{"id":43081,"date":"2018-09-21T11:30:56","date_gmt":"2018-09-21T10:30:56","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/?p=43081"},"modified":"2018-10-01T13:05:46","modified_gmt":"2018-10-01T12:05:46","slug":"reginald-hall-talking-with-the-patient","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2018\/09\/21\/reginald-hall-talking-with-the-patient\/","title":{"rendered":"Reginald Hall: Talking with the patient"},"content":{"rendered":"<p class=\"standfirst\"><span style=\"font-weight: 400\">Most doctors are very good at talking to the patient, but not so good at talking <em>with<\/em> them\u00a0<\/span><\/p>\n<p><!--more--><span style=\"font-weight: 400\"><img loading=\"lazy\" decoding=\"async\" class=\" wp-image-43099 alignleft\" src=\"https:\/\/blogs.bmj.com\/bmj\/files\/2018\/09\/reginald_hall.jpeg\" alt=\"\" width=\"131\" height=\"162\" \/>Hearing the doctor say, \u201cI\u2019m sorry, it\u2019s not good news: it\u2019s cancer,\u201d is almost always devastating and for those who hear it life is seldom the same again. Although many improvements in the treatment of cancer have been achieved and the causes of some cancers are better understood, the &#8220;Big C&#8221; can still seem a formidable and lonely mountain to climb. Very often a cancer diagnosis means dealing with uncertainty, anger, fear, grief, loss of control, faltering self-confidence\u2014so many emotions and practical problems that people who have not had cancer never understand.<\/span><\/p>\n<p><span style=\"font-weight: 400\">What is it like to discover you have a possibly fatal disease? What does it feel like to go home from hospital to tell the family? How will I manage if I lose my job and struggle financially\u2014all because of cancer? Do the doctors realise how many sleepless nights I spend waiting for the result of the biopsy? Does anyone care how hard it is to share my fear with the people I love most? Am I going to die? I accept that I\u2019m going to die but what will it be like? Questions such as these are discussed only rarely in the surgeon\u2019s office or the oncology clinic. <\/span><\/p>\n<p><span style=\"font-weight: 400\">When I edited a book on the management of bladder cancer, the draft of the final chapter was titled, &#8220;Talking to patients about bladder cancer.&#8221; I knew there was something wrong with the title but I couldn&#8217;t figure out what it was. Then one night it came to me:<\/span> <span style=\"font-weight: 400\">most doctors are very good at talking <\/span><i><span style=\"font-weight: 400\">to<\/span><\/i><span style=\"font-weight: 400\"> the patient, telling them the diagnosis and describing treatment options, but not so good at talking <\/span><i><span style=\"font-weight: 400\">with <\/span><\/i><span style=\"font-weight: 400\">the patient. <\/span><\/p>\n<p><span style=\"font-weight: 400\">The comedian, television personality, and palliative care specialist, Bob Buckman, described the situation precisely: the interview with the patient has two components. <\/span><\/p>\n<p><span style=\"font-weight: 400\">\u2022 Divulging of information by the professional to the patient.<\/span><\/p>\n<p><span style=\"font-weight: 400\">\u2022 A therapeutic dialogue during which the professional listens to, hears, and responds to the patient\u2019s reaction. <\/span><span style=\"font-weight: 400\"><a href=\"#_ftn1\" name=\"_ftnref1\">[1]<\/a><\/span><\/p>\n<p><span style=\"font-weight: 400\">When facing end of life and critical management decisions, Atul Gawande, the 2014 Reith lecturer, passed on guidance he received from a palliative care colleague: \u201cA family meeting is a procedure, and it requires no less skill than performing an operation. We focus on laying out the facts and the options but that\u2019s a mistake. Arriving at an acceptance of one\u2019s mortality and a clear understanding of the limits and possibilities of medicine is a process, not an epiphany. The process requires as much listening as talking.\u201d \u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400\">Before decisions can be made, certain questions need to be answered: \u201cWhat does the patient understand their prognosis to be? What are their concerns about what lies ahead? What kinds of trade-offs are they willing to make? How do they want to spend their time if their health worsens?