After nearly 40 years as an internist, Dr. Ron Naito knew what the sky-high results of his blood test meant. And it was not good
But when he turned to his doctors last summer to confirm the dire diagnosis – stage 4 pancreatic cancer – he learned the news in a way no patient would. Naito had known for 10 years, refused to acknowledge the results of the "off-the-scale" blood test that showed unmistakable signs of advanced cancer. "
A second specialist performed a tumor biopsy, and then discussed the results with a medical student outside the open door of the exam room where Naito waited
"They walk by one time and I can hear [the doctor] say '5 centimeters,'" said Naito. "I knew what it was," Naito said last month, his voice thick
with emotion. "Once [tumors grow] beyond 3 centimeters, they're big. It's a negative sign. "
The mischievous delivery of his grim diagnosis left Naito determined to share one final lesson with future physicians: Be careful when you tell the patients they are dying. six months to live, Naito has mentored medical students at Oregon Health & Science University and was publicly speaking on the need for doctors to improve the way they break bad news
"Historically, it's something we have never been taught," said Naito, thin and bald from the effects of repeated rounds of chemotherapy. "Everyone feels uncomfortable doing it. It's a very difficult thing. "
Robust research shows that doctors are notoriously bad at delivering life-altering news, said Dr. Anthony Back, an oncologist and palliative expert at the University of Washington in Seattle, who was not surprised that Naito's diagnosis was poorly handled
"Dr. Naito was given the news in the way that many people receive it, "said Back, who is co-founder of VitalTalk, one of several organizations that teach doctors to improve their communication skills. "If the system does not work for him, who is going to work for?"
Up to three-quarters of all patients with serious illness receive news in what researchers call a "suboptimal way," Back estimated. ] "Suboptimal" is the term that is less offensive to practicing doctors, "he added.
The poor delivery of Naito's diagnosis reflects common practice in a country where Back estimates that more than 200,000 doctors and other providers could benefit from communication
Too often doctors avoid such conversations entirely, or they speak to patients using medical jargon. They are often not aware that patients are not following the conversation, or that they are too overwhelmed with emotion to absorb the information,
"[Doctors] come in and say, 'It's cancer, "They do not sit down, they tell you from the doorway, and then they turn around and leave," he said.
That's because for many doctors, especially those who treat cancer and other challenging diseases, "death is seen as a failure, "said Dr. Brad Stuart, and palliative expert and chief medical officer for the Coalition to Transform Advanced Care, or C-TAC. They will often continue to prescribe treatment, even if it's futile, Stuart said. It is the difference between curing a disease and healing of a person physically, emotionally and spiritually, he added.
"The curing is what it's all about and healing has been forgotten," Stuart said. often ill-informed. A 2016 study found that just 5% of cancer patients accurately understood their prognoses well enough to make informed decisions about their care. Another study found that 80% of patients with metastatic colon cancer thought they could be cured. In fact, chemotherapy can prolong life by weeks or months, and help ease symptoms, but it will not stop the illness
Without a clear understanding of the disease, a person can not plan for death, Naito said. ] "You can not go through your spiritual life, you can not prepare to die," Naito said. "Sure, you have your [legal] will, but there's more to it than that."
The doctors who treated him had the best intentions, said Naito, who declined to publicly identify them or the clinic where they worked. Reached for verification, clinicians refused to comment, citing privacy rules.
Indeed, most doctors consider open communication about death vital, research shows. A 2018 telephone survey of physicians found that almost all thoughts of end-of-life discussions were important – but fewer than a third said they had been trained to have them
Back, who has been urging better medical communication for two decades, said there's evidence that skills can be taught – and that doctors can improve. Many doctors bridle at any criticism of their bedside manner, seeing it as something like "character assassination," Back said.
"But these are skills, doctors can acquire them, you can measure what they get," he said.
It's a bit like learning to play basketball, he added.
For example, doctors can learn – and practice – a simple communication model dubbed "Ask-Tell-Ask". They ask the patient about their understanding of their disease or condition; tell him or her in a straightforward, simple language about the bad news or treatment options; then ask if the patient understood what was just said.
Naito shared his experience with medical students in an OHSU course called "Living With Life-Threatening Illness," which paired students with ill and dying patients. able to talk very openly and quite calmly about his own experience, "said Amanda Ashley, associate director of OHSU's Center for Ethics in Health Care. "
Alyssa Hjelvik, 28, and a first-year medical student, wound up spending more hours than required with Naito, learning about what it means to be be a doctor – and what it means to die. The experience, she said, was "quite profound."
"He impressed me that it is so critical to be fully present and genuine," said Hjelvik, who is considering a career as a cancer specialist. "It's something he has cultivated over several years in practice."
Naito, who has endured 10 rounds of chemotherapy, recently granted the $ 1 million fund from the foundation formed in his name. He said he hoped that future doctors like Hjelvik – and current colleagues – will use his experience to shape the way they deliver bad news
"The more people know this, it does not have to be something you dread," he said. "I think we should remove that from medicine. It can be a truly heartfelt, deep experience to tell someone this, to tell another human being. "
Kaiser Health News (KHN) is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation, which is not affiliated with Kaiser Permanente
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