Eric E. Prommer
“I think the best physician is the one who has the providence to tell to the patients according to his knowledge the present situation, what has happened before, and what is going to happen in the future”
Hippocrates
I. INTRODUCTION. Communication between physicians and patients is a fundamental aspect of cancer care, yet most physicians have had little training in communication. The aspects of communication most valued by patients are those that help patients and their families feel guided, build trust, and support hope. There are a set of concrete skills that can be used to effectively lead to these outcomes. A wide variety of empirical studies document that physician-patient communication is suboptimal. Physicians and nurses typically miss the full range of concerns held by people with cancer. These deficiencies in communication increase the psychological and existential suffering of patients and their loved ones. Compounding these problems is the finding that oncologists lack accuracy in detecting patient distress. Finally, poor communication also hampers a physician’s ability to provide pain and symptom management.
The National Cancer Institute named cancer communication as an “extraordinary opportunity” in 1999; the American Society of Clinical Oncology named communication as a key clinician skill. New educational models exist that have been documented to result in physician communication skill improvement. These models are being used in settings ranging from practicing physicians to oncology fellows in training. Communication skills training is associated with less burnout and work-related stress. This chapter highlights some of the techniques useful to improving communication with patients and families.
II. FUNDAMENTAL COMMUNICATION SKILLS
A. Behaviors to avoid
1. Blocking occurs when a patient raises a concern but the physician either fails to respond or redirects the conversation. For example, a woman with metastatic colon cancer might ask, “How long do you think I have?” and the doctor responds, “Don’t worry about that,” or “How is your breathing?” Blocking is important because physicians typically fail to elicit the range of patient concerns and consequendy are unable to address the most important concerns.
2. Lecturing occurs when a physician delivers a large chunk of information without giving the patient a chance to respond or ask questions.
3. Collusion occurs when patients hesitate to bring up difficult topics and their physicians do not ask them specifically—a “don’t ask, don’t tell” situation.
4. Premature reassurance occurs when a physician responds to a patient concern with reassurance before exploring and understanding the concern.
B. Behaviors to cultivate
1. Ask-Tell-Ask. Always ask about the patient’s understanding of the issue. “What have your other doctors been telling you about your illness since the last time we spoke?” “How do you see your health?” Tell the patient in straightforward language what you need to communicate—the bad news, treatment options, or other information. Stop short of giving a long lecture or huge amounts of detail. Information should be provided in short, digestible chunks. A useful rule of thumb is not to give more than three pieces of information at a time. Do not use medical jargon. Ask the patient if he or she understood what was said. Consider asking the patient to restate what was said in his or her own words.
2. Tell me more. Ask patients if they need more information or if all their questions are being answered. Ask about how they feel about what has transpired and its meaning.
3. Respond to emotions. An important mnemonic to help cover emotional responses is NURSE. This involves naming, understanding, respecting, supporting, and exploring the emotional response.
III. BREAKING BAD NEWS. This is perhaps the communication task that has been studied most extensively. Bad news can be defined as any information that adversely alters one’s expectations for the future. Its basic format is the basis for subsequent discussions at various points during the patient’s disease trajectory.
Oncologists give bad news thousands of times during the course of a career and it can be highly stressful. In a large survey of oncologists, 20% reported anxiety and strong emotions when they had to tell a patient that his or her condition would lead to death. In a more detailed study of 73 physicians, 42% indicated that although the stress often peaks during the encounter, the stress from a bad news encounter can last for hours—even up to 3 or more days afterward.
Giving bad news is more difficult when the clinician has a long-standing relationship with the patient, when the patient is young, or when strong optimism had been expressed for a successful outcome. On the other hand, when bad news is communicated in an empathic manner, it can have an important impact on outcomes such as patient satisfaction and decreased patient anxiety and depression. The physician’s caring attitude can be more important than the information or reassurance given. As with any medical procedure, giving bad news requires a coherent strategy. In this case, the strategy encompasses a series of six distinct communication steps that can be summarized using the mnemonic SPIKES. This protocol includes recommendations endorsed by practitioners and patients.
