When Good Bedside Manner Becomes An Afterthought

Guests

Dr. Manoj Jain, infectious disease physician
Theresa Brown, oncology nurse

Medical schools strive to teach students the importance of good bedside manner in communicating with their patients. But sometimes, in the midst of examinations, paperwork and delivering difficult news, showing compassion can become an afterthought for doctors and nurses.

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JENNIFER LUDDEN, host:

This is TALK OF THE NATION. I'm Jennifer Ludden, in Washington. Neal Conan is away.

Anyone who's ever stretched out on an operating table or sat in an exam room waiting for the results of a test knows the importance of bedside manner, the way a doctor communicates the news, good or bad.

In a recent piece in the Washington Post, Dr. Manoj Jain writes that in the midst of examinations and difficult diagnoses, doctors often struggle to show compassion. This touchy-feely part of medicine, he says, has become an afterthought in patient care.

Doctors, nurses and patients, what are the challenges you face in communication? Our number is 800-989-8255. Our email address is talk@npr.org. And you can join the conversation at our website. Go to npr.org and click on TALK OF THE NATION.

Later in the program, we'll look back at Oprah's journey from small-town journalist to media mogul as the countdown to her final episode begins.

But first, bedside manner. Dr. Manoj Jain is an infectious disease physician in Memphis, Tennessee. He's a regular contributor to the Commercial Appeal in Memphis and the Washington Post. Welcome to the program.

Dr. MANOJ JAIN (Infectious Disease Physician): Thank you, Jennifer, glad to be here.

LUDDEN: You, in your most recent piece for the Washington Post, you talked about how this issue came up when you had a conversation with one of your patients. Tell us about that.

Dr. JAIN: Sure. I was talking to Mike Penotta(ph). He's a patient who had pancreatic cancer. And I was standing at his bedside, and he was having chills and rigors, temperature of 103. And sweat was dripping down his side, and I was examining him and talking to him, and I prescribed him some antibiotics.

But being there, I was wondering: You know, how can I show compassion at this very moment to this man who was suffering? I sort of thought about it, and then I realized I could do something.

I grabbed a washcloth from the cabinet, wiped his sweat, gave him some iced water - you know, these tasks which are usually, you know, relegated to the nursing assistant. And that got me thinking on this whole topic of compassion and what doctors and nurses can do.

LUDDEN: Now, is it this patient or another who you found out had actually been told some terrible news in quite a brusque way?

Dr. JAIN: Sure, it was this patient. In fact, what happened was his fever got better, and then a couple of days later I talked to him and I said: Would you be interested in talking about your end-of-life experience?

And I was doing a story on that. And he said very much so. He wanted to share his feeling. And I asked him a simple question. I said: When you were told your diagnosis of the cancer, what went through your mind?

And I was expecting the usual, the usual shock and denial and so forth. But he surprised me. In fact, he startled me. He said, and I'll sort of quote him. He said: Well, the first thing I wanted to do was I wish I was 10 years younger. I would have reached across and slapped the blank out of the doctor.

LUDDEN: Oh my.

Dr. JAIN: Yes. And I sort of stood there, and I said: Why? And then he told me. And he said: You know, the doctor sort of came in, looked at his piece of paper, looked at him, and said this is terminal and then walked out.

LUDDEN: Ugh...

Dr. JAIN: Very, very painful and saddening. And that's when I realized that this is something I should be writing about.

LUDDEN: You have a - we have a lot talk with you about. But let's bring a caller in. There are people who have been on the other end of conversations like that.

Dr. JAIN: Sure.

LUDDEN: Let's listen. Paula(ph) is in Durham, California. Hi there.

PAULA (Caller): Hi, can you hear me well?

LUDDEN: Yes, go right ahead.

PAULA: Okay, hello, nice to talk to you. I wanted to talk about my experience. I'm a breast cancer survivor and an ovarian cancer survivor. And my breast cancer treatment went very well, and I had a great doctor with that. I felt he was my teammate.

