Alberta Cancer Foundation

Bedside manners becoming common practice in oncology

bedside_story The television dramedy House, won awards and had viewers in the millions worldwide laughing at the folly of its fictional main character, Dr. Gregory House, a medical genius known for his arrogant disdain for his patients’ emotional life. The show ran for eight years until 2012, with the central character unwavering blunt in his disinterest of his patients’ feelings. But in real life, such failure in bedside manner is no laughing matter, especially when it comes to delivering bad news. Fortunately, for doctors and patients alike, sensitivity can be learned and there are experts tasked with training medical professionals in bedside manner. “Part of what we learn is that some people are better communicators than others, but all of us can improve. It is a skill that’s no different than starting an IV – it is something that is on continuous improvement,” says Diane Severin, associate clinical professor and acting director of oncology at Edmonton’s Cross Cancer Institute. “Even if you are good, you can always be better.”

A good doctor will take whatever time is necessary for a patient appointment that’s going to include bad news.

Through Severin’s career, she has trained to facilitate courses that help doctors learn the steps and subtleties of communicating – offered through the Institute for Healthcare Communication (IHC). The inclusion of courses on bedside manner for young medical interns is seeing a heavier emphasis. It was once a commonly-held belief that communication skills could not be taught: they were natural talents – inborn attributes of the “good doctor” – and a young doctor was either endowed with them or not. On the flipside, some new doctors who are naturally caring individuals feel insecure about exploring both their own and their patients’ emotions because they are concerned it could cloud their objectivity in critical situations. Severin says that even veteran medical professionals can unknowingly use language about a patient’s disease as though it is separate from the person. “The important factor and premise of all communications courses is learning to respect every person as an individual. They are not just a rectal cancer to be treated, they are Julie Smith, and we teach techniques to show we’re thinking about how it is affecting them,” Severin explains. “You might say the right words, but if you are not seeing them as a person, you are not travelling with them on that journey, they are going to know.” She points out that poor bedside manner does not just lead to patients feeling hurt, but bad communication can also create angst for families coping on limited resources, or lead them to make treatment decisions based on poorly understood information. For doctors, poor communication could lead to allegations of malpractice, and otherwise good physicians can burn out. In fact, in a 2007 Journal of the American Medical Association study, researchers at McGill University in Montreal found the scores on a communication assessment in medical school could predict a new doctor’s future patient complaints. Those who were perceived as condescending or flippant had the highest number of patient complaints about 10 years later. Dr. Peter Venner, a doctor at the Cross Cancer Institute in Edmonton is not surprised. “Sometimes when we find out patients are unhappy with their care, primarily it is communication,” says Venner, who mentors younger doctors, and is praised among patients and peers as having an especially kind approach in delivering grave facts. “It is a tremendous responsibility and change in a young doctor’s life. They finish their life in training as residents, and the next day they’re responsible. Suddenly the rubber is hitting the road and they are the ones responsible for having those discussions. Hopefully we have taught them how to do that,” Venner says. Communications courses sometimes include actors portraying patients in a variety of scenarios and students participating in a role play, Severin says. The young recruits learn from one another when they watch the recorded role play and receive feedback – both good and bad. “Medical schools are doing a much better job teaching communication these days,” she says. Severin and Venner say a good doctor will take whatever time is necessary to ensure an unhurried atmosphere for a patient appointment that’s going to include news of a terminal diagnosis. Both have heard tales of doctors blundering through the exchange with subtle actions like checking their watch, and standing over the patient or near the door to send a signal that they are not ready to invest anything more into the patient. If anything, a compassionate discussion is everything that the doctor can offer, says Venner. “When treatment stops working or doesn’t work at all, we have to tell them their life will be shortened because of cancer,” he says. “Patients and their family are very much involved in all the decision-making and must be in a position of knowledge. They have to know in terms that they can understand what the situation is and each step likely to follow.” Regardless of a patient’s religious beliefs, says Venner, “peace” is a term that seems to be universally used to describe the moment when they grasp the truth. Venner emulates the bedside manner techniques pioneered by Dr. Robert Buckman, a British-Canadian expert on doctor-patient communication. He was an oncologist at Princess Margaret Hospital in Toronto until his death in 2011, and was a key influence behind medical schools’ curricula including courses on bedside manner. Buckman authored 14 books, and was a popular keynote speaker at medical conferences because of his ability to add humour to dry subject matter. He produced more than 45 humour-driven medical information videos with comedy actor John Cleese, whom he first met while performing comedy at Cambridge University. While patients will often resort to humour as a natural defense to break tension when hearing bad news, the doctor shouldn’t initiate a light approach, says Venner. However, he has often followed suit and shared a laugh with patients and their family who have heard dark news moments before, but cope by casting a one-liner to ease the sombre mood. Venner is careful to adopt an appropriate tone. He will ask the patient how much detail they want in terms of estimated life expectancy, and expresses time left in terms of the potential for future events, such birthdays or holidays on the horizon. He also avoids interrupting a patient, and makes eye contact, while sitting on the same level. If family members or friends are present, he addresses everyone, but primarily focusses on the patient. Sometimes patients have become angry at hearing bad news, and the doctor – as the messenger – will become the target for hostility. But these are not among the worst-case scenarios for doctors, say Venner and Severin. Radical denial is the most challenging scenario, especially when the patient refuses traditional care that could prolong life. Sometimes they refuse to deal with or discuss the prognosis because alternative practitioners have advised positive thoughts will heal them, and negative thoughts will cause cancer to become worse. Sometimes patients can feel extraordinarily guilty and responsible for causing their own disease, says Severin. Meanwhile, family members can indefinitely delay dealing with the loss of a loved one if they are forbidden to speak about it while the patient is still alive, she adds. In one instance in Venner’s experience, family members of a terminally ill patient for whom English was a second language attempted to shield their loved one from the truth, and used misleading translations so the individual thought his cancer was manageable. But their efforts inadvertently thwarted his chance to make a final visit to Asia to visit family. Doctors may not meet everyone’s expectations, but the skill and effort invested in their caring words have the power to make an indelible impression on patients, their families, and their friends. Executed badly, patients may never forgive a doctor. Done well, they may never forget it. During a Christmas shopping trip to the mall, Venner was waiting in his parked car when he was startled by a knock at his window. Venner assumed it was another driver investigating the potential of snagging his spot. Instead, it was a female family member of a patient who had died years ago. Recognizing Venner, she approached him to thank him for his kindness during the most difficult time of her life. “I was thankful I was able to make that difference,” he says.