A. Setup. Prepare yourself with the necessary medical facts, take a moment to have a plan in your mind, and find a quiet place if possible. Turn off TVs and pagers. Enlist support for the patient, which means have family there, or if no family is available, find a nurse or social worker or a friend of the patient. Sit down, make eye contact, and sit no closer than 2 feet away from the patient. Have tissues available.
B. Perception. Find out if the patient understands the medical situation. What has he or she been told about the disease? What does he or she know about the purpose of the unfavorable test results you are about to discuss? If this is a first contact, what has the patient been told about why he or she should see you in referral? Correct any misconceptions or misunderstandings the patient may have. Try not to talk for at least 1 minute (which is difficult); let the patient tell his or her story.
C. Invitation. Find out how much information the patient wants to know. These days most patients want a lot of information, but this is not universally true, especially as the disease progresses and patients may want to focus on “What do we do next?” “Are you a details person or do you want the general picture?”
D. Knowledge. Use language that matches the patient’s level of education. Be direct. Avoid using jargon as it will confuse the patient. Give a warning that bad news is coming: “I have some serious news to tell you.” This will allow the patient to prepare psychologically. If the patient’s perception (step 2) was inaccurate, review pertinent information: After giving this news, stay quiet for at least 10 to 15 seconds—resist the urge to tell the patient how to feel. Give the patient time to absorb the information and respond.
E. Empathize. NURSE ! (see Section II.B.3.)
F. Strategize and plan. Summarize the clinical information and make a plan for the next step, which may be further testing or discussion of treatment options.
IV. DISCUSSING DIAGNOSIS, TREATMENT, AND PROGNOSIS
A. Decision making. A number of empirical studies demonstrate that patients are interested in having some role in decision making; the question is, what kind of role does the patient wish to have? Most patients desire some decision-making role for both the patient and the physician, and a majority prefer shared decision making. One of the reasons for patient interest in the Internet for medical information is to enable them to verify treatment options they are offered and to check about options that were not offered. Shared decision making does not have to take more time and is associated with greater patient satisfaction. Steps to enhance shared decision making include
1. Elicit the preferences of the patient for information and decision making. People vary in how they want to make medical decisions. Inquire about what the patient wants in terms of involvement and decision making. You are inviting the patient to tell you how involved he or she wants to be.
2. Identify the choices to be made. Providing the patient with a road map of the conversation in a sentence or two can give a sense of what lies ahead. An example would be chemotherapy for lung cancer. First-line therapies differ little in terms of response rates, but toxicities and schedules do differ and may be important to the patient.
3. Describe treatment options and understanding of them. Describe the adverse effects, how people handle the therapy. Talk about response rates. Don’t use jargon.
4. Discuss how patient values and concerns relate to treatment options.
5. Negotiate a time frame for the decision.
B. Discussing prognosis. Realism, optimism, and avoidance are the most common strategies physicians use in discussing prognosis. Although these strategies are well intended and commonly used, they also create unintended consequences. None of these strategies are completely satisfactory, but each has useful features.
The useful feature of realism is that prognostic information helps patients and physicians to make sound medical decisions. Patients also report that realistic prognostic discussions can be blunt and sometimes brutal. A physician who presents prognosis realistically but without structuring the conversation before the information or responding empathetically afterward can be perceived as uncaring. Moreover, empirical data suggest that roughly 20% of patients, particularly those with advanced, metastatic disease, do not want complete information about their prognosis. Giving these patients realistic information may cause psychological harm, although there are not empirical studies that address this question.
Optimism can play a useful role in supporting a patient’s hopes, and many patients report that they want a doctor who is hopeful. In discussions about prognosis, however, physicians who deliberately exaggerate or overemphasize optimistic information may risk losing the trust of patients who later discover that the information they received was not entirely true.
A third strategy is to avoid prognostication altogether, often by emphasizing individual differences, unpredictability of disease course, or exceptional outliers. Collusion is a variation of this strategy in which physicians avoid providing realistic information by creating a tacit understanding that neither the patient nor the physician will bring up the topic.
