Wednesday, October 1, 2008

Doctor and Patient - Before the Diagnosis, a Dance of Evasion -

Late one recent Friday afternoon, doctors informed the father of a friend of mine that he had pancreatic cancer. When I heard the news from my friend's wife, it came as a complete surprise. I had met the father, a lifelong Democratic activist, just a few months earlier, and we had enjoyed a lively discussion about the candidates. Nothing led me to sense that cancer was lurking in this vibrant man's abdomen.

But even if I could have suspected it, I wonder if I would have shared my concern with him.

In the hours before the doctors came to the hospital room to deliver the pathologists' final report, my friend knew the gravity of his father's case. He knew the mass in his father's pancreas was a malignant tumor. And he knew not because the doctors in the hospital had shared their suspicions, but because they could not look at him in those hours before.

The diagnosis was in their body language.

"I understand that they needed to be sure before they could say anything definitive," my friend's wife later told me, "but they had strong suspicions. Why were we dancing around the issue?"

As a doctor, I know I have evaded the probing looks of patients and families. I have heard myself speaking carefully and measuring my words, fearful that hunches shared prematurely might worry or anger them, or even dash their hopes.

I am not alone in this dance of avoidance. But in trying to protect patients, doctors may be misjudging them and the consequences of not sharing our suspicions. We may be assuming that patients and families are more fragile than they really are and that keeping our hunches to ourselves will protect them, when in fact we may be making the situation worse.

No matter what our specialty, communication is at the heart of what doctors do. Since 2002, the Association of American Medical Colleges and the Accreditation Council of Graduate Medical Education have made interpersonal communication one of the six core skills taught in medical schools and residencies.

But many doctors can be woefully evasive in talking with their patients. In a 2007 study, for example, researchers monitored doctors in simulated office visits with actors trained to portray cancer patients in remission; the doctors were supposed to inform them that their cancer had recurred. Fewer than 20 percent of the doctors said the word "cancer."

Research in nonverbal communication is even scarcer than in other areas of the patient-doctor interaction, in part because of the challenge of measuring and assessing nonverbal behavior and personal qualities like "sensitivity." Nevertheless, investigators have repeatedly come up with one finding: doctors are not always good judges of their patients' emotions. In fact, we can be pretty bad when it comes to reading worry, anger and disappointment.

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