I recently gave Grand Rounds at Women & Infants’ Hospital--a women’s specialty hospital that provides some of the best care for obstetrics/gynecology in the region. It is also the home to my specialized program for women with breast and gynecologic malignancies. I spoke on delivering bad news and confronting end of life; two issues that I know as part of the job of providing comprehensive care for women with cancer.
Still, as I shaped this talk I wondered if an audience of obstetricians and gynecologists would find what I had to say relevant. Obstetrics prides itself on the process of delivery, of bringing life in to the world. Oncologists have as their career the treatment and care of patients with malignancy, and even today, it calls us to be there when patients are facing their death. In a way, then, oncology was the extreme opposite of obsetrics. As I wondered how to make it relevant, I recalled my days in medical school--and the emotional distress faced by providers and by mothers when babies were stillborn. These are still the experiences I recall most vividly today.
Delivering bad news and helping patients maintain dignity and hope are not inherent to oncology; these are embedded in all parts of medicine and must be ones that garner our attention--as part of medical school and training curricula, in lecture halls, and specialized teaching venues.
So, what did I say. I realize there is a difference between being comfortable delivering bad news and actually knowing how to do it. A study by Orgel and McCarter from UCLA Children’s Hospital illustrated that vividly (1). Using self-assessment questionnaires, they demonstrated a significant disparity between “knowing how” and “comfortable doing”—one that was present at the resident, fellow, and the attending level. So, even while the ability to engage in these discussions comfortably increased with level of experience (from less than 50% in residency to 90% at the attending level), the knowledge on how to do so increased less dramatically (from 20% as a resident to approximately 60% as an attending). I also learned that as an oncologist, we must engage patients in two levels: cognitively and affectively. We cannot rely on science and physiology in something so emotionally laden as cancer, but rather we must engage patients by how we speak and by actively listening. A good example of this is separating discussion about their diagnosis from decision on next steps/treatment- particularly in the initial consult.
I wished someone had told me how to do this as a medical student; at Rochester, I learned biopsychosocial medicine- engaging the entire patient as a person, not as a diagnosis. But I did not learn how to talk with patients at the end of life. I learned it over time, as a resident at Yale, fellow and then an attending at Memorial Sloan-Kettering. I feel we can do better though--and I think oncology can lead this change in training.
(1) E Orgel, R McCarter, S Jacobs (2010) J Pall Med 13:677-83.