the patient need to work together as a team. The whole cancer procedure, from diagnosis to treatment—even until the end of life, is actually a result of team work. The physician will make a diagnosis and at the same time explain to the patient about the illness, the treatment options, the available resources, etc. He will ask the patient whether she has any questions, needs, or any clarifications. He will take into consideration the patient’s beliefs, values, expectations, culture, and personality traits.2
Different patients may have different points of view about the illness. Some patients may not be allowed to use different treatment options owing to their cultural or religious beliefs and the doctor needs to respect that. Other patients may decide not to use the specific treatment because they cannot deal with the current treatment’s side effects. It is very important to let the patient always have a choice and take into consideration her opinion or decision.
The quality of the relationship between the patient and health professional can be therapeutic for the patient. It plays a significant role in the outcome of the whole treatment and it is as healing and as important as chemotherapy.
Trust is the most important component of this relationship. And trust is not something that we buy or demand from others but it is something that we gain.
If we want others to trust us, we need to respect them first. A health professional who is a good communicator respects his patient. He understands that in front of him there is a human being who has opinions, points of view, feelings; the patient might also be a person who comes from a different culture and has a different background.
A good communicator listens to his patient. He doesn’t interrupt her but he actively, emphatically tries to understand what she is talking about. He asks open-ended questions and he tries to learn things not only about the illness but also about the patient as an individual. He tries to understand the patient’s point of view even if he disagrees with her and he never criticizes the patient. He doesn’t command, warn, judge the patient, or tell her what she has to do.3
There are so many communication skills, some more complex than others and almost all of them can be learned. We can learn about the way we talk and the way we look at the patient and how our body language needs to be, etc. However, I’m not going to focus on that right now. I’m not going to get into all those skills and how exactly we need to behave with the other person. I will talk about something more fundamental and deeper than that—I’m going to talk about the humanistic site of our profession. A doctor is a doctor but he always needs to remember that he is a human being as well. It is very important for a health professional whether he is a physician, nurse, psychologist, social worker, or physiotherapist to be able to join his job skills with his human skills.
In my opinion, transparency is a very good weapon that health professionals need to have in their armamentarium. A good doctor let patients see through him; he expresses his thoughts and feelings too. A question a health professional needs to ask himself is “Am I real with this person?” Pretending that he cares while he doesn’t is not a good thing and it is something that can be easily recognized by patients.
In addition, the information health professional shares needs to be in terms the patient can understand. He needs to avoid medical jargon because it may confuse the patient even more.
Last, but not the least, a good communicator needs to be able to put himself in the patient’s shoes and see the world through the patient’s eyes so he can understand how it is to be her.
If a patient realizes that her doctor focuses on her and he really cares about how she feels, she may be able to trust the doctor more; if she trusts the doctor more she will be more likely to listen to his opinion and accept his advice.
In addition, taking the patient’s opinion and point of view regarding treatment plan seriously is a very therapeutic thing for the patient. She gets this feeling that she is involved in her treatment. It is not just the doctor’s treatment but she is a part of the decision-making. She has a role in it. She will be able to follow treatment better because she is committed to it. She will be able to cope with treatment better because she knows what’s happening. Because she knows about the medication side effects, the possible barriers of the treatment, for how long the treatment is going to last, what alternatives she has got, her anxiety, fear, and uncertainty will diminish and her satisfaction, self-confidence and sense of control will increase.4
Furthermore, a good relationship and communication between patient and doctor can have a positive impact on the doctor’s life as well. The honesty and the realness of the interaction between them help the doctor to be not so anxious about what he may need to say to his patient and it makes it easier for him to talk about difficult issues later on, even at the end of life. Basically, the doctor’s anxiety and tension diminishes and his burnout chances lessen.
