Abraham Verghese, MD, director of the Center for Medical Human-ities & Ethics, advocates sensitivity to patients that is part of medical education at the UTHSCSA.
How can physicians promote patient involvement in ex-tremely complicated decisions?
Preserving the patient’s autonomy is one of the cornerstones of bioethics. We have to ensure that the patient is well-informed and able to make a decision after hearing all the pros and cons of different approaches and treatments. Medicine is much less paternalistic than it used to be, and the attitude of “we know what is good for you” is a way of the past, or should be.
Every year we bring in Dax Cowart, who was severely burned in the early 1970s, to talk to our students. Dax survived horrible burns and is blind and lacking both hands. During his hospitalization, this active former fighter pilot and high school football star begged not to be treated, and just allowed to die. But his wishes were overridden and he suffered through a series of agonizing treatments against his will.
He has gone on to become a lawyer and now travels about the country explaining why he should have had the right, as a competent adult, to decline treatment. Not to ask anyone to help him die, but just to decline treatment. He tells the students, “Don’t get me wrong. I am happy to be alive. But the ends don’t justify the means.” Today, he could not have been subjected to treatment against his will.
Language can be a barrier and requires us to work extra hard to convey the choices involved. In some cultures, patients tend to defer too much to their physicians. It is important to convey to patients that the decision is ultimately theirs. As physicians, we must respect the decision even if it seems a poor one medically. An example is a Jehovah’s Witness patient whose beliefs prohibit having a blood transfusion. This patient must clearly understand the implication of the decision and the life-and-death issue involved, but if the choice is to decline and the patient is competent and not a minor, it’s a choice we must accept.
Is there a risk of making information too simple?
Definitely. We often present choices as if they are black-and-white when, in fact, there are many gray areas. The art of medicine is negotiating the gray. Evidence-based medicine and practice is great, but clearly not every patient will benefit from the recommended treatment, and the art lies in knowing which might serve a particular patient best.
What communication strategies do you think work best?
I think it’s important not to be interrupted. Having a family member present to help recall what was said is a good idea since a patient may not always remember, particularly if he or she is elderly or quite sick. We have to anticipate that a patient will not absorb all the information and may ask the same question several times. Particularly when hearing bad news, it’s common for a patient to hear only part of the message.
I have a physician friend who has a rule that he tries not to speak for the first five minutes with the patient. It’s tougher than you’d think! Our tendency is to try to quickly shoehorn the complaint into our repertoire of symptoms and ask questions to confirm our bias. Perhaps listening may be the real key to communicating well.
What are the responsibilities of the physician in obtaining consent from people with poor or limited literacy skills?
Poor literacy skill does not mean at all that the patient cannot understand the issue at hand if it is thoroughly explained. I think it’s important to read the informed consent form carefully and to explain each part to the patient to make sure he or she understands. This also ensures that we, as physicians, can be seen as very willing to answer questions.
Many patients appear to possess an adequate level of health literacy when they actually need assistance. Given a physician’s time restraints, how can you identify them? Should you ask them, or test them?
Time is so critical in modern practice. It’s very important to probe, ask questions, and make sure your patient understands what is happening, and what might happen. Often times, the nurse or physician assistant can spend more time and unearth concerns that help us if we cannot spend that time. There are nuances and consequences to every decision, and it requires an expenditure of time to make patients feel that they have contributed to that decision.
If, for example, you see a lesion on a chest X-ray that you think is old and of no consequence but you can’t be sure, you can opt for another X-ray in six months, a CAT scan now to get a better definition of the lesion, or, in some circumstances, proceed to an immediate biopsy. With each step, there is a risk of an iatrogenic complication that must be weighed against the risk of missing an early malignancy. The patient’s desires and the level of understanding of each strategy are critical. The decision to do nothing and wait is a legitimate choice, as is the decision to perform a procedure. Too often we focus on the consent for the procedure, but we also need their consent, at least verbally, to pursue a strategy that does not involve a procedure.
Do you use e-mail in your communications? What do you think are the strengths and weaknesses of e-mail in this context?
In my patient population, I don’t use e-mail much, although this doesn’t mean it is not a valid option. I think nothing can substitute for face-to-face interaction, but there may be situations for other physicians where
e-mail is an excellent option.
How can a physician appropriately address situations in which his or her medical judgment clashes with a patient’s religious or cultural beliefs?
It’s critical in these sorts of situations to empathize with your patient’s beliefs, but also to very clearly point out the medical implications of making a decision based on a particular belief that limits medical intervention. It all comes back to patient autonomy.
As an educator, is there anything you would like to add on the subject of health literacy/ communications?
I do think that communication is an increasingly important issue in medicine. With the cultural diversity we have everywhere these days, it’s important for all of us to be sensitive to others’ beliefs and concerns. At the medical school, where our course in humanities and ethics is integrated into each year of the four-year curriculum, the use of literature and film is part of our strategy to broaden cultural understanding and to enable the student to walk in the patient’s shoes. We have to be able to empathize with and serve the charlatan, the misanthrope, the saint, and the criminal equally. It would be a shallow art if we only took care of people who were like us in every way.
How do you teach medical students about communication? Even more pertinent, how do you inspire them with a desire to carve out time for communication when they have a heavy case load?
One of our great interests at the center is in the bedside examination. We believe that in this technological age, the physical exam is getting short shrift, and the skill and art are dying. You can argue that a CAT scan is better than palpating the abdomen, and it certainly is. But unless every patient is going to get that test, the abdominal exam remains important – the palpating hand might pick up something unsuspected. My sense is that a careful, skilled physical exam conveys our attentiveness to the patient at a time when many patients feel medicine is inattentive and is too willing to shunt people from this suite to that suite.
I also believe students come to medicine with a great desire to serve and a great empathy for patients – they have a great capacity to imagine the suffering of patients. We want to pre-serve that capacity even in the face of a heavy clinical schedule – when their language becomes the language of the patient chart, when there is a risk that a person can be labeled “the diabetic foot in bed three or the heart attack in bed two.” Through literature, film, and narrative, we hope to keep alive in their minds the patient’s experience and the nature of suf-fering, reminding them constantly of why they came to medi-cal school in the first place.
Our mission statement paradoxically, you might say, has nothing in it about ethics or humanities. It is: Inspiring students to discover in themselves the sensitivity, caring, and sense of service to patients that, combined with superb clinical skills, will allow them to fulfill their highest potential as physicians.
