Prescriptions for Health Providers

Tovia G. Freedman, DSW, LCSW

Disclosures

Cancer Nurs. 2003;26(4) 

In This Article

Conclusions and Recommendations

Patients are troubled by the decision of some physicians to omit explanations of procedures still in the realm of patient- oriented clinical research that have apparent potential to limit long-term side effects. In this study, a case in point was sentinel lymph node biopsy for pathologic investigation of the axillary nodes. When many nodes are removed, as in the traditional axillary dissection, short- and long-term physical problems are not infrequent. Nearly 40% of women experience inconvenience, hospitalization for cellulitis, and even disability from lymphedema, sometimes years after surgery.[3] The removal of only the sentinel nodes has the potential to prevent lymphedema as well as the discomfort and pain after surgery caused by the more extensive axillary dissection. However, at the time of this research, sentinel lymph node biopsy was in the 'experimental' or registration trial phase. More to the point, many surgeons had not learned the technique for performing the procedure, whose quality and reliability of which are highly dependent on surgeon skill and experience.[3,4] In this study, surgeons not performing the procedure did not offer it as an option to patients, nor did they refer patients to other surgeons for consultation about sentinel lymph node biopsy.

Both physicians and patients make assumptions about age, ethnicity, race, and religion that may affect early detection, prevention efforts, and even medical care. When there is no family history of cancer, many women concentrate their healthcare surveillance and vigilance on afflictions more common to their families. Among African American women, these would include heart disease, stroke, and diabetes. Primary physicians also may focus on these diseases among their African American patients and relegate to secondary concern breast examinations and even mammograms. Young women also may incur primary physician oversight solely on the basis of their age.

Taking the patient seriously and showing this by listening to what the patient is saying and asking is of vital importance to medical care. The physician can demonstrate to the patient that listening is taking place simply by repeating what the patient has said or by referring to it later in the conversation. When physicians in this study demonstrated that they heard the patient by making a reference to what the patient had said earlier, the patient visibly relaxed and gained a further sense of trust in the physician. One patient said, 'I know she really did hear what I was saying even though it took me so long to tell my story.' Questions can be hidden in statements that seem overly long and complex to the physician, but often buried within these statements are important patient concerns about life and death that need to be addressed. A truthful and trusting relationship built between the patient and the physician can go a long way when there are difficult and complicated medical choices to be made. The caring attitude of the physician built early in the relationship enables a more efficient delivery of healthcare services throughout the course of treatment and follow-up evaluation.

Enhancement of knowledge about the complexities of decision making between patient and physician can improve and even expedite the medical encounter. The need on the part of both patient and physician[24] to diminish the uncertainty involved in cancer treatment is of prime importance. Much of their ensuing engagement, as observed in the current medical encounters, was directed, most often implicitly, toward this goal. The need for information, starting with what is to be done, is followed closely by a need to know what the outcome will be. Will I live? How will I feel? What will I have to go through to do well? As shown in this study, the development of trust is of great importance to the patient-physician relationship, and subsequently to the consideration of medical recommendations.

The data make it clear that patient-participants' psychosocial needs in relation to their cancer care are not complex. Yet, they are often not treated with the same degree of importance as the physical medical treatment. Nevertheless, it is known that psychosocial and physical care are inseparable in offering the best care to patients.[18] An atmosphere of respect between patient and physician can provide a context within which open communication can take place. Open communication can enhance a discussion of emotional and interpersonal concerns and provide a view of the patient's perspective on her illness. This has the potential for opening the door to discussions concerning any conflicts, disagreements, or misunderstandings that are an inevitable aspect of care. Planning ahead for how to deliver bad news and asking the patient how she would like to handle her situation can go a long way in the development of trust. The notion of shared decision making can enhance patients' sense of well-being and help provide a sense of self-determination that increases feelings of control over a complex and difficult situation. Physicians who respond to their patients' suffering with care, empathy, and attention[10] not only can meet the needs of patients, but also can reaffirm the basic tenets of medicine and medical care while doing no harm and working for the best interests of the patient.

Considering that both the lay media and professional journals focus a great deal on the downside of the medical system, it may seem surprising, even gratifying to health professionals, that overall, the patient-participants in this study were enthusiastic about their physicians and devoted to them, and that these qualities appear to be closely tied to their medical decision making. It is important that physicians facing the constraints placed on them from within their medical institutions remember that sharing medical facts and information with patients is essential, and that patients filter vital information and recommendations through the lens of personal characteristics attributed to their physicians.

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