We discussed my drugs together. He told me about research, and we did a fine job together, and we beat it and with the help, of course, of my body.

But when I got ovarian cancer, you know, he was there for me again, and we worked together. I was diagnosed with this in 2004. And unfortunately I had a recurrence in 2006, and then something else happened in 2008.

And unfortunately after that the doctor moved out of the area, and I had a new doctor who came into his position. And I felt, you know, very confident, although I had had to retire from my job and I'd had a number of setbacks. And I'm pretty aware of the chance of ovarian cancer when you get it and the stage and your survival rate.

But I came in to meet this new doctor, and I said, you know, hello, nice to meet you, you know, welcome to our town, et cetera. And I said: Well, I had it was stage actually I was 3B I thought it was four(ph) -3B. But it's been over five years. So I've beaten the 40 percent rate.

And he held up his clipboard in his hand and he said: Well, and he draws a line very firmly across the page. You were at 40 percent. And he scribbles 40. But at your recurrence - scribble another line - that made you 30 percent survival. And then he says: Then your other recurrence -scribble a line - that made you 20 percent survival.

LUDDEN: Oh my.

PAULA: And I looked at him, and I'm thinking: You're not my partner in this. I just didn't feel a sense of camaraderie with him at all. That doctor actually has since left our community. I think the whole community felt that same way, especially filling the boots of our other partner doctor.

And since then, I have a new oncologist, new to me. He's been in town a long time. And again, I have a partner. He - I was in a clinical study. I've had to go out of the study because I had a growth and a tumor that just was resistant.

But I said: Well, how about this drug that I took last time? Well, that sounds like a good idea. Why don't we combine it with that? And again, I had a partner.

And so although I've been really realistic, and he's been really realistic to me about when he might have to talk to me about hospice, I'm so glad that I have a doctor like this who talks to me as if I'm intelligent and not lecturing a kindergartener...

LUDDEN: So it's not that you don't want straight-up, realistic information and can handle it. You just need - you need a little compassion when it's delivered.

PAULA: I need compassion when it's delivered, and I needed to be treated as if I was intelligent, as if I could handle this. Well, you do understand that with each recurrence that it might reduce your chances of survival.

Even the tone made a huge amount of difference. But I will never forget that line written across that piece of paper, as if each line was, like, you could feel years scratching away from my life, as if he was looking at me as if, you know, dismissive. I'm not going to spend much time with you because you're terminal.

LUDDEN: Well, Paula, thank you so much for calling.

PAULA: You're welcome.

LUDDEN: Dr. Jain, I mean, how - how do you deliver terrible news like that?

Dr. JAIN: A couple of thoughts on Paula's situation. I think she's making the right statement about, one, getting rid of a doctor who was unwilling to partner with her. I think she used that term very appropriately.

And we all need to think about that, that the whole idea is that we need to partner doctors and patients together to reach our goal, the goal of not just quantity of life, not just the length of life, but also the quality of life.

So that's a critical element that she sort of brought out. And there's a whole movement towards patient-centered care, which is talking about this idea, this idea of doctors and patients partnering. Even in the ICU, we're beginning to see patients and families together talking about diagnosis.

Some of the new ICUs, new initiatives in the ICUs, relate to a family member being part of the team, as well as other family members and patients being part of hospital teams and coming about to new ideas and new ways of solving problems.

LUDDEN: Let's bring someone else into the conversation. Nurses spend a lot of time with patients. They pull 12-hour shifts. They may not be the ones who deliver the diagnoses, but they support patients in the moments before and after.

Oncology nurse Theresa Brown joins us now from a studio in Pittsburgh, Pennsylvania. She's a regular contributor to the New York Times Well blog and wrote the book "Critical Care." Welcome to the program.

Ms. THERESA BROWN (Author, "Critical Care"): Oh, thank you.

LUDDEN: I'm just curious if you can - you know, you must observe different styles. Does it - you know, how much difference do you see when, depending on, you know, the way the doctor has delivered, say, bad news?

