How Doctors Can Better Communicate with Cancer Patients and Their Families

Communication between doctors and patients and their families is a fundamental aspect of treatment. Good communication not only helps build trust between doctor and patient and promote mutual understanding and sympathy, but is also beneficial to the patient's recovery. At the same time, because oncologists face death every day and are under enormous mental pressure, communication also helps relieve the psychological pressure on oncology doctors. In the current climate of frequent medical disputes, good communication also helps reduce doctor-patient disputes.

Yet most oncologists have not received professional training in communicating with patients and families; even the literature on this in libraries is very sparse. Most medical works focus only on treatment regimens, and few mention communication skills. I have encountered confusion on this in practice and have read the relevant literature; I now write down some thoughts from my reading and personal clinical practice for everyone's reference and correction.

What must first be admitted is that, before I studied this topic specifically, I did many things poorly in communicating with patients and families, and at times even caused them a degree of psychological harm; because I lacked skills training in this area, I remained unaware of it. For this I offer my deep apology and hope for the forgiveness of my patients and their families.

In the Clinical Oncology Handbook edited by Dennis A. Cascinto, the editor notes that the doctor-patient communication patients value most is the doctor's helping and guiding patients and families to build confidence and hope of overcoming the disease. This should be the consensus of almost all patients and families.

Usually, medical staff lack this awareness of needing to care comprehensively for patients and families, and lack communication with them on this front; this lack aggravates the suffering and pressure patients and families bear. This is probably also what patients complain most about regarding medical staff: patients and families often feel deeply frustrated and angered by doctors' indifferent attitude toward their psychological feelings.

From my own observation and experience, sometimes some medical staff are avoiding this kind of communication, because it is a very difficult task. Upon learning that they or their loved ones have cancer, most people's spirits easily collapse, so oncologists often face patients and families in extreme emotional lows; this easily causes the oncology staff themselves to be under excessive mental pressure and burdened with too much negative emotion.

Especially under the current situation in China where doctors are overwhelmingly overworked, the mental pressure doctors bear is too great. I have personally come across two oncologists who, under excessive pressure, attempted suicide to seek relief. For a time I myself was also very depressed, deeply despairing about life, and developed stress-induced gastric ulcers.

On this issue, my advice is that colleagues in medical work should also face up to their own mental health, find ways to relieve and release their psychological pressure, and, when necessary, seek help from psychiatric colleagues. Of course, generally speaking, as professional experience grows, most medical staff master techniques for coping with the negative emotions they encounter at work.

As for patients and their families, when you notice your doctor is in a bad mood or irritable, you should consider appropriately putting yourself in their shoes, or, when the doctor is particularly off, try switching to another doctor for communication. Rather than clashing and conflicting with each other and intensifying the painful experience of seeking care—which benefits neither your own nor your loved one's recovery.

The difficulty of communicating with mentally collapsed patients and families exists not only in China, where doctor-patient relations are poor; in developed countries such as the United States, oncologists suffer from this problem too. The Clinical Oncology Handbook even advises doctors to keep tissues handy, so that when patients and families break down in tears they can be handed a tissue; this small gesture is, for patients and families, a warm one.

Even the single issue of helping patients and families build confidence in overcoming the disease puts doctors in a quandary. As everyone knows, treating cancer—especially mid- and late-stage cancer—is a worldwide problem currently recognized by the medical community. Many patients and families are psychologically fragile and cannot bear the blow of the threat of death, and urgently hope to be cured. If the doctor blindly indulges this expectation, the wording of communication inevitably departs from the basic facts, turning the doctor into a liar.

Moreover, and especially importantly, patients' and families' emotions are uneven; while seeking medical care, they also learn about their disease through other channels. As they gradually master more and more information, those simple comforting words that help patients build confidence in overcoming the disease will greatly diminish patients' and families' trust in the medical staff.

So many times, medical staff do not know how to open their mouths or how to have beneficial communication with patients and families. When telling patients and families facts they find hard to accept, most doctors feel sad; sometimes when a patient's emotional breakdown is too obvious, some doctors even struggle for days afterward to get over the shadow. I often face weeping patients and families, and most of the time, after they leave, I find it hard to calm down immediately. During a particularly serious spell, I suffered greatly from stress-induced gastric ulcers and reflux esophagitis due to excessive depression and anxiety.

