Chapter 23: Compassionate Care
Dr. Fisch begins this chapter by defining compassionate care along with the division of labor required between symptom management, communication and inter-disciplinary team work. He stresses that “words matter, how you talk about things matters,” and notes the importance of learning how to ask patients questions to encourage them to tell their story, though current time pressures make this challenging. He stresses, however, that there are skills a physician can learn to make patients feel they are receiving compassionate care.
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History of Science, Technology, and Medicine | Oncology | Oral History
Tacey Ann Rosolowski, PhD:
I had some other topics that I kind of gleaned from my background research, and I don’t know if they’re actually kind of themes that you’ve championed in the institution or if they’re topics of research, but I thought they sounded really interesting. One was compassionate care, and I’m wondering what the story is with your involvement with that.
Michael Fisch, MD:
Right. Well, so, compassionate care, first of all, the compassionate way of talking to patients and an attitude and approach to patient interactions and team interactions is part of what you learn in palliative care. People will ask things like, “Oh, well, what is palliative care and what’s in that palliative care syringe?” And it’s really symptom management skills, knowing drugs to prescribe and ways to prescribe them and ways to assess patients over carefully and repeatedly. But that symptom management piece is probably 25 percent of the work product, you know, and then communication and compassionate care is probably 40 percent of what palliative care is all about, and then interdisciplinary teamwork is probably the rest, the other 30 percent or so, 35, whatever, whatever those proportions turn out to be. I’m making those numbers up, but that’s the flavor I have. But the point is that words matter, how to choose your words, how to talk about topics, and even more important, how to elicit things from patients by asking them questions and by listening. One of my colleagues, Tom Smith, said at a recent conference where he was speaking at MD Anderson, he referred to the three most important words in the English language: “Tell me more.” And I know that you specifically could relate to that in your work. But that takes some skill to learn how to ask questions. We often learn in medicine how to—we have our own agenda of what we don’t want to find out. I’m going to go take a history. I’m not going to be given a history; I’m going to go take a history. I’m going to get the review of systems. Have you had frequent urine? Have you been going to the bathroom a lot? Have you seen blood in your urine? Are you coughing? Are you having trouble sleeping?” blah, blah, blah, blah. But you ask specific questions, you get an answer, you elicit some things, you take a history, as it were. But then many times you’re left with a very narrow view of your own construct of what’s happening. But figuring out how to get patients to tell their story, and, you know, we don’t have forty-five minutes in every encounter, so how do you allow patients to tell you what’s important, and how do you do some listening and still get through your day? You know, that’s the ultimate thing, that that’s the fear factor that oncologists bring to the mix, and all doctors. If I go around listening, then I won’t be able to finish rounds, I won’t be able to finish my work, and I’ll be very ineffective. So I don’t understand how that would happen unless I just get to see five patients a day. But the truth is, there are skills for being able to get the same amount of information in basically the same amount of time with a different style, but it’s a skill you learn. And you learn how to sit down, do experiments, as Dr. Bruera has done here, kind of using a videotape technique where showing patients a video of one doctor and a video of another doctor and sort of doing the same encounter, and really the only different thing is one doctor sat down and the other doctor didn’t. And then the patient’s not being told that was the purpose of their—grading how compassionate the doctor was, how long they were there, estimating how long they spent listening, and figuring out that people feel like they’re better cared for, they feel like they were listened to longer by people who sat down. So if you do research like that and you figure out that you’ve got to learn how to sit down. And then the question might be, well, how do you do that when there’s no chair in the room? And then we figure out, you’ve got to bring your own chair, you have this, like, little chair, the kind that you would take, like, to a golf tournament, these little pump-out chairs. They look like a little cane, almost, and you just fold them out. People then see me carrying around this little chair when I’m going on rounds, and then that becomes a distracter in its own right. People think, “Well, have you hurt yourself? Or what’s going on with that?” It becomes a talking point that sometimes make me weary. But when you can pop into a room and pop that chair and sit down and actually put it wherever you need to, right, you can position yourself where you can be close to the patient and talk to the patient at eye level but also their caregiver, who’s nearby, and not be sitting on their bed or standing in places that doesn’t work very well. But, you know, you learn some things and you figure out how to solve a problem, like where’s the chair going to be, and then how to deal with carrying the chair around and trying not to lose it and making sure that it’s clean and safe to do that kind of thing. But, anyway, there’s a lot of skills and a lot of research that can be done in the realm of compassionate care.
Fisch, Michael J. MD, MPH and Rosolowski, Tacey A. PhD, "Chapter 23: Compassionate Care" (2015). Interview Chapters. 846.
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