Ms. BROWN: Well, it definitely makes a huge difference. And what I tend to see more than this callous doctor who Paula unfortunately experienced but is a difficulty on the part of anyone on the team to really tell the family that we've run out of options.

And it's almost like hospice becomes a dirty word. And so people talk around it and want different service - say, the oncology service will say, well, here's what's going on with your cancer, but to really talk about your kidney failure, we need to have renal talk to you about that.

And so giving the whole picture of this is a person who really we just can't make them whole again gets partialized sort of in terms of parts of their body and who deals with those parts.

LUDDEN: It's hard to connect everything together.

Ms. BROWN: Right.

Dr. JAIN: Oh, I think this is something that we see all the time. And in fact, I'm guilty of this. You know, recently there was a patient who had heart disease and diabetes and leg ulcer. And the cardiologist sort of went in and was sort of viewing the patient as clogged arteries. The endocrinologist was seeing a failed pancreas. And I was going in and seeing an infected leg.

And you know, I had to step back and say: Wait a second. There's a whole patient, there's a wholeness there, and we as practitioners and doctors need to see that and work with patients more.

LUDDEN: Well certainly in everyday life it is hard to - I can imagine it's hard to deliver difficult news.

Ms. BROWN: And I think also what we see a lot is what I call the hallway conversation, which is where the medical team will say: This really is not good. There's such a poor prognosis here.

Excuse me. And then they go into the room, and their piece of it, it's possible maybe to offer some small amount of hope, but then there's a disconnect.

LUDDEN: All right, both of you, if you can stay with us, and we'll bring in more calls in a moment. Doctors, nurses, patients, what are the challenges you face in communication? Give us a call, 800-989-8255. Our email address is talk@npr.org. I'm Jennifer Ludden. This is TALK OF THE NATION from NPR News.

(Soundbite of music)

LUDDEN: This is TALK OF THE NATION from NPR News. Im Jennifer Ludden in Washington.

We're talking with doctors, nurses and patients about the importance of bedside manner and the challenges many busy doctors and nurses face when it comes to delivering difficult news.

Our guests are Dr. Manoj Jain, an infectious disease physician in Memphis, Tennessee. We've posted a link to his Washington Post piece, "Doctors Often Struggle to Show Compassion While Dealing with Patients." It's on our website.

Also with us, Theresa Brown, an oncology nurse and contributor to the New York Times Well blog. She wrote the book "Critical Care: A New Nurse Faces Death, Life and Everything In Between."

Doctors, nurses and patients, what challenges do you face in communicating? Our number is 800-989-8255. Our email address is talk@npr.org. Or join the conversation at our website. Go to npr.org, and click on TALK OF THE NATION.

Here's an email from Cathy(ph) in Clarksville, Iowa: I am a registered nurse and have worked in management, geriatrics, hospice and psych. In all these settings, the single-most important way of showing you care is presence: eye contact, listening with your whole body, letting the patient express their feelings and questions.

The patient wants to know they are not alone and someone hears them. You may not have the answer, but they know they are not alone.

And let's take a phone call. Julia is in Medical Lake, Washington. Hi, Julia.

JULIA (Caller): Hi. Oh, this is such a wonderful conversation. Thank you so much. I wanted to share with you a very positive aspect to this story, starting with our primary care physician, who diagnosed leukemia in my daughter three years ago.

And obviously when we got that news, it was completely devastating, and suddenly life was in a very suspended state of reality. And I remember we had to go to our hospital and there we were consulting with an oncologist.

And all the time we were there, it was this shroud of, well, we suspect it's leukemia. And for me, that gave me this really, oh, just this glimmer of hope that, well, maybe it's not.

And yet we were in the hospital. We were being admitted. They were talking about surgeries and a bone marrow (unintelligible) and all of these things that really led to, okay, they think they know that this is leukemia.

