WITHSome time ago, a thoughtful and attentive surgeon described the complex operation that our mutual cancer patient required. The operation required a large incision, long anesthesia and possibly a second operation. Then there were long-term complications, including pain and disfigurement. The patient was elderly and somewhat vulnerable to begin with, so just hearing the plan filled me with dread.
So, without telling him how to do his job, I politely asked, “What does the patient want?”
He looked at me as if I was worried before saying, “She wants to live. Isn't that what everyone wants?”
His question didn't need an answer because I knew he knew it, according to evidenceMany of our elderly patients have strongly chosen quality of life over longevity.
But I had reason to wonder whether the patient had told the surgeon the same thing she had told me during the consultation, which took the better part of an hour. We 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 losing her independence was not on her wish list.
This got me thinking about the information asymmetry between what patients told their oncologist or internist and what they told their surgeon, resulting in vastly different treatment plans, none of which are “wrong,” but each with different consequences.
Traditionally, patients expected doctors to do the “listening” part of their treatment and leave the “doing” part to surgeons. As if to highlight the depressing public belief that a surgeon's technical prowess must come at the expense of good bedside manners, a cardiologist friend recently recalled in a magazine New England Journal of Medicine that when she told a patient he needed a heart valve replacement, he said, “I need the biggest asshole in the world.”
Really? Why?
I wasn't around to see how the average surgeon behaved 50 years ago, but I was fortunate to be trained by one or two people who were paragons of excellence both in and out of the operating room. The narrow view of surgeons as technically proficient and lacking in other qualities seems anachronistic and undeserved, not to mention unhelpful for patients who should expect holistic care from all of their providers.
So what do patients really want from their surgeon?
A recent study gives some answers.
Patients value surgeons who provide emotional support and optimism, combining facts with compassion and recognition of the emotional burden of illness. They want their surgeon to discuss the long-term effects of treatment. especially quality of life. They like to be shown publicly available tools such as decision aids, graphics and information written in simple language.
Some patients want to delegate decisions to their surgeon, but many seek shared decision-making, which involves the art of combining professional knowledge with respect for the patient. Patients are increasingly aware that optimal decisions about cancer treatment require interdisciplinary input. A team of surgeons and oncologists will focus on the disease, but add nursing, allied health, social work, nutritionist, interpreter, and palliative care, and suddenly the whole person comes into view.
Finally, some interesting findings about the prognosis. Most patients want to know the “numbers.” What is their duration and is it longer or shorter than other patients? Given the vagaries of the (incredibly intelligent) human body, this is no easy task for any physician. To complicate matters, patients want to know good news, but not necessarily bad news.
For example, the high cure rate after surgery for many early-detected forms of cancer is good news for the surgeon.
But in advanced stages of cancer, the prognosis is guarded, depending in part on its molecular nature. This discussion requires the oncologist to have detailed knowledge of a variety of medications, their various side effects, and the trade-off between risk and benefit. If a person has no experience prescribing medications, it is difficult to convey what treatment may be like. It is now possible to appreciate how a well-intentioned conversation about prognosis can quickly move into unfamiliar territory for the surgeon.
I wonder if it is easier to visualize a successful operation than a successful conversation? Patients often mention a long and complex operation and are glad that the surgeon “did everything.” But difficult conversations never seem to achieve everything: there is always something untapped, unspoken, unfulfilled to be discovered next week or next year. One of the most difficult things I encounter as an oncologist is when patients express belated disappointment at how they were spoken to when they were at their most vulnerable: it's a missed opportunity.
They say that from those to whom much is given, much is expected. It's reasonable to admire surgeons for their exceptional commitment to training (usually 15 to 20 years after high school graduation), physical endurance, and mental flexibility—but we also want them to be like the person next door who is easy to talk to.
Studies like this tell us what patients want. They also reinforce the need to raise expectations and train future surgeons in communication skills to achieve results.
After our conversation, my surgical colleague returned to the patient and asked what she wanted. She decided that the proposed multi-team, multi-hour feat was not in her best interest, and was content with less effort (but not inaction).
After taking time to understand her goals, he canceled the operation. An 87-year-old patient subsequently asked me if the surgeon (half her age) was “offended” by her posture.
No, I said. We were there to meet her needs, not the other way around.
