Prescriptions for Health Providers

Tovia G. Freedman, DSW, LCSW

Disclosures

Cancer Nurs. 2003;26(4) 

In This Article

Results and Discussion

On entering a surgeon's examination room, a woman is often a 'precancer' patient. There is no breast cancer diagnosis, and sometimes the woman little suspects her possibility of joining the ranks of women with breast cancer. In this early phase, the woman has not been alerted to awareness of cancer by the referring physician. The referring physician is often seeking confirmation about suspicions that may not have been relayed to the patient. In other situations, the patient has some idea that she may have breast cancer. The first visit to the surgeon is diagnostic or confirmatory, setting the stage for the type of ongoing relationship the patient will establish with the surgeon who is the lead-in to the oncology realm. The uncertainty, emotional stress, and deep concern experienced at this time may influence the patient's ability to comprehend the diagnosis. The patient is unprepared to hear the words that emerge in the foreign language of cancer medicine. Comprehension, and the subsequent ability to make informed decisions also may be compromised by the shorter medical encounters imposed by medical institutions.

Each patient and physician has a perspective and vision unknown to the other. These two worldviews come together in the examination room. They must be negotiated and understood by each for the process of medical care to go forward with a sense of trust. The degree to which the patient gains a sense of trust toward the physician appears related to the patient's willingness to accept the physician's advice and recommendations throughout the course of the cancer. The trust may even contribute to a sense of hope. As one patient-participant explained:

I have to get to know him so he will take a personal interest in me, and have a greater incentive to take better care of me. I make sure we shake hands at the end of the appointment so he won't forget me. He will remember that I am a real person with children and a life when we are in the operating room. He will take better care of me.

Without exception, patient-participants in this study evidenced a need to orchestrate medical encounters in such a way as to gain a degree of control, via participation, over the cancer event. Because medical technology belongs to the physician, the usual recourse for gaining this sense of participation is a social one. Remarks are made from patient to physician about family: 'What would you tell your wife or mother to do?' or 'Oh, so you have teenage children too?' In an attempt to find common ground with the physician, the patient may use cancer-related jokes: 'Well, I always wanted to look like Dolly Parton, and now I have my chance.' Shaking hands, paying respectful attention, and trying to prolong the encounter, the patient may say, ' Oh, I forgot to ask you . . .' or 'You took care of my friend Mrs. Smith last year and she said to say hello.' These are strategies to draw the physician into an arena more familiar to the patient, with the hope of creating a relationship that will not only enhance medical care, but also ameliorate uncertainty. The underlying belief, whether explicit or implicit, as stated by the patient, is that 'if there is a trusting relationship with the physician, things will go better for me. He or she will take care of me as a person, and I will live.' This belief generates hope and even optimism in patients, and a reciprocal optimism in physicians. One physician stated: 'Caring for an 'upbeat' patient energizes me as a physician.'

As one patient said, it can be assumed that 'getting the cancer news is a traumatic experience even when it is anticipated.' The validation that a cancer diagnosis brings with it great stress is captured in the detailed accounts given by cancer patients about the delivery of the news. They recall the place, time, exact circumstances, and manner of the delivery as well as the physician's demeanor, the 'look on his face,' and ' how he or she carried him- or herself.' The details of the emotional state and atmosphere are recollected.

One of the interviewees reported that she was alone, undressed, and seated in the examination room when a physician she had never met before came into the room. She expected to have her biopsy stitches removed and her incision examined. It was a holiday weekend. Her physician was away, and she had been told that her pathology results would not be ready until the next week. She readily accepted this because she had no suspicion that she might have cancer. Her physician had not even requested a mammogram before performing the biopsy. She was 30 years of age. The patient recalled this encounter:

A young physician entered the exam room and blurted out, 'I am afraid that you have cancer, but it is curable.' I was shocked. I said, 'You are kidding, right?' 'No, I am not kidding.' I was very anxious to talk to my 'own' doctor, and I had to wait until the holiday was over. So when we went back to see him and he said the same thing-'It is cancer, but it's curable'-I think it started to sink in, reality took hold, and I had to accept it more. Yet there was also doubt because no one had ever done a mammogram. Then he recommended a mastectomy, and wow, that was not what I was expecting to hear at all.

