A Letter to Myself: Dear Future Doctor…

Dear future Doctor,

If I may, I would like to endow you with a few pearls of wisdom, as you embark on this transformative journey. I pray that this will help mold you into the best physician you have the potential to become. After all, simply having potential does not suffice. You must know how to channel that potential wisely with diligence and hard work, in order to create the future you aspire towards.

Equip yourself with clarity of vision: Who is the physician you will choose to become and what type of impact would you like to have on the lives of your patients and their experience of their disease? Your resilience and your ability to learn are limitless. Your well of compassion has no bottom should you choose for it to be so. You have been blessed with the opportunity to pursue your passion for medicine. Your purpose, however, is to pay this forward by serving your patients to the best of your ability. In order to do so, you must develop a mature understanding of the language you use and the manner in which you approach your patients, every time you open the door to introduce yourself.

Language is a powerful tool, not only for communication, but also for healing. The words and metaphors you use colour your patients’ experience of their illness. For example, the metaphor of a journey might help a patient navigate the experience of their disease one day at a time, while one of a warrior may overwhelm the patient with feelings of shame and guilt towards their loved ones for having lost the war against their cancer. In contrast, the war metaphor may fuel the motivation of another patient to continue with their difficult treatments. (1) To each their own metaphor. Allow your patients to create and embrace the metaphors which empower them. No metaphor is perfect, so take heed of their pitfalls.

Our language in medicine can be dehumanizing. You will often hear “The Moya Moya patient in room 20” as opposed to “Elizabeth”, or patients “dying on me” as if it were a crime for them to decompensate on your watch. This can be dangerous as it subconsciously affects the quality of care you provide to these patients at their most vulnerable moments, when you have great power. Importantly, it also shifts all the blame onto the patient, ridding you of the responsibility to address their complex circumstances. (2) So next time a patient is labelled as “non-compliant” or “non-adherent”, take the time to explore the reasons behind this, in a non-judgmental manner. Assume responsibility for your patients’ well-being without readily slapping these all-too-sticky labels which tint the lens of the next professional who will care for them.

Most of your patients will not remember their discharge instructions, and a subset often won’t recognize what they don’t comprehend. (3) Fight the temptation to place the blame on the patient for not asking questions or for not being “compliant”. The onus is on you to ask the right questions to ensure they understand. Provide them with the written material they require. Make use of allied health care professionals that will reinforce the details of their treatment plan. Most importantly, take the time to assess the gaps in your patients’ understanding of their condition, and of their instructions. Address them accordingly in a gentle, non-condescending manner. This is an efficient way to improve your therapeutic alliance as well as adherence to treatment, hopefully resulting in better outcomes.

Burdening your patients with your personal experiences, problems, or emotions in attempts to build a therapeutic alliance simply does not work. Self-disclosure can be disruptive and counter-productive. (4) Instead, focus on the patient’s needs. Practice empathy, and never underestimate the therapeutic power of actively listening. This is how you truly build a reliable therapeutic alliance with your patients.

If you don’t elicit the patient’s agenda once or twice during an encounter, you risk them raising an issue that is important to them only at the end of the encounter, when you won’t be able to do it justice. To avoid this, ask open-ended questions in the “some” form. For example, ask “Is there something else you would like to address today?” This has been shown to be effective in eliciting the patient’s concerns without increasing the length of consultation. (5, 6)  Try to understand, validate, and answer their questions accordingly, without jumping to purely biomedical answers which are easier for you to provide. We are often well equipped, through our training, to answer questions that are biomedical in nature. In contrast, the questions the patients have most difficulty asking and we have most difficulty answering are often psychosocial or biopsychosocial in nature. (6) When we hear these questions, I believe that we subconsciously substitute the question in our minds with a question we are able to answer more readily, often within the biomedical realm. Daniel Kahneman, Nobel Prize Winner in Economics, calls this phenomenon substitution and heuristics. (8) Falling into the trap of substituting difficult questions in our minds with easier ones, leaves the patient’s actual question unanswered. The challenge here is to pause for a moment after the patient asks their question, identify what the root of their concern is (biomedical or psychosocial), and only then try to craft an answer that responds to the need conveyed through the question. Recognizing the substitutions we make is an acquired skill, so practice and your patients will surely reap the benefits.

A positive consultation and patient-practitioner relationship seem to create a valuable placebo effect. (7) Dr. Philip Gordon, a retired colorectal surgeon states that “Physicians should provide hope, without being unrealistic” when he wrote about his experience as a pancreatic cancer patient. (9) Indeed, communication of confidence and positive expectation in the context of a healthy physician-patient relationship appears to produce clinically significant improvement. In fact, the therapeutic alliance is noted as the most powerful component of the placebo effect. (7) One may argue that given the clinically proven positive outcomes related to nurturing the physician-patient relationship through active listening, a friendly demeanor, empathy, and confidence, that it is a patient’s right to receive such care. While you can never truly convey certainty without being dishonest, you may convey confidence liberally, with a welcoming, knowledgeable, and positive approach so that your patients may, at the very least, benefit from its placebo effect. Reminding yourself as well as your patients that a positive outlook invariably improves quality of life, is also of value.

Just as you consider your time to be valuable, so is your patients’ time. Make it count. Use language to your advantage to equip your patients with the tools they need in order to continue to carry on, despite their infirmity. Create a safe space for them to express themselves fully in your presence, as you would like your physicians to. The more you learn, the more you will realize you don’t know. Don’t shy away from this challenge! Be patient, learn from your mistakes, embrace the rich learning experiences which await you, and know that you will grow ever wiser from them.

Take care of yourself,

Sondos

References

• Reisfeld, G.M. and Wilson, G.R. Use of Metaphor in the Discourse on Cancer. J Clin Onco. 22(19):4024-4027, 2004.
• Ofri. When the Patient is Non-Compliant. New York Times Nov 15, 2012.
• G. Engel, M. Heisler, D. M. Smith, C. H. Robinson, J. H. Forman, and P. A. Ubel. Patient Comprehension of Emergency Department Care and Instructions: Are Patients Aware of When They Do Not Understand? Ann Emerg.Med, 53: 454-461, 2009.
• McDaniel, S.H. et al. Enough About You, What About Me? Arch Intern Med 167:1321-1326, 2007.
• John Heritage, Jeffrey Robinson, et al  Reducing Patients’ Unmet Concerns in Primary Care: the Difference One Word Can Make. J.Gen.Intern.Med. 22 (10):1429-1433, 2007.
• Rodondi, et al. Physician Response to “By-the-Way” Syndrome in Primary Care. J Gen. Intern.Med 24(6):739-741, 2009.
• J. Kaptchuk, J. M. Kelley, L. A. et al Components of placebo effect: randomised controlled trial in patients with irritable bowel syndrome. BMJ 336 (7651):999-1003, 2008.
• Kahneman, Daniel. Thinking, fast and slow. Farrar, Straus and Giroux, 2015.
• Gordon, Philip H. “Chemotherapy.” Diseases of the Colon & Rectum, vol. 61, no. 3, 2018, pp. 275–278., doi:10.1097/dcr.0000000000001040.