Avoidance is based on reasonable concerns. First, physicians realize that they are often inaccurate when predicting survival for an individual. Second, physicians worry that discussing survival communicates a subtle psychological message that a patient will die at a given time. Third, physicians find that some patients do not want prognostic information. Finally, physicians find that bad news often causes patient distress. Yet physicians who avoid prognostication may seem evasive and consequently untrustworthy, especially when studies indicate that many patients want to talk about life expectancy.
Strategies to provide a middle-of-the road approach are few, but theoretical proposals include
1. Ask explicitly how the patient wants to talk about prognosis. Because many patients may not understand the term prognosis, an alternative is to ask, “How much do you want to know about the likely course of this illness?” This question invites a response that goes beyond “yes” or “no.” A physician could even normalize a range of patient interest: “Some people want lots of details, some want the big picture, and others prefer that I talk to their family. What would be best for you?” There will be three kinds of patients:
a. The patient who wants information
b. The patient who does not want information
c. The patient who is ambivalent
2. Patients who want to know the prognostic information. Start by negotiating the content of the discussion. Physicians can negotiate information giving by establishing a patient’s information needs and proposing ways to meet those needs. Thus, the physician should provide information according to the needs of the patient. Some patients want statistical information; some want the worst-case or best-case scenarios. Again, it is important to acknowledge the emotional responses of the patient and family. Check for understanding and have the patient and family write down questions they may have forgotten to ask. This can be covered on subsequent visits. Remember that this is not a onetime conversation.
3. Patients who do not want information. Try to elicit an understanding about why the patient does not want to know the information. Include possible emotional level of the patient’s decision by stating, “I know this can be difficult to talk about.” This segue might enable the patient to reveal underlying emotional concerns or other practical concerns that he or she may have, such as being fearful, or that the information may affect his or her spouse, or that the patient is sad and worried that the discussion will deepen that sadness. In the patient who does not want information, it is also important to assess whether the information regarding prognosis is absolutely necessary at that moment.Inquire about whether the patient would want other people to receive the information or would accept a very limited disclosure.
4. Patients who are ambivalent. These patients both want to know and do not want to know. These ambivalent patients can frustrate physicians because the patient may go back and forth in one visit, wanting the opposite of whatever the physician proposes. Ambivalence may also be subtle: patients might say that they want to talk about prognosis, but simultaneously give other signals—they change the topic or look away. The first step is to acknowledge that the patient has good reasons for wanting to talk and for not wanting to have the information. Ask patients to explain both sides of their dilemma. Let patients know that whatever they want to do, you will be there for them. Sometimes the process involves waiting for the patient to initiate the next step in determining how much information he or she needs.
V. DEALING WITH CANCER TREATMENT
A. Preparing the patient for treatment. Patients who are offered choices in their treatment show better psychologic adjustment, and those who feel they have little control over their disease and treatment have a poorer psychosocial outcome. Studies suggest that patients who believed they were more responsible for treatment decisions and perceived that they had more choice in treatment selection went on to have better health-related quality of life. There is also some evidence to suggest that patients who perceive that their physicians are making an effort to facilitate their involvement in decision making tend to be more involved in that process. Patients who had a physician that employed a participatory decision-making style, including inviting patient assistance in making treatment decisions and giving patients control over their treatment, had higher patient satisfaction and physician loyalty.
There is a continuum of decision making with informed decision making at one end and the physician making all the decisions for the patient at the other (“You’re the doctor!”). In the informed decision-making model, patients make treatment decisions after the physician transfers his or her knowledge of the options, treatment efficacy, and risks to the patient. As the patient’s agent, the physician is able to elicit the patient’s values and then selects the best treatment for the patient based on the patient’s value system. Most clinical decisions appear to be made with the patient and physician meeting somewhere in between these two ends of the decision-making spectrum. Always ask about treatment expectations and the patient’s goals.
B. Discussing clinical trials. Research suggests that there is a wide variation in the manner in which physicians talk to patients about clinical trials. No research has established a method that will increase the likelihood of a patient choosing to enter a clinical trial. The possibility of clinical trial participation usually occurs when physicians and patients are discussing treatment options. Recommendations for discussing clinical trials build upon previous discussions regarding treatment options.
