“I am so sorry you have ovarian cancer,” the young doctor told a friend of mine. “I was really hoping to take your college course, but I guess I won’t get to now.”
Even if, in the end, the patient did not have ovarian cancer–which she did not–this is a dreadful way to break news to a patient.
Does it matter what doctors tell patients?
Dr. Lawrence Weed thought it did. “IN NO PLACE IN THE AMERICAN RECORD DO WE HAVE AN ORGANIZED APPROACH TO WHAT WE ARE GOING TO TELL THE PATIENT,” he told a group of doctors at his famous medical grand rounds at Emory University in 1971.
In his lecture, he offered a revolutionary systematic approach to patient care. Every note should follow a rubric: for each problem, he said, the patient’s subjective symptoms, the tests that had been ordered, the assessment and the plan should be carefully documented.
Moreover, he explained, the plan should have three parts:
1/ What the doctor’s differential diagnosis is;
2/ What the doctor is going to do to treat the patient; and lastly,
3/ What the doctor is going to tell the patient.
For example, he asked: for the patient with newly diagnosed hypertension–does the doctor tell her it is serious or not serious? Does the doctor tell her how he or she is going to study it, or whether the plan is NOT to study it–and the reasons for those decisions?
What doctors tell patients is critical.
But training in this area–if reading medical records and reviewing myriad medical appointments is any measure– remains just as neglected in medical education and practice today.
A recent article describes this component of the plan as “patient counseling and education.” But it is really much more than that. It is sharing the roadmap with the patient, acknowledging that each patient is unique and that the physician is really a sort of guide… “not,” Dr. Weed adds, “an oracle that knows all the answers.”
“Medicine,” he said, “is like a chess game; the doctor makes a move; sees what nature does; then makes another move; and so on.”
One patient I advocated for saw an endocrinologist who took the time to explain to her what hypothyroidism was and why hers might be challenging to treat. She had been diagnosed with the condition at age five. The patient said, incredulously, this was the first time–at age 22–that anyone had taken the time to tell her what the disease is and how she should treat it. She was so very grateful. And newly empowered.
This is the art and practice of medicine.
I once asked at a clinic appointment for a patient who was about to undergo a kidney transplant, who was the most important part of the medical team?
“The patient,” answered the nurse.
“Was that the right answer?” she asked me.
I think the right answer is–everyone. The whole team. And the team includes the patient. But the most important team member is sometimes left out of the play. That is a mistake.
Doctors need to develop a more organized approach to what to tell patients; and it should be part of medical training, so that excellent communication isn’t the exception, but the rule. If your doctor doesn’t share this roadmap with you–ask him or her to do that: “What is my diagnosis? How are you going to treat me? Why? What are the alternatives?” This is something worth asking your doctor to do. And you will improve your medical care, and his or her training, in the process.