The communication between patient and health professionals is not always easy. Many times health professionals have to face different dilemmas in their interaction with patients that can cause them different and conflicting feelings. Shall the doctor disclose the diagnosis to the patient or not? Shall he tell her the truth or hide it from her? How about breaking bad news? What’s the doctor’s answer to the patient’s question “Am I dying?” And what if the family wants different things from what the patient does? To whom will the doctor need to listen? The above questions are just some of the many dilemmas the doctor needs to face and make a decision about. This decision is not easy to make and the answer is not a specific one. By informing the patient and telling her the truth, she may get upset, which is not a desirable thing. On the other hand, by not telling her how things really are the patient doesn’t get the truth, which is not a good thing either. So what is the right thing to do? Inform or protect the patient?
Bad news can happen at any phase of the process of the “Cancer Journey.” For the patient, “bad news” is not just telling her the diagnosis of cancer. Telling the patient that she has got metastasis, that’s bad news, too. Telling the patient that she needs more treatment is also bad news. Telling the patient that the doctor can do nothing more to help her out or telling the family that the patient is in the last stage is even more bad news.
Again, we need to have in mind that not all people are the same. There are some patients who want and demand to know everything about their illness. On the other hand there are patients who want to know nothing. “I don’t want to know anything about that. Whatever you have to say, say it to my kids” they say. In addition, there are patients who are in a great denial and even if they know the truth they will not accept or understand what is happening.5
I believe that there is no certain answer to the above questions. There is no right or wrong answer and of course there is no specific answer. There is no recipe for that. The most important thing about how we deal with all those questions is not about what answer we give but how we answer. An empathetic humanistic response is the best a health professional can give at that point. It is also important to stay with the facts and to always keep hope alive. It’s important for the doctor to focus only on what he sees and to explain, if he is asked, how difficult things are but that he cannot predict the future. He cannot say to the patient “You are going to die in a week.” Of course, he doesn’t give false hope either such as “Tomorrow everything is going to be ok.” So, for a patient who is diagnosed with a very aggressive type of cancer and asks us how serious is her condition, we can say to her. “It is difficult. Things are not very good. However, we are not going to stay here and do nothing. We will fight it; Together. We have to fight it and this is what we will do…”
The word “we” is a very powerful weapon… the “We” versus “I” statement. By using “we” you show your patient that you are there with her and that she is not alone. You show her that you will fight the illness as a team, together.
It is also very important when we really don’t know something to admit our ignorance to the patient. To a patient who asks about how it will be after she dies or whether there is another life, we can say, “I really don’t know. I have got the same questions and same fears as you. Religion supports that there is another life. Science believes there is nothing after we die. Honestly I don’t know. Nobody does.”
Furthermore, we need to learn to get comfortable with silence. We don’t have to talk all the time. When someone tells us her problem we healthcare professionals tend to want to give her a solution or say something to cheer her up because we feel uncomfortable watching her suffering. That’s not always the right thing to do. There are times that we need to learn to say nothing and just listen to the other person. Silence goes far beyond words.
Last but not least we need to realize that we health professionals are human beings too and sooner or later we will all have to deal with existential issues too such as death and fear of the unknown. We need to have in mind that we are not something different from what our patient is.
To sum up, health professionals—whether physicians, nurses or psychologists—need to focus on and improve, if necessary, their communication with patients; basically, learn how to unite the humanistic side of care with the technical side; how to be professionals without losing their humanistic identity.
1. Engel G. The need for a new medical model: a challenge for biomedicine. Science. 1977;196:129–136
2. Stewart MA. Effective physician-patient communication and health outcomes: a review. CMAJ. 1995;152:1423–1433
3. Platt FW, Platt CM. Empathy: a miracle or nothing at all? J Clin Outcome Manage. 1998;5:30–33
4. Simpson M, Buckman R, Stewart M, et al. Doctor-patient communication: the Toronto consensus statement. BMJ. 1991;303:1385–1387
5. Baile WF, Buckman R, Lenzi R, et al. SPIKES—a six-step protocol for delivering bad news: application to the patient with cancer. Oncologist. 2000;5:302–311