1. Describe a clinical trial as a treatment option. Describe it as an alternative to the “best standard” therapy.
2. Always ask the patient his or her understanding of what a clinical trial means.
3. Delineate the differences. Make it clear that the process of a clinical trial is more involved than getting treatment out of the trial. It involves detailed consent forms and special procedures if toxicities develop, and it means that often the doctor or patient does not get to choose therapy.
4. Right to withdraw. Emphasize to the patient that he or she may withdraw from the trial at any time.
5. What happens if a patient withdraws? The physician should discuss how medical care will be transferred back to the patient’s primary oncologist or physician after the participation in the clinical trial has ended or if the patient withdraws.
C. Completing curative therapy. The end of a planned course of anticancer therapy is a source of ambivalent feelings for many patients. Although it is a relief to be finished with anticancer therapy and its side effects, many patients also worry about not being watched as carefully, losing the support of their medical providers, and cancer regrowth if chemotherapy is no longer ongoing. Patients are often unsure about resuming old activities they enjoyed before the cancer diagnosis. Important points to cover at this point are
1. Support the patient on a job well done.
2. Invite questions about any concerns.
3. Emphasize the follow-up plan.
4. Provide resources. Survivor support groups include the National Coalition for Cancer Survivorship (www.canceradvocacy.org).
D. Discontinuing palliative chemotherapy. One of the most challenging tasks faced by oncologists is talking to a patient with a life-threatening cancer about discontinuing palliative chemotherapy that has proven to be ineffective. Although this is well known to oncologists as a challenge, there has been little empirical study of this task, perhaps because of the difficulty of capturing these conversations. One of the most important things to do when beginningpalliative chemotherapy is to specifically delineate why it’s being given, how a response will be measured, and finally what the indicators for stopping the therapy are. Other important strategies for when palliative chemotherapy is being discontinued include
1. Structure the discussion like the “bad news” conversation.
2. Assess patient’s values and goals at this point as therapy is no longer going to be given.
3. Reframe goals to one of continued support and focus on symptom control.
4. Respond to emotion.
5. Propose a new care plan. This may include discussing treatment limitations and hospice.
6. Follow-up. Use follow-up to address symptoms or items discussed in step 5.
VI. TRANSITIONING TO HOSPICE
A. Introduction. Hospice programs offer unique benefits for patients who are near the end of life and their families. Growing evidence indicates that hospice can provide high-quality care. Despite these benefits, many patients do not enroll in hospice, and those who enroll generally do so very late in the course of their illness.
Some barriers to hospice referral arise from the requirements of hospice eligibility, which will be difficult to eliminate without major changes to hospice organization and financing. However, the challenges of discussing hospice create other barriers that are more easily remedied. The biggest communication barrier is that physicians are often unsure of how to talk with patients clearly and directly about their poor prognosis and limited treatment options (both requirements of hospice referral) without depriving them of hope.
Hospice programs provide a unique set of benefits for dying patients and their families. For instance, hospice patients receive medications related to their hospice diagnosis, durable medical equipment, home health aide services, and care from an interdisciplinary team. Families also receive emotional and spiritual support and bereavement counseling for at least a year after the patient’s death. The median length of stay in hospice is approximately 3 weeks, and 10% of patients enroll in their last 24 hours of life.
It is not known what proportion of patients should enroll in hospice or what the optimal length of stay is. Nevertheless, there is widespread agreement among experts in the field and physicians that more patients could enroll in hospice and many of those who enroll should do so sooner. From the oncologic point of view, the factors that should trigger the consideration of hospice for cancer patients are
1. Poor performance status
2. Leptomeningeal carcinomatosis
3. Malignant bowel obstruction
4. Malignant pericardial effusion
5. Spinal cord compression
6. Brain metastasis (multiple)
7. Widespread metastatic disease
B. Having the discussion. When patients have a poor prognosis and treatment options are limited, physicians should discuss hospice more directly and recommend it when appropriate. Physicians often find these hospice discussions difficult and uncomfortable because patients are being asked to “give up” on disease-directed treatment. However, just as they can with other “bad news” discussions, physicians can make hospice discussions more compassionate, and more effective, by following a structured approach similar to that first described by Buckman for breaking bad news. The overall aim of a hospice discussion that follows this approach is to define a patient’s treatment goals and needs for care and then to present hospice as a way to achieve those goals and meet those needs. Steps in the conversation include
1. Establish the medical facts. Set the stage. Identify a time and place for an uninterrupted conversation. Because hospice decisions are often shared with family members, they should be present.
