Having Difficult Conversations And Staying Efficient

There is always something new in patient care every day. As a hematologist and medical oncologist, I have the privilege to take care of patients with many different diagnoses. The more patients I meet, the more personalities there are and the more I encounter challenging situations. Some of the most difficult discussions I have had with patients are the ones regarding their new cancer diagnosis or their cancer is progressing through treatment.

If there is only one patient on your schedule, then you have the luxury of spending as much time as you want with that patient. In real life, as full-time physicians, your schedules are most likely packed and probably double-booked in multiple time slots. That is usually what my schedule looks like. For the outpatient schedule, thankfully, there is usually some control over it.

When it comes to delivering bad news or having other more serious conversations, you are likely to spend more time than your schedule is set. When it is a new cancer diagnosis, your patient may be dealing with the initial shock and will likely have many questions about the diagnosis, treatment and prognosis. When it is an end stage cancer and no further aggressive treatment will be beneficial for the patient, the conversation about hospice and the related end of life care is another time that you cannot rush through.

Preparation is always important and it can drastically increase your efficiency. Imagine when you go into a patient’s room only to be handed a stack of papers about the patient’s diagnosis which you did not know about. Whenever possible, always review the patient’s chart beforehand. This is to minimize any surprises and you have an idea of what the upcoming encounter will be about. When you realize that you likely have to spend more time talking to a patient, see if you can rearrange your schedule so that you are not double-booked with another patient.

When you realize that you will have to spend extra time with a patient because of a change in diagnosis or because the patient has many questions to ask, notice what you are thinking. You may be annoyed because you think that the patient is asking too many questions which is delaying your day. You may be sad because the previous chemotherapy was not effective. You may feel helpless because no matter what you do, according to the standard recommendations, the patient is getting worse. No matter what emotions you are experiencing, acknowledge them. Ask yourself what you are thinking that is causing how you are feeling. The patient’s situation does not affect how you feel. How you feel is a direct result of your opinion about something, in this case, your patient.

If you are experiencing some unpleasant emotions, allow their existence. Trying to avoid them will not make them disappear. When you realize what you are thinking is causing that emotion, ask yourself if there is another way to view the situation. Once you manage your emotions, focus on caring for your patient and the patient’s emotions.

It is always important to actively listen to what the patient is saying verbally, and what the patient is not saying. Is the patient behaving a certain way because there is fear? Are they not saying certain things because they do not know what to ask or they are too afraid to ask?

Having empathy for the patients is important in any specialty. As much as you want to stay on time, you are here for the patients. Learn what the concerns are. Why are they feeling and acting a certain way? Active communication and clarification are vital to enhance the doctor-patient relationship and for you to express empathy.

At the same time, it is important to set boundaries. Set in advance how much time you plan to spend with the patient. Decide ahead what questions or topics you are focusing on, which means that other discussions are going to be put aside during that visit. The challenging but doable goal is to address the patient’s needs and be on time with your schedule, without rushing or without the patient feeling rushed. Sometimes, patients need to be redirected to the topic of discussion.

In many situations, it is essential to have teamwork. For example, if I am about to start a patient on chemotherapy, I let my nurse know in advance. After I discuss with the patient about the diagnosis and treatment plan, I will ask my nurse to set up for a chemotherapy teaching session before starting the first cycle of treatment. That is to supplement the overview of the chemotherapy schedule and adverse effects I offer to the patient. I also ask my nurse or nurse practitioner to set up the schedule for the treatment cycles. The more we can delegate and utilize our team, the more efficient we are.

In clinical medicine, most of us have a tight schedule to see patients. While it is important to stay as close to being on time as possible, the more important thing is to address what the patient needs physically and emotionally. Preparation ahead of time will allow you to know what the topic of discussion will be about with a patient. It is important to acknowledge how we feel, and realize what we think that causes how we feel. Manage our own mind before taking care of the patients. This will allow us to give the patient our full attention to actively listen and to show empathy. It is important to be mindful of the time and set boundaries to limit the discussion to pertinent questions. With patient care, it is important to coordinate with teamwork. These are the steps to care for patients who require a longer discussion while keeping your efficiency.