Physician, Know Thyself When Communicating With Cancer Patients

Fran Lowry

November 19, 2018

New recommendations from the third European consensus meeting on communication skills training emphasize that oncologists should be aware of their own feelings, attitudes, and life experiences when they talk with their cancer patients.

The new position paper was published online in the Annals of Oncology.

The new recommendations, which build on those set by two previous consensus meetings, seek to promote the following:

  • Oncology clinicians' awareness of their lived experience related to their inner world (feelings and attitudes) and outer world (institutional and societal constraints) experiences and how these shape their dealings with their patients;

  • Clinician's appreciation of how they relate to their patients;

  • Recognition of individual patients' psychological state and vulnerabilities to help guide the way they relate to both patient and significant others.

One Size Does Not Fit All

"We were afraid that training in communication has become somehow standardized. For example, telling oncologists to always start an interview with an open question, or if someone cries, to say, 'Yes, I can understand how difficult this is for you' — we thought this could be quite alienating for some patients," Friedrich Stiefel, MD, lead author of the position paper and psychiatrist at Lausanne University Hospital, Switzerland, told Medscape Medical News.

"Certain skills in medicine are observable and objective — either you get it right or you do not — but communication is not like this. Sometimes it may be comforting for a patient to talk about his emotions, but some patients don't like to talk about their emotions, so the word 'skills' does not really fit," Stiefel said.

Communication is always context bound, and what can work for one patient may not work for another.

"It's not a one-size-fits-all approach. Because of this, we thought what is more important is to take into account relational aspects of how physicians communicate with their patients," he said. "This means, for instance, as a doctor, what is my fear when I see a patient? What can I handle well? When do I become defensive and try to talk about medicine to avoid talking about other topics?"

The new position paper also recognizes that medicine is not practiced in a vacuum and that world views, institutional factors, and societal views can affect communication.

"We are not alone with our patients, there is a wide world around us. There are institutional factors which influence the consultation, such as clinical productivity, economization of the medical field, legal aspects, algorithms, and prescriptions, which all affect how we communicate with our patients," Stiefel said.

Society often dictates how we should face death. Also, the language relating to cancer is full of military terms, like "fighting" or "battling," which may not be applicable or even suitable for everyone, he noted.

"We are being told you should be able to talk about death, you should finish your unfinished business, you should master death, have a successful death. Or, for survivors, there is the notion that they must not only survive their cancer but emerge a better person as a result of their experience. But for some of our patients and their families, it's just a horrible experience," Stiefel said.

Years ago, people who got cancer were told they were cancer-prone personalities, he commented.

"That was in the old days, but now, they want you to survive in a way that is not acknowledging how very problematic this can be. Patients are told, just go through it and come out better than before. We need to deconstruct these types of discourses," he said.

It is also vital for good communication for physicians to be aware, as much as possible, of what is actually going on with the patient.

"Communication takes into account your relationship with the patient. The more we understand a little bit about the psychology and singularity of the patient we have in front of us, the more we can relate to him or to her. We need a sharpened sensitivity about the patient. Why is he the way he is? What is her background? Why is she in denial about her illness? So the more we understand, the better our relationship will be," he said.

I Wish I Had Known….

Asked if there was anything he would have liked to have known when he started taking cancer patients, Stiefell said:

"I think what would have been interesting would have been for someone to ask me, 'What is going on with you when you talk to these patients? Tell me what happens to you when you encounter this patient. What are you afraid of? What did you try to avoid? Where do you feel uncomfortable? What does it evoke in you? Do you remember somebody from your own family?

"These kinds of questions would have helped me to realize that when we talk to patients, we put a lot of ourselves into the communication. It's not just a one-way thing — it's also about us, not only about our patients," he said.

The position paper was sponsored by the Swiss Cancer League. Dr Stiefel has disclosed no relevant financial relationships.

Ann Oncol. 2018;29:2033-2036. Full text


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