\u201d<\/span><a href=\"#_ftn2\" name=\"_ftnref2\">[2]<\/a><\/p>\n<p><span style=\"font-weight: 400\">As a volunteer at a cancer support charity, I spend several hours each week talking with people about their cancer and about dying. It still surprises me that, as they leave, so many say, \u201cI feel so much better having been able to talk about it.\u201d I have the luxury of holding these conversations in the comfort of a quiet sitting room over a cup of tea with a box of tissues at hand. Practising clinicians have to do it in the middle of a busy clinic but, as Buckman pointed out, <\/span><span style=\"font-weight: 400\">the conversation can be therapeutic<\/span><span style=\"font-weight: 400\">. <\/span><\/p>\n<p><span style=\"font-weight: 400\">Clinicians spend most of their time taking a meticulous history; examining the patient; reviewing scans; attending the weekly MDT meeting; planning, undertaking, or supervising treatment; writing letters. But s<\/span><span style=\"font-weight: 400\">pending time talking<\/span><span style=\"font-weight: 400\"> with the person and their family should be regarded as an equally important part of their management. <\/span><\/p>\n<p><span style=\"font-weight: 400\">Talking can be therapeutic and is the first part of the healing process. Taking the time to listen to the patient\u2019s experience of their cancer is time consuming but is, I would suggest, essential, and should be factored in when planning work schedules.<\/span><\/p>\n<p><span style=\"font-weight: 400\">As clinicians whose prime objective is to cure, or at the very least, to prolong life, discussions about the end of life can be daunting\u2014even an unwelcome admission of failure. For this reason, it is quite possible to focus on the quantity of survival rather than its quality. With the patient or their family pressing for everything possible to be done, it is all too easy to accede to their requests and prescribe yet more chemotherapy rather than address the difficult task of talking about dying.<\/span><\/p>\n<p><b><i>Reginald Hall<\/i><\/b><i><span style=\"font-weight: 400\"> is a retired consultant urologist and previously director of the Northern Cancer Network. His book <\/span><\/i><span style=\"font-weight: 400\">Connecting with Cancer,<\/span><i><span style=\"font-weight: 400\">\u00a0 which received the Council Chair&#8217;s Choice Special Award at the 2018 BMA Medical Book Awards, is based on his experience as a volunteer at Cancer Connections, a cancer support charity in the North East of England.<\/span><\/i><\/p>\n<p><b>Competing interests<\/b><span style=\"font-weight: 400\">: None declared.<\/span><\/p>\n<p><a href=\"#_ftnref1\" name=\"_ftn1\">[1]<\/a><span style=\"font-weight: 400\"> Buckman R. &#8220;<\/span><i><span style=\"font-weight: 400\">Breaking bad news \u2013 a six-step protocol.&#8221;\u00a0<\/span><\/i><span style=\"font-weight: 400\"><em>How to Break Bad News: A Guide for Heath-Care Professionals<\/em>. Papermac, London; 1992: pp.54-81<\/span><br \/>\n<a href=\"#_ftnref2\" name=\"_ftn2\">[2]<\/a><span style=\"font-weight: 400\"> Gawande A. (2014) &#8220;<\/span><span style=\"font-weight: 400\">Letting go<\/span><span style=\"font-weight: 400\">.&#8221;\u00a0<em>Being Mortal: Illness, Medicine and What Matters in the End<\/em>. Profile Books, London; 2014: pp.181-182<\/span><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Most doctors are very good at talking to the patient, but not so good at talking with them\u00a0 [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/blogs.bmj.com\/bmj\/2018\/09\/21\/reginald-hall-talking-with-the-patient\/\">More&#8230;<\/a><\/p>\n","protected":false},"author":1,"featured_media":43082,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[223],"tags":[],"class_list":["post-43081","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-guest-bloggers"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.4 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Reginald Hall: Talking with the patient - The BMJ<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/blogs.bmj.com\/bmj\/2018\/09\/21\/reginald-hall-talking-with-the-patient\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Reginald Hall: Talking with the patient - 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