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Discussing Disease Progression and End-of-Life Decisions

Discussing Disease Progression and End-of-Life Decisions

As mental health professionals become integral members of the treatment team in many oncology settings,[1] 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 doctor’s 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 personal accomplishment.[2]

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.[2] 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 physician’s preoccupation with patient care.[3]

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.[4] 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.[5] 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 human interactions.

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 patient’s questions.[6] 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.[7] 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 1.5 minutes.[8]

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.[9]

Even more ironic is the fact that patients who are the most bothersome to the oncology staff—ie, those who demand extra information and attention, have conflicted relationships with family members, or have diagnosable psychiatric disorders—often 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 patients’ concerns.


1. Holland JC: Establishing a psycho-oncology unit in a cancer center, in Holland JC (ed): Psycho-Oncology, pp 1049-1054. New York, Oxford University Press, 1998.

2. Ramirez AJ, Graham J, Richards MA, et al: Burnout and psychiatric disorder among cancer clinicians. Br J Cancer 71(6):1263-1269, 1995.

3. Miller D, Gillies P: Is there life after work? Experiences of HIV and oncology health staff. AIDS Care 8(2):167-182, 1996.

4. Razavi D, Delvaux N: Communication skills and psychological training in oncology. Eur J Cancer 33(suppl 6): S15-S21, 1997.

5. Baile WF, Lenzi R, Kudelka AP, et al: Improving physician-patient communication in cancer care: Outcome of a workshop for oncologists. J Cancer Educ 12:166-173, 1997.

6. Stange KC, Zyzanski SJ, Jaen CF, et al: Illuminating the “black box”. A description of 4454 patient visits to 138 family physicians. J Fam Pract 46:377-389, 1998.

7. Callahan EJ, Jaen CR, Crabtree BF, et al: The impact of recent emotional distress and diagnosis of depression or anxiety on the physician-patient encounter in family practice. J Fam Pract 46:410-418, 1998.

8. Jaen CR, Crabtree BF, Zyzanski SJ, et al: Making time for tobacco cessation counseling. J Fam Pract 46:425-428, 1998.

9. Loscalzo M, Brintzenhofeszoc K: Brief crisis counseling, in Holland JC (ed): Psycho-Oncology, pp 662-675. New York, Oxford University Press, 1998.

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