2. Assess the patient’s understanding of his or her health.
3. Define goals of care. Inquire about patients’ hopes and fears, which offer insights into their goals.
4. Identify needs for care. Identify problems that respond particularly well to the multidimensional treatment that hospice can provide, such as dyspnea, depression, anxiety, and existential distress. Important items to examine are availability of caregivers, location of residence, and safety of residence.
5. Introduce hospice as a way to meet patients’ needs but don’t forget other programs. Home hospice is poorly equipped to meet the needs of debilitated patients without informal caregivers who want to remain at home, unless they can pay for help. Similarly, frail older adults who require extensive supervision may receive more home care services from a Program of All-Inclusive Care for the Elderly (PACE).
6. Respond to emotion and provide closure.
7. Make the appropriate referral.
VII. SOCIAL DYNAMICS AFFECTING CANCER TREATMENT
A. Families. It is no surprise that the family is an important source of support. The type of family support is important. Family members who do not reside with participants and pop in and out of their lives without making particular impacts upon the process of enduring chemotherapy are felt to be more of distraction than a help.
B. Partners and spouses. Partners or spouses are a source of support, encouragement, and great strength. Living with someone undergoing chemotherapy treatment can cause distress, due to intensity of emotion, anxiety, and the possibility of an unpredictable illness trajectory. The patient and his or her spouse often develop a different set of problems resulting from the chemotherapy situation. Behaviors can change, and spouses can be conscious of their reaction to the disease and treatment in relation to the other.
C. Children. Research on adolescents identifies that their lives are complicated by the parent’s illness and that some of these complications arise from poor assessment of their information needs. Children of all ages do not like the parent to talk about the futility of the disease and the possible failure of chemotherapy to cure the cancer. They had difficulty coping with parents who had little hope or who had a negative outlook. Children may purposely adopt a position of non-involvement to protect themselves from the possibility of losing a parent, and sometimes they demonstrate intolerance to ill health. Children wrestle with the possibility of separation during a parent’s illness, and apparently the feeling of imminent death of a parent is emphasized during chemotherapy.
D. Friends. Research suggests that support from friends is highly valued. It was regarded almost as important as support from family, and friends were perceived to be significantly more important than care professionals in supporting people with cancer. Unlike family and spouses/partners, friends of our participants appear to be confidants and motivate patients to socialize.
VIII. DISAGREEMENTS ABOUT THERAPY
A. Types of conflicts. Physicians often assume that conflict is undesirable and destructive, yet conflict handled well can be productive, and the clarity that results can lead to clearer decision making and greater family, patient, and clinician satisfaction. Conflict in medical settings has been defined as “a dispute, disagreement, or difference of opinion related to the management of a patient involving more than one individual and requiring some decision or action.” Common sources of conflict include family versus physician, physician versus physician, and family versus family. Brief examples are
1. Family versus physician. The son of a patient wants life-preserving therapy, yet the medical professionals think that it is futile.