And our oncologist at the time was terrific, and she was just so informative. But toward the end I finally looked at her and I said: You know, I know we need to do all of these additional things in order to make this really definitive. However, I need to know right now. I can't wait until tomorrow. So based on everything that you know about Aria's(ph) leukemia, does she have it or not?

And she - our doctor took a deep breath and she looked me deeply in the eyes and she just said yes. And at that moment I just felt this relief. I fell into this well of trust that was just never going to be questioned or doubted again. I was able to surrender to this enormous process that lasted two and a half years and - of chemotherapy - and it was just an extraordinary thing.

And later that day our primary care physician showed up in the hospital and - just in tears. And the fact that she could allow herself to be so vulnerable, she could hang up her doctor's coat and be with us as a family and herself a mother and relate to me on that level, it was just extraordinary.

LUDDEN: Julia, how is your daughter now?

JULIA: Thank you for asking. She is - she's rocking the house.

(Soundbite of laughter)

JULIA: (Unintelligible) first grade. She's just doing great.

LUDDEN: That's so good. We're glad to hear that.

JULIA: Thank you.

LUDDEN: Thank you for your call. Theresa Brown, that is - that's wrenching, and - but I can see, it must be so difficult to - to do. I mean, the tendency must be to not tell the whole story.

Ms. BROWN: I think, and I think even sometimes it's very well-motivated, or it's even hard for doctors to say - I mean, for example, we just had a very young patient come in and the talk was, you know, this could be a virus. I mean, a lot of things look like leukemia. And I kept hearing over and over again: It could be a virus, it could be a virus.

And then I realized the medical staff also wanted to believe this very nice man, who was in his early 20s, didn't have leukemia, he just had a virus. And I think it can come from a very human place, this inability to be completely honest.

LUDDEN: Is there, either one of you, another - this may be a strange analogy, but her story made me think of a rule of thumb with children, sometimes, when it's - you say: Well, tell them only when they ask. They're not ready to hear it until they ask. Is there anything like that that goes on with patients or no?

Ms. BROWN: My feeling is people want, they want to know the truth. They want to know what's going on. But they want to be told it in a way that's kind.

Dr. JAIN: And you know, there are lots of uncertainties when one is going through the diagnostic process. And you don't want to be, you know, right up front and say, oh, you know, I really think it's a cancer, and it turns out to be an abscess or an infection of some type. And that actually happened to one of my patients.

He had a large mass in his brain. The neurosurgeon came to him, his bedside. He had seen the MRI, and the neurosurgeon sort of said: I really think this is a cancer. I really believe that we're going to go in, take it out.

And the whole family was in the room. I came back to see him after looking at the MRI and looking at some of his culture reports, and I told him, I said: We really don't know, because it could be an abscess.

As it turned out, the patient did have a brain abscess, and he was fully cured and is doing perfectly well. And so we have to be careful not to give a diagnosis very early on and make the family very anxious and worried.

But obviously in some of the other cases you presented, it was very appropriate to tell the truth or tell as much as you know at the time you know it.

LUDDEN: Okay. Let's take...

Ms. BROWN: But tell as much as you know, right, yeah.

LUDDEN: Let's hear from another caller. Sandy(ph) is in Michigan. Hi there.

SANDY (Caller): Hello, I'm calling - it's a little different spin on the issue that you're talking about. But I am an OB/GYN physician that's also an abortion provider. And I found it very difficult when I would transition from, you know, establishing long-term doctor/patient relationships with my obstetric patients to shifting to a more kind of clinic mindset and trying to establish a well-founded doctor/patient relationship in the essential five to 15 minutes that I had to deal with the patient.

And that was, you know, that was a big transition because our patients come in with a lot of very difficult emotions to deal with, and also they have to deal with the fact that they have a lot of misinformation about the procedure and how they are going to feel about the procedure.

And we try, in the two hours that they're at the clinic and in the 15 minutes that I spend with the patient, to make them comfortable, to understand why they're there and try to fulfill any type of need that they may need. But it's in 15 minutes. So that's - you know, that's a little different atmosphere that(ph) I deal with.