This woman subsequently had several consultations and discarded two physicians who 'did not spend any time with us.' She chose instead,

the physician who took a lot of time to explain things to me and even hung around in case we had more questions after seeing the other specialists on the breast cancer evaluation team. He talked to us about more than just cutting up my skin. He explained how I might feel and what I would have to go through. I liked the surgeon we picked because he was younger and I felt that I could relate to him better than the older doctors.

The whole thing was not as horrible an experience because we were calling the shots. You know, we stayed educated. We were allowed to make decisions and choose our options. I like being treated like an equal partner in the decision making and making the medical language something that I can understand.

Patients vary in the degree to which they state how much they want physicians to be involved in the medical decision-making process. One patient said:

Doctor, tell me what you think I should do. You see a lot of patients with this problem, and I don't know anything about it. Just tell me what to do.

Other patient-participants want to believe that they have made each and every decision on their own, albeit in consultation with their physicians. Yet, even where it appears that each decision along the continuum of medical events is made by the patient, it must be recognized that in most instances, the decisions themselves are based on information given out by the physician. The information cannot cover the broad spectrum of options generally available. Information is presented from the physician's perspective, with the individual patient situation taken into account . The physician makes deliberate choices about what to present to a patient.[24] From this menu of options, a decision has to be made. The patient decides on the basis of her understanding of the facts that exist within the context of her emotional state and medical status.

In addition, patients have information generated by physicians who represent different disciplines, each with its own set of values and priorities for patient care. Each discipline may see itself as the primary caretaker of the patient, and it is not unusual to see the disciplines disagree about the best treatment regimen for a particular patient. For instance, surgical and radiation oncologists provide different advice to patients about the extent and purpose of radiation treatment. The following example shows contrasts between patient and physician:

The patient, a 30-year-old African American woman, is heavy set and amply fills out her shirt and pants. She is sitting on the end of the examination table, a sullen look on her face, eyes downcast. The radiation oncologist, also in her early thirties, arrives brusquely in the examination room. Her long blond hair hangs down onto her suit jacket. She is wearing a skirt not much longer than her jacket and high heels. She is in dramatic contrast to the patient's elderly mother sitting in the tiny examination room, completely clothed in dark colors, engaged in reading her prayer book, and not acknowledged by the physician.

The patient underwent the sentinel node biopsy (SNB) procedure, which resulted in a node negative pathology status. She was told by her surgical oncologist that she would not need radiation to her axilla. However, the radiation oncologist disagreed with the surgeon, stating: 'The SNB is experimental; results are not published, and in my opinion radiation is called for to the whole underarm area.' Later, in describing her decision not to have additional radiation treatments, the patient-participant stated strongly that the combination of her positive relationship with the surgeon and her lack of trust in the radiologist, based on her appearance, manner, and disrespect for her mother, pushed her to her final decision.

In other circumstances, the patient may be presented with a variation in options reflecting the medical discipline and expertise of the physician. The patients in this study generally followed recommendations offered by the first physician they felt 'paid attention to me as a person, and not just a patient.' They then proceeded to see additional specialists recommended by this physician, most often within a tight network of trusted, likeminded physicians. Patient-participants, unless they wanted to 'shop around,' most often followed this advice. Many times, the referring physician does more than offer the patient a name. Along with the specialty are personality assessments: 'You will like him; he likes to joke around like me'; 'she is a nice person'; or 'patients really like him.'

In one case, the referring physician wanted the patient to go through a complex and sometimes life-threatening procedure and so, according to the patient, he explained:

There are three docs who can do this, and they are all very good. Two of them are nice, but they will tell you to make up your own mind. I want you to see the third one. She is kind of cold and not friendly, but she will just tell you to do it, and that is what I think is best for you.

This referring physician alerted the patient to the personality of the physician because he did not want her to turn the therapy down on the basis of the physician's 'cold and seemingly unfriendly' personality. As it turned out, the description of this physician was evidenced in the medical encounter, and did cause the patient to hesitate about the procedure. The physician barely greeted the patient, ignored the family, tersely explained the procedure, and went ahead and set the date for the start of the procedure, as if the patient had agreed. She did not visit the patient while she was an in-patient for 3 weeks. However, weeks later, when the procedure was completed and the patient was an outpatient, the physician greeted her with great warmth and enthusiasm: 'You have done so much better than we expected. You are like a normal person now.' The two went on to discuss personal matters: clothes, weddings, and childbirth. The patient erased her earlier reluctance and anger about not seeing the physician during the difficult weeks of her medical treatment, and joined the optimistic mood of the physician.

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