COMMUNICATION! Physicians are infamous for our illegible handwriting, but we are equally guilty of not being able to relay life and death information using honest and understandable words.
For example: “Your anatomic pathology report has been interpreted as a pT1B Nottingham Histologic score 3+3+3 triple negative invasive ductal carcinoma with basal-like phenotype associated with macrometastatic involvement of the sentinel lymph node. The NCCN guidelines for premenopausal women with breast cancer recommend TC or AC chemotherapy, but given your phenotype I want you to consider AC-weekly T.
”Translation: “You have a bad breast cancer that already spread to a lymph node. You should have the best chemotherapy that we have.”
Early in my career I was tempted to use euphemisms: “spot,” “tumor,” “cells,” and “nodule” equate CANCER. In reality these euphemisms may help the doctor deliver bad news, but only confuse patients and their loved ones. A spoonful of sugar does NOT make the diagnosis of cancer more palatable.
Frequently touch relays more than words can express. A hug means “I understand.” Eye to eye contact means “I would not lie to you.” A hand in a patient’s hand promises that “we are in this together.”
FAITH, Perspective and Humility. When I was a young doctor I thought I was going to cure cancer. I tried hard. But if one is vain enough to take credit for the successes, I also had to accept responsibilities for the failures and deaths. I had to take a leave from my first practice and nearly lost my family, marriage and sanity. The painful but important lesson I learned was that I am a worker bee. My sole responsibility is to be honest. No matter how hard I try, I cannot control who will respond and who will die. My revitalized faith also allows me to admit that I may not always be right when another treatment approach is suggested—such as homeopathic or alternative medicine. While I may see 150 patients a year with colon cancer—this person’s colon cancer is the only one they have known. At the end of the day, the patient and their family have to be able to fall asleep knowing they are doing everything that they can.
Physicians seem to refrain from asking about a patient’s faith and sharing their person beliefs. I have found that although many patients do not associate themselves with an organized religion, even self termed “agnostics” have a sense of spirituality. I believe that we all are God’s children and that he has many messengers.
CONSCIENCE and Intuition. The most controversial topic that I will share is that I hope that future Oncologists will have and follow their conscience. I have practiced with physicians who have chosen treatments solely based upon profitability to the practice, using additional drugs that are not indicated, and continuing treatments even up to the deathbed. There are “successful” practices that do NOT do any charity care. I have also seen patients bankrupted by medical copayments and families sent to collection agencies after already losing their loved ones.
Intuition is akin to faith. I will simply repeat to you what my dear friend and mentor Dr. Ron Alexander asked of me: “Roy, how many times in your life has your intuition been wrong?” Quite honestly, never.
HUMOR. It may be hard to initially believe, but successful Oncology nurses, physicians, office staff and patients generally share an incredible sense of humor. Cancer and its treatment can be physically debilitating, but a grin and especially laughter lifts the spirit and lightens the burden. I always have time for a good joke or amusing story and have found that every person has a story to tell and responds to light hearted teasing. It seems to instill a sense of family.
EMPATHY, impartiality, and restraint. While Mrs. G may be the 3rd breast patient seen today and the 12th this week, the terminology and procedures are not routine to her. She likely is more worried about her children, husband, and how she is going to pay the bills than if she is going to lose her hair. I have heard a patient’s relationship with their Oncologist is the second most important relationship that they will have in their lives. If the first date with my lovely wife had not gone well, I doubt there would have been a second date—much less a wedding.
I also feel strongly that no person has done anything for which they deserve to have cancer. It does not matter if you smoke cigarettes, never had a recommended mammogram or colonoscopy, or have Hepatitis or HIV. With few exceptions, once you are diagnosed with cancer it simply matters what needs to be done now.
Alternatively I have had the opportunity to care for politicians, professional athletes, celebrities, the independently wealthy, and a Crown Prince. Every patient deserves individual care and reasonable access to their Oncologist. Every patient leaves my office with my email address and cell phone number.
Restrain relates to perspective. The most difficult treatment recommendation is not which chemotherapy regimen to use, but when NOT to treat and focus entirely on symptom control. There are chemotherapy regimens that I would not recommend for my loved ones, and although I do discuss them with patients—I cannot honestly recommend them to someone else’s loved ones. Furthermore, I have also come to respect the skill of a surgeon not by the results of his operations—but when he or she knows not to operate. In fairness, a surgeon helps people by operating and usually I help people with chemotherapy—but sometimes I would have been more helpful by not recommending chemotherapy.
An HONEST and loving support system. My precocious 13 y/o daughter says it best: “Daddy, do you want me to be nice or honest?” I function best personally and professionally when I am surrounded by family and coworkers who are not afraid to be honest with me. At least this Oncologist was trained to believe that exhaustion and masochism were the hallmarks of a true physician. Truck drivers and pilots have legally required work limitations and rest periods. Oncologists are required to have continuing medical education, but I would have been better served with mandatory courses in meditation and time management. Early in my career I had come to almost resent even the most desperate patient’s reasonable request of my time. Oncologists have among the highest rates of “burn out,” alcoholism, and divorce. I continue to struggle with the undeniable fact that 3 well understood and cared-for new cancer patients is better than just 6 “faceless” new cancer patients daily.
In summary, I pray that future Oncologists focus more on patient centered care and not the medical literature. Oncology staging and chemotherapy regimens are now widely available on the Internet and even cell phone apps. Communication and bedside manner are the highest predictor of patient satisfaction and best insurance against malpractice complaints, but are not taught in any training program. Physically, mentally, and spiritually fit Oncologists are the only physicians that will enjoy a long and rewarding practice AND personal life. I cannot honestly say that I always abide my suggestions listed above—yet. I have humbly documented many of my most important lessons so that perhaps another practicing Oncologist, fellow in training, or family member of a cancer patient can learn from my pain.
Written by Roy Williams M.D.