Dr. JAIN: I can understand that. In fact, we were talking about this issue this morning with several doctors at our hospital. And one physician assistant told me about a senior surgeon who would -cardiothoracic surgeon, and what he would do is sit at the patient's bedside, hold their hand, look them in the eye. And he would say: You know, Mrs. Jones, I'm sorry to tell you this, but you have lung cancer. And we're going to do everything we can.

And in just two minutes he would alleviate 20 minutes of distance, talking, the touching, the eye contact, like we've heard. It really shows that you care, and that's what patients want to know.

They forget - and they don't even listen to the statistics and everything that you tell them. They want to make sure that the person who is going to invade their body possibly, who's going to pour chemicals which are going to be toxic in them, really cares about them. And we can do that in a few minutes if we know the strategies, the techniques to do that.

LUDDEN: All right, Sandy, thanks for the call. We have an email here that gets at another part of this issue. It's from Greg(ph), who's a nurse in Oregon. He writes: Are you nuts? We're getting paid to do what we do.

Yes, we show compassion every day, but nearly all of the compassion must be shown by family and friends. We cannot follow the patients day after day and meet all the patients' needs, only some.

I bristle when I hear people who feel we, as nursing staff, don't show enough compassion. All of us struggle with the time and workload constraints we deal with daily. Theresa Brown?

Ms. BROWN: Yeah, I I hear that. I remember recently another nurse I work with saying so-and-so got some bad news today and I really have to carve out some time to just sit down with her.

And much as we are the person who's there with the patient over a 12-hour shift, and as much as we do try to provide passionate care, sometimes the task burden on us is so great that we are also not able to be there.

One thing that would help all of this, I mean, I love the example of the cardiologist sitting down and holding the patient's hand.

But this idea of partnership, if the doctors would partner with us when they're going in to deliver news, if then we could partner with them about what's going on with the patient, just more communication between all the members of the team, including the patient and the family, might make what little time there is to be compassionate go a longer way.

LUDDEN: Well, Dr. Jain, do you - I mean, do you not have to build some sort of an emotional barrier just to do this job or you'd be overwhelmed? I mean, how do you kind of walk that line?

Ms. BROWN: Oh, I can address this.

LUDDEN: OK. Go ahead.

Ms. BROWN: People often ask me that. And, yes, I think that you do have to, in some ways, find ways to disconnect or the job would make you crazy. There are also times, though, when allowing myself to give in, let down my barriers and really be there with someone just renews my complete commitment to what I'm doing. It reminds me why I'm there. And...

LUDDEN: Actually, let's - we've got a call right on this topic.

Ms. BROWN: OK.

LUDDEN: Let's listen to Connor(ph) in Colorado.

CONNOR (Caller): Hey. Howdy? I'm a surgical assistant. And I was working in the OR up at our regional hospital. One of the biggest problems for me was getting too attached to patients. Oftentimes, I'd feel myself (unintelligible) come with me, and, you know, kind of doting on patients that maybe weren't doing so well. And so it was really difficult to kind of let go or just to insulate myself from being too empathetic about patients' issues.

LUDDEN: And so what do you do about that?

CONNOR: It's really just kind of a personal exploration thing. You really have to find a, you know, a middle ground between caring too much and then coming off as cold or maybe impersonal. And it really depends on the type of person. Myself, personally, it was just spending as much time with the patients as I could, getting to know them.

Unfortunately, we didn't have too much patient contact in - as surgical assistants. But after the surgery was over, often I'd go to the post-anesthesia care unit and visit with patients, see how they were doing, making sure that they were recovering fully. Even though that wasn't in my job description, I'd go and do that just to form that connection with patients.

LUDDEN: And to - but to keep yourself from getting too attached, how would you pull back?

