Difficult Conversations In Medicine

I have spent the past 15 years of my life traveling teaching and researching, but things change. On July 24th of this year, I was diagnosed with a cancer of my lower esophagus.
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I am an internist who's primary work has been in preventive cardiology and physician health. I have spent the past 15 years of my life traveling teaching and researching, but things change. On July 24th of this year, I was diagnosed with a cancer of my lower esophagus. At the time of the diagnosis, it had already spread to my lymph nodes in my neck, making this a very difficult cancer to treat.

My intention in this blog and possibly subsequent ones, is to find ways in which this experience can serve us all well as clinicians trying to do good work and patients trying to understand the physician's mind set and how you can help yourself in times of need.

As you can imagine, the past few weeks of my life have been filled with difficult conversations; discussions with my physicians at the time of my diagnosis and regarding treatment options, my discussions with my family and friends, conversations with consultants, and long talks with myself (generally not out loud or in public). It would be rather narcissistic for me to focus on myself here. I thought, instead that I would focus on awareness of the physicians' and patients' moment-to-moment responses at these times. For example, what is going on for you and the physician the moment they are about to tell a patient 'bad news?' Here are some likely possibilities:

* The physician is likely to be agitated about sharing bad news with anyone. As clinicians we would much rather impart good news and hope. We do tend to be people-pleasers. Sometimes this is not possible and that is difficult for us.

* The physicians' tone of voice is often and indicator that something is wrong, way before the content of the conversation is delivered. This creates stress for the patient.

* In a situation like this, both the physicians and patient are likely to be under duress as above. As much as you think you can control your nervous system and hormonal response, you can't over-ride basic survival/stress mechanisms. Your body is going to do what the body does under stress, release adrenaline and other hormones. This will adversely affect both parties patience, compassion and ability to understand each other. When stress hormones increase, the thinking mind decreases in function. This is often experienced as confusion and a lack of understanding. Interestingly, two people listening to a doctor deliver difficult news will often hear a completely different story because of this.

* Fears of death will invade and distort the conversation for both the physician and the patient. While the physician may not want to admit it, they will often project their own fears and beliefs onto the patient and this will color their presentation of the information. The patient, meanwhile will also, often, experience a fear of dying and further 'muddy' their thinking.

* The physician may also project their personal beliefs onto the patient. Very often we see our patients as ourselves. "What if this were me?" becomes the question. How would I tell my spouse/kids/friends/co-workers etc?

* The physician will also, often, project his or her own religious/spiritual belief structure, which will also color this conversation.

All of the above (and probably more) will be happening simultaneously in the physician and patient in these difficult moments. So what can you do? I have a few thoughts:

* Physicians - Don't be a people pleaser. This sounds harsh, but it's important to be aware of those tendencies. Unfortunately, we can't always bring good news. You can, however, always bring compassion to the conversation.

* Physicians and patients - Don't try to control your stress response. Frankly, you can't. It is a natural mechanism. Awareness of the response can help decrease the likelihood that you will impart stress. Sharing the stress with each other might help to create a bond and compassion. However, physicians, don't make it about you. This is the patient's most difficult moment. When you are aware, you are no longer the slave of your neuro-endocrine system. You are more likely to respond with emotional intelligence and compassion. You also are not going to beat yourself up for your stress response, ("I am not Zen enough,") because "The body will do what the body will do." Keep reminding yourself of this and stay aware.

* Physicians - Try to find the time and place for this conversation that fits the patient's needs, not yours. Sometimes a patient calls and catches you off guard. You would prefer not to have this discussion by phone, but here it is. There is no preparation. Any deferment of the conversation will feel false and your patient will detect the truth. Is the average patient deluded by, "Can you and your spouse come see me in the office tomorrow?" I would suggest that you may just be giving them a terrible night of worry as opposed to compassion and a plan. I am not suggesting this for all cases. This is just a personal observation from the patient side. I would suggest an alternative response. "We have a lot to talk about, I am happy to do this with you now or in my office tomorrow, which do you prefer?" Let them have the choice.

* Patients - Be compassionate as well. Understand that this is not easy for the physicians even if they have had more practice.

* Patients and Physicians - What are your personal issues around death and dying? Does Death scare you, or is "today a good day to die?" I propose to you that you can learn to live every day as if it were your last, with gratitude. How can this be learned? Focus each day on the sweet aspects of your life, being grateful for friends, family and colleagues, knowing how lucky you are to do things that you that you love and resolving issues as they arise instead of stewing in them. It takes time and intention, but I really believe that this can be learned through meditation, prayer, and practice, practice, practice.

* Physicians - Don't project your own stuff. It is not possible for you to know how a patient will respond to these conversations. I know that you already have been surprised by many individuals in these times, so don't project your own likely response onto them.

* The failure of the medical structure and psyche. Physicians are trained that death is failure. Our entire western system of hospital-based training tells us to avoid letting people die. This is not the same in other parts of the world where death is considered a natural occurrence, not a feared event. These conversations make physicians feel like failures, especially if the diagnosis is a bad one. I am encouraging my colleagues to relax this concept and realize that death is a part of life. This is not an easy task as most physicians have been indoctrinated towards life "over all" for many years. If death is failure, then we fail royally every day!

* Medical information is limited to population-based statistics, not an individual's experience. Survival statistics only have meaning for a population. They will be on one side or the other and you cannot predict where they will fall. For example, statistically there is a 90% chance that I will be dead in five years. Personally, I will live or die and I can't predict or, frankly control this. All I can do is listen to my very smart and often wise colleagues and listen to my heart. Only in time will I know the outcome. Until then, every day is a treat, a hug and when I can handle it a great meal or two.

These are just a few thoughts that have arisen in the past few weeks. More to come, I am sure. I wish you well.

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