Bedside manner is a topic that is rarely discussed as an important part of treating a patient with cancer, as battling their disease takes priority. However, there are many questions an oncologist might face when it comes to communicating and interacting with their patients.
For example, how should you communicate with a patient you’ve told will likely die from their cancer? Do you ease a patient’s fear by withholding potentially frightening information the patient did not ask to know? Is it appropriate, at times, to step out of your professional demeanor to personally comfort a patient? Do you communicate differently with the patients’ family members once a cancer diagnosis has been confirmed? As an oncologist, is crafting positive, non-technical communication unique to each patient part of your job?
In 2007, the Journal of Clinical Oncology presented a study that suggested “a cancer patient’s quality of life might be significantly improved if doctors were better trained to recognize and address patients’ emotional concerns as they battle the disease,” according to HealthDay reporter Alan Mozes.1
This study, based on almost 400 audiotapes of conversations between physicians and patients with cancer and authored by Kathryn L. Pollak, a professor at Duke University, pointed out that “when patients expressed negative emotions, doctors did not always respond empathetically.”2
The methodology of the study consisted of surveys of 51 oncologists caring for a total of 270 patients with cancer.2 All the patients involved in the doctor-patient relationship study “had advanced-stage cancer, and their physicians indicated that they would not be surprised if they ended up dying from their illness within a year.” Ninety percent of the patients in the study indicated they had known their doctor for at least 6 months. The oncologists, who were mostly white males, were asked how comfortable they thought they were with speaking with patients with cancer on a personal level. They were also asked which they were more inclined to do: A) Speak with patients about the scientific and technical aspects of their disease; or B) speak with patients about the more emotional side effects of the disease and its treatment.
Overall, more than two-thirds of the 51 oncologists taking part in the study said they felt they were strong in both the areas of scientific and personal conversations with their patients.
After reviewing the 400 audiotapes of the 51 oncologists interacting with their patients with cancer, however, Professor Pollak’s team reported that when the negative emotions of fear and worry were expressed by a patient to their doctor, “almost three-quarters of the time doctors chose to ‘terminate’ the conversation by offering blanket reassurance that time would heal the problem.” The research team came to the conclusion that better education is needed for oncologists to appropriately respond in a positive way to patient concerns.3
The study raises the question: Does it make a difference to a patient’s health and mental well-being when oncologists respond more empathetically to their concerns and fears?
Shayma Kazmi, MD, a hematologist and medical-oncologist at the Eastern Regional Medical Center in Philadelphia, PA, thinks it does.
“An empathic bedside manner—a friendly rapport with the patient—has many healing properties. It diminishes anxiety, it helps form a therapeutic relationship between the physician and patient, and it builds confidence in the patient that ultimately results in better understanding of disease and options, better compliance, and a positive attitude,” says Dr. Kazmi.
When Dr. Kazmi talks about bedside manner, she looks at it from the perspective of the patient, not from what is expected of her as a clinical expert.
“Every patient reacts differently to having cancer,” Dr. Kazmi says. “It’s very important to get to know how they’re feeling about it before approaching them with information. For instance, if one is in denial, giving them some realistic information would be helpful in engaging them in their care. But if the patient is overcome with crippling fear, it’s worth being very gentle in guiding them along the treatment path instead of scaring them more with details and information.”
Dr. Jason Kapnick, Assistant Consulting Professor at Duke University and a practicing oncologist in Florida, is himself a cancer survivor. Dr. Kapnick says “Bedside manner is part of a bigger rubric of events and content.” Once cancer is introduced, the doctor-patient conversation changes to something greater than a routine medical discussion, says Dr. Kapnick, who has his own four-step method for dealing with patients with cancer.
Step 1: Educate the patient.
First, Dr. Kapnick explains the patient’s cancer to them and answers any questions.
Step 2: Gather what the patient knows.
The second part of the formula, Dr. Kapnick says, is the most important: Gather what the patient knows. Patients will run to the Internet to do their own homework on their condition and this is not always productive because what they are reading may have nothing at all to do with their case, he notes.
Step 3: Achieve a balance with known data and the patient’s knowledge of their disease.
Third, he reconciles what the patient knows or believes about their condition with the data he has, and tries to bring the patient to a balanced understanding of their cancer. From here, bedside manner comes into play as treatment begins and continues.
Step 4: Use appropriate bedside manner.
This bedside manner must be very open, personal, and caring, because every patient handles their cancer in a dramatically different way, Dr. Kapnick says.
“There is where the doctor-patient relationship comes in. How (the patients) handle it. Cancer is not a disease, it’s a scourge… In a way it’s degradation. It’s a violation of any sense of justice. It’s the only thing in the whole world that every single human being hates and fears.”
