As mental health professionals become integral members of the
treatment team in many oncology settings, we often find ourselves
itching to guide and comfort our medical colleagues instead of our
patients. Sometimes we have to intervene when physician-patient
communication is ineffective, mediating between angry or distressed
parties. At other times, we are silent witnesses to the depression or
emotional distancing of physicians overburdened with inhuman
schedules, Burdensome paperwork, increasing demands to produce
revenue, and the task of fighting a disease that often requires the
removal of the word cure from the doctors approved vocabulary.
Delivering Bad News and Physician Burnout
As Dr. Baile and his co-authors point out, the necessity of
delivering bad news is an important cause of burnout among
oncologists. Components of professional burnout include emotional
exhaustion, feeling depersonalized, and having a low sense of
Studies of oncology health professionals find that at least
one-quarter meet the criteria for psychological distress and burnout.
Those who perceive themselves as poorly trained to communicate with
patients are at greater risk. A large minority of oncology
physicians in one British study also reported that their work
interfered with intimate relationships and that their significant
others complained about the physicians preoccupation with
Programs that teach physicians better patient communication skills
are clearly an important part of stress management, but proving their
value to a skeptical oncology community will entail publishing
statistics that show cost-effectiveness. It is heartening to see a
collaboration between psychiatrists and other oncology specialists in
designing a program to improve physician-patient communication.
Several of the authors of this paper have also previously taken an
important step by showing that a 3-day, small-group training program
based on the SPIKES model increased physicians
self-confidence. In the future, it will also be important to
demonstrate that such training can reduce burnout among physicians
and improve patients satisfaction with their interactions with oncologists.
The Time Factor
The authors analysis of patient-physician dialogues and the use
of the SPIKES mnemonic provide a helpful guide to physicians
motivated to enhance their communication skills. It is important to
keep in mind, however, that one of the biggest barriers to improving
our communications with patients is the limited time allowed for such
A recent study of over 4,000 outpatient visits to family physicians
revealed that the average duration of such visits was 10 minutes;
this included history-taking, the physical examination, providing
feedback, planning treatment, and answering the patients
questions. If a patient reported recent emotional distress, the
visit length increased from a mean of 10 minutes to a mean of only
12.8 minutes. When patients were smokers with a tobacco-related
illness, only 32% received advice to stop smoking from family
physicians, and the duration of that advice was typically less than
With increasing economic pressures on physicians to see more patients
in less time, it is unlikely that oncology clinics are very different
from more general practice offices. Indeed, the complex, specialized
nature of cancer care means that oncologists must take more precious
time just to help the patient understand the disease and its
treatments. Niceties, such as finding a peaceful setting for a talk,
waiting until a family member can be present, or giving the patient
extra time to respond, go by the wayside. We can only hope that the
increasing attention, in outcomes evaluation, to improving patient
satisfaction and quality of life will slow the erosion of the
empathic physician-patient relationship.
Cause for Optimism
The growing collaboration between mental health professionals and
oncology specialists also provides some cause for optimism. For
mental health professionals trained in traditional psychiatric
settings, working with oncology patients can be surprisingly
uplifting. Instead of dealing with the severe, chronic distress that
often brings people to mental health treatment, one sees mostly
people with good coping skills and supportive families who simply
need some guidance in marshaling those resources to cope with a
life-threatening illness. Brief counseling in individual or group
format can help these patients and their caregivers feel in far
greater control of their lives.
Even more ironic is the fact that patients who are the most
bothersome to the oncology staffie, those who demand extra
information and attention, have conflicted relationships with family
members, or have diagnosable psychiatric disordersoften provide
the mental health professional with intellectual stimulation and a
deeper sense of involvement and accomplishment. Ideally, the mental
health professional can train oncology colleagues to communicate
effectively and avoid burnout, while remaining on-call as consultants
when brief, albeit good, communication is insufficient to allay
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