Communicating with Cancer Patients PDF

Preface

I have written this book primarily for doctors training in oncology but hopefully to be of use also for doctors in other branches of medicine and any healthcare professional involved in explaining the complexities of cancer to patients in their care. It is not a textbook but a guide, reflecting a distillation of the experience that I have gained over 30 years as a Professor of Medical Oncology, involved in the teaching of students but especially the training of young oncologists. The individual chapters address different aspects of the challenges we all face in helping anxious patients and their families to understand what is happening to them, what choices there are, and what they may expect in the months and years following a diagnosis of cancer.

Few experiences in life compare with the devastation of being told that you have cancer. Despite all the advances in our knowledge of how to manage cancer – in its many manifestations – and the real advances in survival and most particularly the quality of that survival, the word "cancer" still strikes fear in the minds of most people and an anticipation that life is almost over.

Information about medical advances is widely available to the public through the media and especially the internet. Curiously for the individual patient, this unselected knowledge can all too often be confusing and, far from bringing comfort, can add to their distress.

In an age of ever-increasing knowledge and its ready accessibility to the public, the role of the doctor in helping patients understand their specific circumstances has never been more important. In the days when there was little to offer, the doctor's kind words, sympathy and pastoral care were all that were expected. Nowadays patients rightfully expect their doctor to have expert knowledge, the resources to implement the best possible treatment, and the ability to explain and communicate all the complexity of this in a meaningful way. To achieve this is a very real challenge – for the doctor and the patient.

Medical students and doctors in training are faced with an enormous amount of scientific knowledge to assimilate and even experienced practitioners are challenged with keeping up to date as knowledge rapidly advances. Pre- and post-qualification, a lot of emphasis is given to teaching communication skills, and correctly so, but nothing can replace the raw experience of putting this into practice. Many medical diagnoses result in illnesses that are far worse than cancer, but given the prevailing perception in the public eye, the word "cancer" seems to have a uniquely devastating impact on people.

The "art" of cancer medicine is to develop the skills to enable you to explain what a diagnosis of cancer actually means, and the "science" surrounding the management of an individual's illness, in an intelligible and empathetic way.

The book is laid out to follow the course of conversations between physician and patient that are needed at the different stages from diagnosis to death. Following the initial shock of diagnosis, patients need to understand the reason for the various investigations required to stage their disease – an essential part of selecting optimal treatment and assigning a prognosis. In the age of multidisciplinary care, patients can easily be confused as to who is in charge of their care. Every aspect of treatment – surgery, chemotherapy, radiation treatment, often overlapping or performed simultaneously – requires explanation and understanding, and each brings the patient into contact with further teams of staff. With ever-increasing success in management, the phase of post-treatment, follow-up and monitoring (so-called "survivorship issues") presents its own difficulties for patients. Fear of relapse is very common and, if and when this happens, patients can be truly devastated. Self-confidence and faith in the medical profession can be lost; you have to try to restore both. Patients may then face further treatment and in many cases eventually progression to the terminal phase of their illness.

I have written a short chapter on research. Progress can only result from research. Encouraging patient participation through explaining the reasoning behind a research study and the various responsibilities involved for both the doctor and the patient is a vital part of modern cancer care. However, the common theme throughout all these pages emphasises your prime responsibility to create confidence and reassurance for your patient. Introducing the concept of research inevitably questions current knowledge, introduces uncertain choice and, if not well explained, can undermine the impression that you have the knowledge and resources to offer the best possible care. Explaining research can be really challenging.

The final chapter discusses a few aspects of complementary and alternative medicine (CAM). I deliberately left this till last in order to encompass conversations that are almost inevitable with every patient that you will meet. However, CAM is increasingly being used and the concept of "integrative oncology" seeks to embrace CAM within conventional medicine. CAM is complex – physically and psychologically. Prescribers and patients sometimes have an evidence base on which to rely, but sometimes "belief" is sufficient. There are benefits and pitfalls and I allude to some of both of these. At each and every stage of this so-called "journey", the patient needs help to understand and, at whatever level possible, come to terms with what is happening. The interaction between doctor, patient and their family is critical and varies at the different stages of an individual's illness. I have separated these various stages into separate chapters, but of course there is continuity to the whole experience.

The advice offered is written in the form of conversations between me and a trainee oncologist. A given knowledge of general medicine is therefore assumed and the emphasis is very much on the "art of medicine" and how to practice it, rather than the "science", which is more readily taught and learned. The traditions of British medical education and training used to be based on an apprenticeship model: students learned from young doctors, and doctors in training learned from their seniors and particularly consultants or specialists. In my own experience, the benefit of being allowed to "sit in" on specialist consultations to observe the conduct of and, most particularly, the mode of conversation between skilled communicators and their patients was both a privilege and an excellent foundation for developing my own personal approach. The classic ward round where a consultant would be accompanied by trainee doctors and nurses going from bed to bed in a hushed ward where there were no visitors or other extraneous diversions may have had an element of theatre, but the opportunity to observe and listen to the conversations and method of explanation in this setting was a very important part of training in this difficult area of medicine. Hospitalbased clinical practice has changed and for a variety of reasons there are many fewer opportunities nowadays for trainee doctors to "sit in" and observe their seniors or to accompany them on the wards in the way that I have described. It is not only the older generation of doctors who regret this loss of apprenticeship in favour of much greater emphasis on doctors becoming self-taught. I hope that my reflections in these pages do not appear patronising or prescriptive. Where the "art of medicine" is concerned, every doctor must develop their own style of communication. What is offered here is intended to help trainees to develop and hone their own skills in this most challenging but rewarding practice of medicine.