CONNOR: It's really just kind of a mental block. It's something that each of us has to go through. When I went to medical school, a lot of us had trouble with that. And some people would just go the extreme distance and be cold to patients, which really doesn't solve anything and makes you look like a jerk, really.

LUDDEN: All right. Connor, thank you so much for calling. You're listening to TALK OF THE NATION from NPR News. Theresa Brown, you can relate there?

Ms. BROWN: Yes, definitely.

(Soundbite of laughter)

Ms. BROWN: Yeah. It's - a nurse told me when I was first started, if you stop feeling sad and caring about the patients, that means you need to get a new job. But the balance is always a challenge.

LUDDEN: Dr. Manoj Jain, you looked at how people are trying to teach compassion in medical school, right?

Dr. JAIN: Yes, we did.

LUDDEN: What's happening?

Dr. JAIN: Well, the whole idea of teaching compassion is not new. In fact, there was a 1983 New York Times story that talked about compassion in health care. And slowly what we're seeing is many medical schools taking on initiatives such as teaching medical students in their first and second year about compassion. What many people are saying is also that you have to get the mentors, those doctors who are practicing and those residents, and get them to learn about compassion and show compassion so that medical students will be compassionate as well.

And William Branch, who's a physician at Emory, has done several studies on this. And, in fact, he did one study where he had a group of doctors go through a training program, a long training program - two years -went through different types of role-playing as well as narrative writings. And what they found was something, which I wasn't aware of, is that you can teach compassion. I always thought that it was a trait that personalities and people had. But we could teach people compassion as well. And this study showed that, and many people can learn from this idea.

LUDDEN: All right. Let's bring in Natalie(ph) in San Antonio, Texas. Hi, Natalie.

NATALIE (Caller): Hey. Thanks for taking my call. You guys really just hit the nail on the head of what I was wondering about. I have a background in counseling. My husband is now in medical school. And I know that even on our end, professionally, we are the counselors. We're there to deal with bereavement, deal with emotions. And even we get jaded. Even, you know, my colleagues will joke about what shouldn't be joked about, or, you know, if you didn't laugh about it, you'd cry about it type of thing. And so I can definitely relate to the idea of creating barriers.

And what I found on our end as counselors or for myself is a lot of boundary creating. And while compassion may be able to be taught, it can also create boundaries with patients. You know, it's the idea of holding the patient's hand, looking into their eyes and giving them news and having them just be these nice people and needed help. That's perfect. But I think, more often than not, there's a shoot the messenger, or there's - there are difficult - difficulties of personalities. People are angry. And I wonder - I guess my question for the doctor is I wonder if it is a personality trait or if there is - if there's a correlation between the amount of time...

Dr. JAIN: I think there's a little bit of both.

NATALIE: ...you're in the field or the amount of - the type of field that you're in or specialization you're in.

LUDDEN: OK, Natalie. Thanks for the call, Natalie. Doctor?

Dr. JAIN: Natalie - yeah. I think it's a little bit of both. I think it's a little bit of a trait and lots of - lot of training. And I'll share an example with you. I have three children, and my middle child is just exceedingly caring and compassionate. When someone in our family gets hurt, like the other day, I had sprained an ankle, she's the one who would put a brace on my leg. She would bring a Band-Aid for her little brother.

And we raised three children the same way. So there is something I find that there is a trait inherent in people that can make them very compassionate. But then, at the other end, we can teach people how to have compassion. It's a skill set that we must get our medical students to use.

LUDDEN: And we must leave it there, Dr. Manoj Jain. We're out of time, but thank you so much for your time. Dr. Manoj Jain is an infectious disease physician in Memphis, Tennessee. And we were also joined by Theresa Brown, an oncology nurse. Thank you both.

Ms. BROWN: Oh, thank you.

Dr. JAIN: Thank you very much.

LUDDEN: Coming up, Oprah calls it quits from daytime TV. NPR's media correspondent David Folkenflik will talk about her legacy. I'm Jennifer Ludden. It's TALK OF THE NATION from NPR News.

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