A few years ago, I was a key witness for a patent dispute at a trial in Delaware. Acting for the complainant, I was briefed that the opening gambit of the opposition lawyer would be to discredit my CV and, therefore, the value of my testimony. “So you are a full Professor at the University of Edinburgh,” stated the snide lawyer. “Is that a regular University?” Trying to sound as British as I possibly could, I replied, “Yes, sir, Edinburgh has been a regular University for the past 400 years.” The judge stifled a laugh, the lawyer looked confused, and we won the case!
That said, medical oncology in Edinburgh is only 33 years old, and it was my responsibility to create the specialty locally when appointed as the first medical oncologist at the university back in 1979. Now an Emeritus Professor, I find it fascinating to reflect on the extraordinary changes that have taken place over the past 3 decades. Here and in future columns, I will highlight areas that pose particular difficulties in modern practice in contrast to situations we dealt with in times gone by. These reflections may offer a little guidance to readers who are still in training, but we can all learn from history.
The Importance of Time
Most of us from that first generation of medical oncologists in Europe did some of our training in the United States—in my case, at NCI and the University of Chicago. We have naturally maintained an interest in comparing practices and attitudes from both sides of the Atlantic. One thing that has changed significantly in both places is the use of our time spent with patients.
In establishing medical oncology in Edinburgh in the early 1980s, I was fortunate to be introducing the new discipline to complement already excellent departments of surgery, radiation therapy, and pathology. What was new was to show what physicians (that is, internal medicine specialists) could add to the overall care of patients. Then, as now, surgeons and radiation oncologists were very busy with large outpatient clinics and bed occupancy pressures. One of the most valuable contributions medical oncologists could make was to spend time with the patient—time to talk, time to explain, and above all, time to listen.
Apart from the treatment of lymphomas, leukemias, and pediatric tumors, we had so little in our therapeutic armamentarium that we had to rely on the basic physician skills—taking a history, examining the patient, confirming the diagnosis, and formulating a management plan. The latter essentially focused on symptom control and, importantly, emotional support for both patients and their families.
New Priorities
What I fear is that now, with the wealth of technology for achieving a more accurate diagnosis, for assigning patients to different prognostic and therapeutic subsets, and for making therapeutic choices, our time with patients is overwhelmed by the need to give out information, leaving little time to answer questions or to just listen. Listening is the only way that you can ever really understand how an individual patient is coping with a diagnosis and its consequences.
Never is this lack of time more obvious than when you first meet a patient. Whether this occurs on a hospital ward or, more usually, in a clinic, the contrast between what we set out to achieve 30 years ago and what is expected of us now is daunting.
Then, our major role was to explain the cause of symptoms and outline the likely prognosis, occasionally influenced by treatment, which was very often experimental and therefore associated with an uncertain outcome. We became comfortable in talking about death in all its aspects. Now, we are expected to obtain detailed family and lifestyle histories, explain the need for staging and other pathologic procedures to fully characterize the disease in an individual, to explain complex multimodality treatments, to offer likely prognosis, and much less often, to open up conversations about inevitable progression and life expectancy.
Against the background of severe anxiety that most new patients express, to achieve all of this in a first consultation is virtually impossible. To make matters worse, in many institutions, financial and other considerations mandate a fixed, almost certainly inadequate time to interview patients.
Strategies for Coping
So what, if any, are the lessons, and how should we cope with this new time pressure? Clearly, if new patients require significant further workup before you can select management options, the amount of detailed information that you need to convey at the first meeting is limited and can be deferred. If the situation is more obvious to you and treatment options are limited, then you will be expected to get through as much of the agenda as you can. In some scenarios, it may be appropriate (or essential) that you delegate areas of explanation to colleagues, especially nurses familiar with your practice. Of course, innumerable written materials are available, but these should never substitute for human conversation.
The contemporary situation is often made worse when patients come armed with information they have gathered themselves, usually from the Internet. In my experience, this self-acquired information is often erroneous with regard to the specific situation, but valuable time is consumed in unpicking the patient’s anticipation of what is relevant, while trying to maintain his confidence in you as the expert and his oncologist.
Time for Listening
Time is very precious. The first consultation is one of the most important occasions your patient will ever experience. It wasn’t necessarily any easier in the old days—time was on our side, but where we could listen and explain, we had less on the positive, hopeful side to convey.
The challenge now is to decide how best to apportion whatever time is available while, importantly, leaving some of that time for listening. Our patients need us to listen to them, to empathize in a professional way, and thereby to personalize their experience. Finding time to explain research, which has to involve the concept of uncertainty, adds another tier to the problem of time allocation—but I will leave that for another column. ■
Disclosure: Dr. Smyth reported no potential conflicts of interest.
Dr. Smyth is Emeritus Professor of Medical Oncology at the University of Edinburgh, Scotland, United Kingdom.
