Every patient is different. Like a detective, the physician looks for clues to solve the mystery presented by each person's concerns, evidence of disease and health threats. The doctor analyzes symptoms and physical exam findings, orders appropriate tests, interprets results and considers treatment options. And at every step, this perceptive physician must build a health care plan with the patient -- explaining it all in simple language. Today's well-read patients come armed with opinions that need to be discussed. And so the doctor and the patient form a partnership. It's a new kind of patient-focused care that requires much knowledge and skill on the part of physicians.
The Osler Center teaches physicians the strategies that work. It shows them how to feel comfortable with the collaborative process, including hooking patients up with the right consultant. It emphasizes good communication among all the people involved in each patient's care. Finally, it helps doctors learn the techniques of fostering attentive, compassionate staff.
The Art of Sharing a Tough Diagnosis
Scene: Primary care doctor's office. An 82-year-old woman returns to her physician following blood work to learn why she had lost both her appetite and 10 pounds in a month. It has been unsettling to wait for the results while anticipating bad news. The challenge for her doctor is how to relate the fact -- in a sensitive manner -- that she has chronic lymphocytic leukemia.
Before the Visit: The physician has considered how the patient and her family may take the news and how it may affect her life, which until now has been independent and active. Anticipating their concerns, the doctor has reviewed the data on the course of the disease, and the value and side effects of treatment. He has thought about which cancer specialists and support groups he might suggest to her.
Reaching Out: The physician emphasizes with the patient about the difficulty of waiting for the test results. He shares the results with her, and waits while she absorbs the news. He listens carefully as she expresses sadness and concern. Then he assures her that he will take responsibility for coordinating excellent care. The patient had realized that cancer was a possibility, but wants to know about the accuracy of the blood tests. She wants to know what the time course of the disease will be, and her likelihood of becoming disabled and dependent. She has heard about bad side effects from chemotherapy.
Moving Forward: The doctor responds to the patient's concerns. Sharing the latest data, he is able to be appropriately reassuring. He recommends a cancer specialist and a support group. He gives her a brochure on chronic lymphocytic leukemia that he has found helpful. Together they agree on a follow-up appointment, after the referrals, to ensure that she understands and is satisfied with her care, and receives the emotional support she needs. The physician makes sure she has access to him and his staff, in case questions or obstacles arise in the meantime. With her he arranges to talk to family members. His staff assists her in making the appointment with the cancer specialist and, with her permission, arranges for a member of the support group to contact her.
Scene: A 49-year-old overweight man with high cholesterol, mildly elevated blood pressure and a family history of heart disease and diabetes arrives for the second visit with his new doctor. During the previous visit he seemed unfazed by his obesity and sedentary lifestyle. His doctor decides to use this opportunity to better understand his patient's perspective and to mutually identify realistic goals for changes in lifestyle. Based on experiences with other doctors, the patient expects to get a lecture and unrealistic recommendations for change.
Before the Visit: The doctor thinks about how to approach the patient on these sensitive and difficult issues. She recognizes that impersonal lectures on diet, exercise and risks of obesity don't work. The doctor decides to bring up the subject cautiously, and to find out more about what the patient knows and wants to accomplish.
Reaching Out: The doctor asks the patient about his life, family and work. She asks about his understanding of his risk factors and past attempts to modify them. She compliments him on his previous efforts, noting that most successes take several attempts, and even small changes are beneficial.
Moving Forward: The doctor corrects some misconceptions and provides new information for the patient to consider. Together they explore future options for exercise and dietary change.. The patient agrees to see a nutritionist with his wife, who does the shopping and prepares most of the meals. He says he will contact a gym near his work place. The patient and doctor agree to a follow-up appointment in four weeks.