If I Paint a Rosy Picture, Will You Promise Not to Cry?

These are powerful words, and it is impressive how very much we want to say them. The patient is in distress. The physician’s voice is calm, reassuring. “You’re going to be OK. I’m a doctor. I know.” If only our words could make it so. I was listening to this conversation between a patient and a physician who had never met him before and who had no idea why the patient was in the hospital. We were doing some quality improvement work and had stopped to talk to a patient about his experience. The patient had a gauze dressing wrapped around his head and could not remember how long he had been in the hospital. He said he was tired. He very much wanted to go home. Could we tell him when he could leave? Could we tell him whether he was going to be OK? Maybe being an oncologist leads me to expect the worst, but I thought that the memory loss and bandage were not necessarily good signs about his prognosis. I pulled his nurse aside and asked what the diagnosis was. He had pancreatic cancer and had just had a brain metastasis resected. Maybe he was not going to be OK. The urge to reassure can get us into trouble. It is a major impediment to caring for our patients empathically, although it seems like such a caring and benign impulse. Soothe people, make them less upset, show them great confidence to maintain their hope and peace of mind. But reassurance can also be a gesture to minimize their concerns, to snuff out their expressions of suffering so that we don’t have to deal with it, an exit strategy from a more difficult, truthful, and empathic conversation. As a fellow, I saw a staff oncologist tell a patient with metastatic cancer that had partially responded to chemotherapy that she was in remission. “You’ve had a great response to treatment,” he said. “Am I in remission?” she asked. “Yes,” she was told. But she was not in remission, as she saw for herself when I showed her the scans later on. And although I value and admire my surgical colleagues, what medical oncologist has not silently cursed a surgeon for telling a patient “I got it all,” leaving us to explain the mystery of the recurrence. I imagine it feels good to utter these words. They are very reassuring. Another version of, “You’re going to be OK. I’m a doctor. I know.” But the surgeon often is not there to answer the patient’s complaint: “But he said he got it all. What happened?” Of course, there have been times when I could not resist the temptation to prematurely or inappropriately reassure patients myself. The pitfalls of reassurance became clear to me only after fellowship training, when I attended the OncoTalk Teach program and also went through training by the American Academy of Communication in Healthcare to learn how to teach communication skills. Don’t respond to emotional distress by reassuring the patient, they said. Instead, empathize. Explore the patient’s experience. Listen more and talk less. Show our patients that we have some grasp of what they are going through. Acknowledge their emotions. Provide emotional support. Partner with them. Stay in the emotional rather than the cognitive realm until strong emotions have calmed down. When the news is bad, find a way to let patients know that you understand that their illness is terrible for them. The episode with the patient with pancreatic cancer made me wonder anew why we are so quick to reassure when it can so obviously lead us astray. Some of the answers seem clear. It is uncomfortable to be in the presence of distress, to face bad outcomes, to watch someone be upset. In oncology, our bad outcomes are profoundly bad. It is easier to reassure the patient with false hope or a change of subject. “Your cancer has spread to your liver and your brain, but I’m very excited about a new drug that’s in clinical trials, and I think we should try it. We’ve seen exciting results in mice.” We reassure because we want people to feel better, but perhaps we are also saying, “It makes me uncomfortable when you get upset, so please don’t get upset.” Or, “If I tell you that I got it all, will you promise to calm down?” Oftentimes patients collude with us. Newsweek ran an article about patients with cancer who loved their oncologists, and it described multiple cases of patients with advanced tumors who had beaten the odds against them after their physicians had refused to discuss their prognosis. Everyone loves a happy JOURNAL OF CLINICAL ONCOLOGY A R T O F O N C O L O G Y VOLUME 30 NUMBER 27 SEPTEMBER 2