In clinical communication, medical staff should consider the following points:

• Listen first, then express

First, we must be listeners; do not rush to express ourselves, and especially should not communicate in a lecture style. We should hear what is on patients' and families' minds before deciding how to communicate next. When patients and families show emotional agitation while speaking, we should soothe them as much as possible. It is best to give enough time to patiently hear out the main point they wish to express, then, based on their specific situation, decide how to communicate with them. Medical work is very complex; the patients we face have varied personalities and are all in extreme life circumstances. Everyone's education differs, and their ability to bear bad news differs too. We need to observe carefully those we are helping; in communicating with patients and families, we should carefully observe their emotional reactions, so as not to worsen the suffering and pressure they bear and to ease their tension as much as possible.

• Respond to patients and families promptly

Some medical workers choose to evade patients' questions, which often makes patients and families anxious and restless. When patients or families have many uncertainties needing guidance, medical staff should respond to them as promptly as possible. But doctors should avoid a 24-hour working mode; if they open a 24-hour mode, few doctors would not break down. You can set fixed times to answer patients' and families' questions, and rest as much as you should when it is time to rest. You should also let patients and families know not to disturb you during rest as much as possible. I believe the great majority of patients and families receiving treatment can manage this.

• Do not lightly deny or criticize

In practice, many patients and families try treatment options that seem unscientific to doctors trained in formal medicine. In fact, the great majority of cancer patients around the world, while receiving conventional medical treatment, are also trying all kinds of other recovery methods. Some are spiritual therapies, some physical therapies, and there are many other bizarre treatments.

Early in my medical career I often criticized the various seemingly unscientific choices patients made. But after seeing more, my heart gradually calmed down. On the one hand, we of course need to provide medical education and guide patients to deal correctly with their disease. On the other hand, we should also see that patients and families are in a psychologically very fragile period. Especially for patients for whom conventional treatments have clearly failed, some choices that seem to violate common scientific sense are their last hope, the spiritual pillar by which they cope with a despairing life; denying and criticizing their choices is no different from pushing them into an abyss of despair.

An end-stage patient once wrote on Weibo: The doctor tells me on the one hand that my disease cannot be cured, and on the other that doing this is useless and doing that is useless too; how am I to cope with this hopeless life? This patient's voice is very representative. We should certainly crack down on practices that deceive patients, but at the same time, from a humanitarian standpoint, we should consider the question of the spiritual support patients need when facing death.

• Honestly tell patients and families the true condition and prognosis, and help them build a psychological support system

Patients and families have the right to know about their own or their family member's disease, and doctors have an obligation to tell them about the relevant prognosis and should not conceal it. But while telling patients the truth, we should encourage them and guide them to build confidence. At the same time, guide and help them build a psychological support system. Generally, patients need psychological support from relatives, friends, doctors, social workers, and even religious clergy.

Doctors, as scientists, often find it hard to accept religious clergy. But in clinical practice we often encounter theistic patients, or some atheists who become theists after falling ill; they have received beneficial psychological support from religious clergy. We must admit that, before the threat of cancer, people are very fragile and helpless, their hearts utterly collapsed. For many patients, without religious faith they would live in even greater collapse.

Some patients, upon learning they have cancer, easily withdraw from society. I believe it is very necessary for doctors to encourage patients to build healthy interpersonal relationships and encourage them to relieve the pressure of illness within normal living and working environments.

In fact, patients who are willing to participate in building interpersonal relationships also tend to live longer, while those who, after cancer, withdraw from society due to extreme emotional swings—even to the point of their family quickly falling apart—have relatively shorter survival. Generally, younger patients are more prone to extreme life upheavals after a cancer diagnosis, such as divorce or broken relations with family. I have rarely seen middle-aged or elderly patients divorce quickly after cancer, but it happens often in younger patients. Of course, one cannot rule out that the breakup of some bad family relationships may instead make some patients feel relieved and better suited to treatment.

The shock of a major life upheaval often leaves one at a loss, doubting life, and with a very unstable personality in the short term. In consultations, doctors should try to help patients and families dispel some negative emotions; while soothing the patient, also soothe the patient's spouse and parents; guide the patient's family to give the patient as much care and understanding as possible, and together with the family build a spiritual support system for the patient.

Doctors should also guide patients to understand cancer correctly, dispel some of their incorrect beliefs about it, and advise patients not to blame others for their illness. From my own observation, most patients who divorce after illness do so because of long-standing grievances in the marriage, and also because of short-term stress disorder in the patient and family.

