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1 hour ago
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Some time ago, a judicious and considered surgeon was describing the complex operation required by our mutual cancer patient. The operation necessitated a large incision, prolonged anaesthesia and possibly a second operation. Then there were the long-term complications, including pain and disfigurement. The patient was elderly and somewhat vulnerable to begin with, so just listening to the plan filled me with consternation.
So, without telling him how to do his job, I asked politely: “What does the patient want?”
He looked at me as if I was disturbed before saying: “She wants to live. Isn’t that what everyone wants?”
His question needed no reply because I knew that he knew that, in keeping with the evidence, many of our shared elderly patients emphatically chose quality of life over longevity.
But I had reason to wonder if the patient had told the surgeon the same things she had told me over a consultation that had taken the best part of an hour. We had delved into her values, what mattered to her, and how she wanted to live the rest of her life. Living longer with the distinct possibility of a loss of independence had not been on her wishlist.
This made me reflect on the information asymmetry between what patients told their oncologist or GP, and what they told their surgeon, which leads to substantially different treatment plans, neither “wrong” but each consequential in its own way.
It has been traditionally assumed that patients expect the “listening” part of their care to be undertaken by physicians and leave the “doing” part to surgeons. As if to underline the disheartening public belief that a surgeon’s technical prowess must come at the cost of good bedside manner, a cardiologist friend recently recalled in the New England Journal of Medicine that when she told a patient he needed a heart valve replacement, he said: “I want the biggest asshole ever.”
Really? Why?
I wasn’t around to see how the average surgeon behaved 50 years ago but was lucky to be taught by one or two who were models of excellence in and out of the operating theatre. The narrow view of surgeons as technically adept and otherwise lacking seems anachronistic and ill-deserved, not to mention unhelpful for patients who should expect holistic care from all their providers.
So what do patients really want from their surgeon?
A recent study provides some answers.
Patients value surgeons who provide emotional support and optimism, balancing facts with empathy and recognition of the emotional burden of illness. They want their surgeon to discuss the long-term impact of treatment, especially quality of life. They appreciate being shown commonly available tools such as decision aids, graphics and plain language information.
Some patients want to defer decisions to their surgeon but many seek shared decision-making, which involves the fine art of melding professional knowledge with respect for the patient. Patients are increasingly aware that optimal decisions about cancer care require multidisciplinary input. A collection of surgeons and oncologists will focus on the disease but add in nursing, allied health, social work, dietitian, interpreter and palliative care and, suddenly, the whole person comes into view.
Finally, some interesting findings about prognosis. Most patients want to know “the numbers”. How long do they have and is it more or less than other patients? Given the vagaries of the (incredibly intelligent) human body, this is a tough ask for any doctor. What makes it harder is that patients want to know the good news but not necessarily the bad.
For instance, the high cure rate after surgery of many early detected cancers is good news for a surgeon to give.
But advanced cancers have a guarded prognosis that partly depends on their molecular fingerprint. This discussion requires an oncologist’s nuanced knowledge about the plethora of drugs, their distinct side effects and the trade-off between risk and benefit. Unless one has prescribing experience, it is hard to convey what treatment might feel like. Now, one can appreciate how a well-intentioned conversation about prognosis can quickly descend into unfamiliar territory for the surgeon.
I wonder if successful surgery is easier to visualise than a successful conversation. Patients often mention the long and involved nature of their surgery and feel happy that the surgeon “got it all”. But difficult conversations never seem to get it all – there is always something left untapped, unsaid, unfulfilled, that one might discover the next week or the next year. One of the hardest things I find about being an oncologist is when patients express delayed disappointment with how they were spoken to when they were at their most vulnerable: it is an opportunity lost.
It is said that from those who are given a lot, a lot is expected. It is entirely reasonable to be in awe of surgeons for their extraordinary commitment to training (commonly 15 to 20 years post high school), physical stamina and mental agility – but then we also want them to be like the person next door, easy to talk to.
Studies like this tell us what patients want. They also reaffirm the need to raise expectations and train future surgeons in communication skills to deliver.
After our chat, my surgeon colleague went back to the patient and asked what she wanted. She decided that the proposed multi-hour, multi-team feat was not in her best interest and was content with doing less (but not with doing nothing).
Having taken the time to understand her goals, he cancelled her surgery. The 87-year-old patient subsequently asked me if the surgeon (half her age) was “hurt” by her stance.
No, I said. We were there to serve her needs, not the other way around.
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Ranjana Srivastava is an Australian oncologist, award-winning author and Fulbright scholar. Her latest book is Every Word Matters: Writing to Engage the Public
