Friday, July 30, 2010

Worth Reading: A Doctor on a Hard Conversation

I appreciate my readers.  One of my readers, Mark Preece, pointed me to a post at the blog dotCommonweal.  That post was a recommendation and brief comment about an article online at the website of the New Yorker.  The article, titled “Letting Go,” was written by Atul Gawande, a surgeon.  It’s an in depth article, the sort of thing the New Yorker is known for, and it’s worth the time to read.

The subject of the article is, really, the difficulty that physicians have being honest with patients when the patient faces a terminal diagnosis.  As much as anything else, the cause is that the physicians have difficulty being honest with themselves.  Having been educated to think that disease and death are enemies, many physicians are reluctant to stop therapeutic treatment even when there’s no reason to think further therapy will benefit the patient.  They’re also inclined to see a patient’s death as a defeat, and both a personal and professional failure.  But, as Dr. Gawande notes, “Death is the enemy. But the enemy has superior forces. Eventually, it wins.”  Or, as I often say, the mortality rate of being human is 100%

Dr. Gawande does speak well of specialists in palliative care, even as he raises another hindrance.  To really understand a patient’s values and to help the patient understand what is and isn’t possible or statistically reasonable takes a great deal of time.  It certainly doesn’t help that physicians are paid to apply treatments and not to really sit down and talk to a patient.  At the same time, I don’t think lack of reimbursement is the most serious reason that physicians don’t have these conversations, nor does Dr. Gawande.  Rather, it is that most physicians aren’t trained to address the personal, and certainly non-clinical issues that really shape how patients hear information and make decisions.

Dr. Gawande is honest about his own difficulties, and clear, too, in his critique of his profession.  He offers a worthwhile reflection on what makes it hard for doctors to be clear with themselves and their patients when therapeutic medicine has nothing more to offer.     


Kirkepiscatoid said...

It's interesting, Marshall. We even gear our language to "failure." I wish I had a dollar for every time I have heard one of our resdents or attendings say in our monthly Tumor Board meetings, "The patient failed therapy so we referred him/her to Hospice." Patients "respond" to treatment, and "non-response" constitutes a failure. This is a very hard thing to get across to a 30 year old resident--namely, "this isn't about you, or your doctoring skills, or the patient winning or losing."

A Deacon's Wife said...

Excellent article, but incomplete (at least to my mind) in that neither faith nor chaplains are mentioned. Both of these play a critical role.

When faced with the first cancer diagnosis conversation with her doctor, my mother stated in a very matter-of-fact way, "You know, I'm not afraid to die." She was recovering from a brain injury due to a car accident, and aggressive cancer treatment would probably have killed her. I think her MD was a little taken-aback by her candor, but Mother knew a great deal about life and death, and she made that particular conversation pretty easy for him. She spent the next eight months at home, with the support of her faith and Hospice, and died surrounded by the family she loved.

During that time I had a friend with a father in cancer treatment. In his 80's, he had an aggressive, invasive disease, and a very pessimistic prognosis. He pursued treatment after treatment, and the quality of his life could be measured in degrees of miserable. My friend confided in me that he wished his father was a person of faith, because he felt sure the determination to extend his life was fueled by his fear of death. He believed this life was all there is, and he was terrified of the end. His was not what I have heard described as "a good death."

It seems to me that some of those end-of-life conversations Dr. Gawande talks about might be more successful with the assistance of a chaplain. As he admits, doctors tend to have a singular perspective, while a chaplain (at least in my experience) tends to have a more global view of what we human creatures might need when faced with the end of our earthly lives.

It's a shame that our culture has largely decided to hide birth and death behind hospital curtains. We might all live better lives if we had a little more exposure to both.

Marshall Scott said...

Kirk, I certainly agree. The language is certainly important. This is really akin to the tendency, which we've had some success, I suppose, in changing, to speak of the patient as the diagnosis rather than by name. Especially in tertiary referral centers, which is where so much of medical education happens, it's hard to deal with patients as persons, since they don't develop relationships. Between short stays and periodic changes due to rounds, even in the moment of crisis the doctor and the patient know little about each other. For the clinician, it's too tempting to focus on what is supposed to be predictable, controllable - which is to say, the problem to be solved, not the person to be cared for.

Deacon's Wife, I certainly agree. I offer now and again to help, but they rarely want it. Interestingly enough, that seems detached from the fact that they seem genuinely glad when I am there. They know I will stay when they leave. Wise physicians involve us.