• Develop the treatment plan together with the patient and family

The treatment plan should involve the patient and family. Where the patient and family fully trust the doctor, the doctor can actively formulate a treatment plan, inform them of the advantages and drawbacks of the various options without exaggerating or evading the weightier matters, and then develop a comprehensive plan together with the patient.

Generally, such a plan is readily accepted by patients and families, and if unexpected accidents arise during treatment, they are more easily supported and understood by the patient and family.

Strictly speaking, the great majority of today's cancer treatment regimens can only be counted as clinical trials; we must be clearly aware of this. Compared with other diseases, the odds of successful cancer treatment are not great. If patients know in advance the benefits, drawbacks, and risks of the various options and, knowing all this, carefully make certain decisions, then when they encounter side effects and accidents during treatment they are more likely to accept them and cooperate much better.

• When treatment plans conflict or the patient dies suddenly

When a treatment plan runs into conflict, the doctor should, as far as possible, give the patient a reasonable explanation rather than blindly shifting blame. Soothe the patient's and family's tense, anxious emotions. Seek as much as possible to win the patient's understanding of the plan.

When a patient dies suddenly, the doctor should promptly comfort the grieving family. For ordinary people, the death of a loved one is the greatest event in life; facing the explosive emotional change in the patient's family triggered by such a death is an unavoidable thing in a doctor's professional life. Sometimes families behave extremely, and the doctor should comfort them from the standpoint of a sympathizer. Often at such times, the doctor's avoidance instead inflames doctor-patient conflict.

Entering the medical profession means being destined to bear a certain amount of risk. Because we deal with human life, at the moment a loved one's life slips away, few people remain calm. We must give understanding and sympathy; generally, with the passage of time, most families gradually calm down within a few days and do not take extreme actions against the staff.

• Humanitarian care in the end stage

Most cancer patients, at some stage of treatment, inevitably enter the end stage, when few medical means remain available. Because most Chinese residents lack death education, there are often end-stage patients or families who still cannot give up and demand treatment.

On the one hand, the doctor should guide the family to recognize and face objective reality; on the other, the doctor may consider giving the patient some less financially burdensome palliative treatment, trying to soothe the patient's physical pain while also easing their despair. In fact, one of an oncologist's tasks is helping people leave this world with dignity and relatively little fear.

In my early days in oncology, I too found it hard to accept this fact, and each time a patient died I was badly shaken. But as I gained more experience, my mindset gradually stabilized. For some gravely ill patients, the doctor truly has more heart than power, and can only offer the patient and family some care and help from a humanitarian standpoint.

• Dealing with difficult patients and families

Around the world there are widely scattered difficult patients and families who behave stubbornly, some even paranoiacally, or with violent tendencies. When the doctor's treatment cannot meet their expectations, they often resort to harassing or retaliating against the doctor, which is an important cause of the many doctor-patient disputes. According to statistics, about 15% of the patients each doctor sees are such difficult patients and families.

There are many reasons for difficult patients and families. On one hand, there are psychological or personality problems on the part of patients or families—for example, some alcoholic patients or family members may be harder to reason with than others, and some patients or families with personality disorders may also behave in ways that are tricky for the doctor.

On the other hand there are doctor-side reasons: some doctors are careless, some are unprofessional, and some are overtired, so when seeing such patients they may behave in ways that disappoint the patient and family, then mishandle the subsequent relationship, gradually making the relationship tenser and the patient and family more difficult.

There is also an institutional reason: the current medical system requires doctors to see patients "faster and more," which guarantees no communication time between doctor and patient and leads to very inadequate communication.

Commonly, some doctors ignore these difficult patients' problems or push them off onto other doctors; neither is a good approach. Condemning difficult patients or families is even more likely to inflame conflict. From news reports of doctors killed by patients, most such incidents involve difficult patients and families; and the handling by the doctor involved may also have been improper.

We must admit that the medical profession inherently carries the risk of dealing with difficult patients and families. When such problems arise, the best approach is to ask psychiatric colleagues to collaborate and jointly help such patients. Before similar conflicts occur, we should try our best to help the patient and relieve their psychological and physical suffering.

For some difficult patients who are poor (it cannot be denied that a considerable proportion of difficult patients have financial hardship), during treatment, giving appropriate financial assistance so as not to make them develop hatred toward doctors is also one way doctors give back to society. To do the opposite is very likely to bring about one's own violent death.