cardinal rule: let your patients talk first
Even in my plastic surgery days, I would typically start my new patient encounter by inquiring as to why they were seeing me. Typically they would clearly tell me what was going on with them, but sometimes I got quizzical looks, and sometimes their response was simply: “my doctor sent me”- which showed how much they trusted their doctor.
In the current era of the electronic medical record (EMR), a new response is common: “didn’t you review my records? It’s right there”. As many hospitals now send out patient satisfaction surveys with a question about whether your provider knew about your history, this question can be fraught with unintended negative consequences for providers. So, with the advent of the EMR, I’ve had to rephrase the question a bit. But my instinct of starting with having the patient tell me what they think is going on, reflects an important communication pearl: the patient talks first.
a Patient
Mrs G, 65 yrs old, was diagnosed with colon cancer 3 years ago. Despite treatment regimens including surgery and multiple lines of chemotherapy, her disease continued to progress and is now widely metastatic. In addition, she has multiple other chronic medical conditions including diabetes and congestive heart failure. Although she tries to remain upbeat and stay active, her health issues are taking their toll; she is losing weight and becoming more frail. In fact, except for attending regular Sunday services at church, she doesn’t get out of the house as much as she used to, she’s just too tired.
At her most recent oncology appointment, the provider note mentioned a potential 4th line chemotherapy regimen, which has a small chance to lengthen her life by perhaps several weeks and comes with the potential for significant side effects. The oncologist specifically wrote that the best option for Mrs G would be to forego further chemotherapy and to concentrate on comfort/quality with home hospice support. However, he noted, Mrs G wants to continue with chemotherapy. And so Mrs G was referred to palliative medicine clinic to discuss ‘treatment goals’.
When I asked Mrs G to tell me about her understanding of her illness, she was fully aware that her disease had continued to progress despite chemotherapy. Although sad, she was accepting of the reality that she may be nearing the end of her life. Her deep religious faith gave her strength. Based on what her oncologist had told her when she was first diagnosed, she knew that if the 1st and 2nd line treatments weren’t effective, that there was little hope that further interventions would significantly prolong her life. So when her oncologist told her the tests indicated that her cancer had spread, she had expected him to say there were no other cancer specific treatment options available. She was surprised when instead he offered another potential regimen. And although Mrs G wasn’t sure she really wanted to do more chemotherapy, because he had recommended it, she agreed to start the treatment, but if the side effects were not tolerable, she would stop.
was this the same conversation?
Mrs G’s description of the conversation with the oncologist was not exactly what the provider notes relayed about their interaction. I would have loved to have witnessed their actual discussion. According to Mrs G, he had not even broached the topic of hospice-type care with her, but only talked about the possibility of more chemotherapy. I wonder, if he would have known how well she understood her disease and her prognosis, if perhaps a discussion about comfort care/hospice could have been explored, instead of heading into further chemotherapy.
So, let them talk first: and as mentioned previously, this goes hand-in-hand with ‘the emr is not always right’
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