2. Physician versus physician. Specialist wants to continue with therapy; palliative care physician thinks it is futile.
3. Family versus family. Daughter wants everything done; son wants the patient put in a hospice.
B. Tools to negotiate conflict
1. Active listening. “What I hear you say is…” “It sounds like you feel that not all treatment has been offered.”
2. Self-disclosure. “I’m worried that the treatments being discussed are not going to prolong life.”
3. Explaining. “There is a 30% chance that the chemotherapy will cause a response.”
4. Empathizing. “I think anyone in your situation would be frustrated.”
5. Reframing. “Let’s take a look at hyperalimentation as part of the bigger picture.”
6. Brainstorming. “Let’s come up with some ideas about how we can improve her symptoms.”
IX. ALTERNATIVE AND COMPLEMENTARY THERAPY
A. Overview. It has been estimated that 83 million Americans used alternative therapies for malignant and nonmalignant disorders. Estimates suggest that from 70% to 90% of patients will not mention alternative therapy visits to their physicians. The reasons why people seek alternative therapies for cancer are broad. Many seek out alternative therapy when options for conventional therapy have been exhausted. There is also the recognition that, for some tumor systems, conventional therapy is of limited effectiveness and that the side effects of chemotherapy, surgery, and radiation are feared. For some tumor systems, no conventional therapy exists and the standard therapy is participation in phase I or phase II trials. Many patients perceive that the conventional approach is emotionally or spiritually empty and provides neither comfort nor solace.
1. Why do patients seek out alternative therapies? A large lay literature on alternative therapies suggests that sufficient will and determination can overcome cancer. Many alternative therapies invent a simple etiology explaining all cancers are due to a common etiology, such as a toxin. The use of alternative therapy allows patients to exert autonomy and gives them a sense of participation in their care.
2. Regulatory status. Vitamins and herbs are considered to be nutritional supplements and are not regulated by the U.S. Food and Drug Administration (FDA).
3. How do patients learn about alternative therapies? A quarter of patients learn about alternative therapies via the lay media, including newspapers, television, magazines, and the hundreds of Web sites that sell bogus cures for cancer. Approximately one-sixth of patients learn about alternative therapy from well-meaning friends and family. One-third learn about alternative therapy from their physician!
4. What therapies are chosen? It has been estimated that fewer than half of patients with cancer receive only conventional therapy; approximately 44% use conventional and alternative therapies. Ten percent of patients with cancer use unorthodox therapy only and forgo any form of conventional anticancer treatment.
5. Is this all harmful? Usually there is no harm. There are low-risk therapies, such as massage, spiritual healing, therapeutic touch, hypnosis, and relaxation, which do not interfere with conventional therapy. Clearly, any therapy is potentially dangerous if it delays effective or curative conventional therapy. Lack of toxicity does not always mean safety.
B. Role of the oncologist. Many patients who pursue alternative therapy do so because they feel that their alternative practitioner listens to them. Physicians need to recognize that patients have the right to forgo conventional therapy. Common law recognizes the patient’s autonomy in making treatment decisions, and this must be respected by the physician.
In most instances, the patient wants the physician’s opinion regarding the therapy, but a judgmental or dismissive attitude often drives the patient away. It becomes important to specifically ask during the course of therapy: “Are you considering or are you currently using therapies that are usually considered unconventional or alternative?”
Good communication skills between the physician and the patient remain the best strategy to combat inappropriate use of alternative medicine. Reassuring patients of continued support no matter what therapy they select remains a key. It is worth remembering that most patients do not have the scientific background to distinguish therapies that have been shown to be effective from completely fraudulent therapies.
A nonjudgmental attitude is important. A particularly useful Web site to which patients can be referred, so that they may get additional information about an alternative therapy, is http://www.quackwatch.com.
X. MANAGING THE DIFFICULT PATIENT
A. Introduction. Most practices include difficult patients; the prevalence is estimated to be 15% of patients. Many physicians enter medicine with the goals of solving medical problems and curing disease. They do not expect to encounter patients who make repeated visits without apparent medical benefit, patients who do not seem to want to get well, patients who engage in power struggles, and patients who focus on issues seemingly unrelated to medical care. The result is often distraction from effective care, waste of physician energy, complaints from patients and staff, and continued health problems for the patient.
A variety of tactics and strategies that reduce common physician–patient communication problems can be applied to difficult encounters. Improving physician communication can lead to increased patient satisfaction, increased health care professional satisfaction, and improved patient health outcomes and a decrease in complaints and lawsuits. Ensuring that patients understand that the physician comprehends their situation and cares about their health is related to better outcomes.
Several factors exist that lead to the generation of the “difficult patient.”