The “C” Word
Dr. Sybilann Williams is a gynecologic oncologist for Cancer Treatment Centers of America at Midwestern Regional Medical Center in Zion, IL. Like Dr. Kapnick, Dr. Williams is also a cancer survivor and has experienced the cancer conversation from the perspective of a patient; their positions on bedside manner differ slightly. Dr. Williams says tempering the drama of a patient’s cancer diagnosis instead of embracing the drama as an outlet for fear can greatly relieve the terror of treatment.
“I think it’s important to communicate in a similar way that one would impart any other diagnosis, so that you do not increase the anxiety that is inherent when one hears the ‘C’ word,” says Dr. Williams. “As a cancer survivor myself I know the impact of hearing the diagnosis, and having an empathic and caring physician at that time is critical. At the same time it is important for the physician to stay calm. Making physical contact with the patient, speaking about what can be done, and imparting a clear plan is important.”
Dr. Kazmi sees a direct connection between a patient with cancer being comfortable with communication with their doctor, and the process of clinical opinion and treatment. Not getting the first conversation with a patient with cancer right when discussing their disease and possible treatments can send them running to alternative cancer treatments such as medical cannabis or exotic diets and nutritional approaches which may not be the best course of therapy for their cancer.
“I know many patients who had a less than perfect first interaction with an oncology physician when they were diagnosed with cancer,” says Dr. Kazmi. “Due to the fear and distrust it built in them, they decided to forgo the treatments offered in lieu of alternative treatments. This ultimately hurts the patients in that the cancer progressed and their lifespan was thus diminished. Ultimately when they decided to seek out another opinion they found that all doctors do not have poor mannerisms in handling patients.”
Physicians must be careful about balancing the information they give a patient with the patient’s expectations. “Often, physicians feel that they know what’s best for the patients while patients have completely different expectations and goals,” says Dr. Kazmi. “You can make a plan to communicate with a patient in a positive and productive way, but there is always the risk of patients following their own opinion, or become frustrated with you. This is why the subject of oncological bedside manner is so important,” she says.
For example, in 2012, the New England Journal of Medicine published a study that illustrated how patients with incurable forms of cancer still believed they would survive.4 The study concluded that “many patients receiving chemotherapy for incurable cancers may not understand that chemotherapy is unlikely to be curative, which could compromise their ability to make informed treatment decisions that are consonant with their preferences. Physicians may be able to improve patients’ understanding, but this may come at the cost of patients’ satisfaction with them.”
Of those patients taking part in the New England Journal of Medicine study, “69 percent of those with lung cancer and 81 percent of those with colorectal cancer felt their treatment was likely to cure them.”5
With that said, if patients with cancer can hold out optimism even when told their condition is terminal, should their doctors do so as well? Is a physician’s expression of optimism just as helpful to a patient’s quality of life as a patient’s own optimism? Dr. Kazmi says there is no harm in trying.
“Helping patients improve their quality of life and helping them focus on their own goals of treatment is definitely healing. Whether this prolongs their life is not known. However, the quality of their life is improved with this positive interaction,” says Dr. Kazmi.
Dr. Williams could not agree more. “Establishing an empathetic relationship while also maintaining sufficient professional detachment helps to give the patient confidence that you are there for them, that you have options for them,” says Dr. Williams. “This can certainly improve quality of life.”
1. Mozes A. Cancer docs’ bedside manner often lacks empathy. The Washington Post. http://www.washingtonpost.com/wp-dyn/content/article/2007/12/19/AR2007121900629.html. Accessed June 10, 2013.
2. Pollak KI, Arnold RM, Jeffreys AS, et al. Oncologist communication about emotion during visits with patients with advanced cancer. J Clin Oncol. 2007;25(36):5748-5752.
3. Mozes A. Cancer docs’ bedside manner often lacks empathy. The Washington Post. http://www.washingtonpost.com/wp-dyn/content/article/2007/12/19/AR2007121900629.html. Accessed June 10, 2013.
4. Weeks JC, Catalano PJ, Cronin A, et al. N Engl J Med. 2012;367:1616-1625. doi: 10.1056/NEJMoa1204410. http://www.nejm.org/doi/full/10.1056/NEJMoa1204410. Accessed June 11, 2013.
5. Most patients with incurable cancer still think they’ll survive, study finds. CBS News/Associated Press. October 25, 2012. http://www.cbsnews.com/8301-204_162-57540242/most-patients-with-incurable-cancer-still-think-theyll-survive-study-finds/. Accessed June 11, 2013.