1. Patient factors. The difficult or frustrating patient, often a “distressed high utilizer of medical services,” has unrecognized psychiatric problems. Patients with mood disorders may present with physical symptoms and persistently search for a medical explanation for distress. Patients with alcoholism and borderline personality disorder may present with somatic complaints. Even if the physician recognizes the psychopathology, the patient may reject the diagnosis. Such patients’ insistence that the physician pursue somatic symptoms until a medical diagnosis is obtained can be significantly frustrating.
2. Physician factors. Physician overwork may be related to greater numbers of patients being considered difficult. Less-experienced physicians more often report encountering more difficult patients. Physicians who have greater need for diagnostic certainty are more likely to consider patients difficult if they present with multiple or vague diagnoses, repeatedly return with poor response to treatment, persistently present with vague physical complaints, or fail to follow through with treatment plans or self-management.
Difficult patients are more likely to identify unmet requests after primary care visits. Patients who feel rushed or ignored may repeat themselves and prolong their visits. These problems may be markers for negative physician attitudes concerning the psychosocial needs of their patients.
3. System factors. Managed care has led to increased mistrust between patients and physicians. Attempts to “see more faster” have led to less time with patients. Together, these changes magnify the potential for conflicting expectations between patients and physicians. If expectations are unmet, patients are more likely to be dissatisfied with their visits. Dissatisfied patients may become more demanding, and physicians may feel less able to respond to patient needs, thus transforming the problems of the health care system into interpersonal frustration.
B. Steps to help manage the difficult patient
1. Psychiatric involvement. The prevalence of undiagnosed and untreated psychopathology in difficult patients suggests that effective management of such patients routinely should begin with a tactful assessment of the patient’s distress. For example, the physician could observe, “You seem quite upset. Could you help me understand what you are going through?” Screen for substance abuse. Targeted psychopharmacology, particularly with selective serotonin reuptake inhibitor therapy, may be considered for patients with symptoms of dysphoria, anxiety, and aggression. Framing medication recommendations in terms of the stress produced by mysterious or intractable medical conditions may facilitate a patient’s acceptance of such a prescription. Incorporating a mental health consultant also is helpful.
2. Physician responsibility. Physicians should practice effective self-management. This includes acknowledging and accepting their own emotional responses to patients, as well as seeking help if necessary, be it via colleagues or formal therapy. It may be quite helpful for physicians to elicit feedback on their communication skills. Possible sources include staff, trusted patients, or a review of audiotapes or videotapes of patient visits. Using the tools described in this chapter such as active listening, empathizing, and reframing can help improve communication.
3. Counterproductive strategies. Ignoring the problem or exporting it to another physician does not make the difficulty disappear. Accusing the patient of being problematic may provoke patient anger and counter-blaming. Telling the patient that there is nothing wrong or that there is nothing you can do for him or her may trigger persistent attempts to prove that a problem exists.
Suggested Reading
Back AL, Arnold RM. Dealing with conflict in caring for the seriously ill: “it was just out of the question.” JAMA 2005;293:1374.
Back AL, Arnold RM. Discussing prognosis: “how much do you want to know?” talking to patients who are prepared for explicit information. J Clin Oncol 2006;24:4209.
Back AL, Arnold RM. Discussing prognosis: “how much do you want to know?” talking to patients who do not want information or who are ambivalent. J Clin Oncol 2006;24:4214.
Back AL, Arnold RM, et al. Approaching difficult communication tasks in oncology. CA Cancer J Clin 2005;55:164.
Baile WF, Buckman R, et al. SPIKES—a six-step protocol for delivering bad news: application to the patient with cancer. Oncologist 2000;5:302.
Buckman R. How to Break Bad News. Baltimore: Johns Hopkins University Press; 1992.
Ford S, Fallowfield L, et al. Can oncologists detect distress in their out-patients and how satisfied are they with their performance during bad news consultations? Br J Cancer 1994;70:767.
Gertz MA, Bauer BA. Caring (really) for patients who use alternative therapies for cancer. J Clin Oncol 2003;21(9 suppl):125.
Haas LJ, Leiser JP, et al. Management of the difficult patient. Am Fam Physician 2005;72:2063.
Leighl N, Gattellari M, et al. Discussing adjuvant cancer therapy. J Clin Oncol 2001;19:1768.