Optimizing Communication With Patients: A Critical Skill Associated With the Experienced Oncology Clinician

In the preceding commentary, I highlighted the frequently complex arena of goals-of-care discussions. The essential requirement for open, honest, and frank communication cannot be overstated, but this declaration of principle may be considerably easier to state than to fulfill.

For example, in my own career, I have witnessed clinicians who were remarkably skilled at delivering unquestionably difficult information, both honestly and empathetically. These physicians answered questions with a tone of realistic hope, clearly emphasizing that no matter what transpired, the patient would never be abandoned in regard to basic comfort needs.

Yet I have similarly directly observed or learned from colleagues and physicians who, regardless of their clinical expertise, appeared to struggle with these essential communication skills. The following personal experiences, briefly noted and for obvious reasons without institutional identification, represent a mere snapshot of the real world of cancer care and the management of other devastating medical conditions. These instances are highlighted here to shed light on the complexities of such communication.

Early in my career, I witnessed patient rounds led by a senior attending recognized for his superb cancer-related surgical skills, during which the senior resident appeared to actively and somewhat aggressively seek to answer all patient or family questions, rather than having the attending surgeon provide a response. When I privately inquired about what I had observed, I was informed that the residents had been asked by their chief to serve as a buffer between this surgeon and the patients (as well as their families) to hopefully soften the impact of his anticipated very direct negative responses related to poor prognostic operative findings.

At a similarly early part of my career, I had relatively frequent contact with a physician caring for patients with advanced solid tumors who would make hospital rounds and order chemotherapy very early in the morning (even before the surgeons made their rounds), seemingly in an effort to avoid having prolonged discussions with the patient. Not surprisingly, this physician would be essentially unavailable when the families arrived later in the day to discuss their questions or concerns. It would not be inappropriate to use the less-than-complementary term chemotherapist, rather than oncologist, to describe the actions and fundamental attitude of this physician.

I note a later experience in which I told a colleague I was somewhat surprised by the rather remarkable size, depth, and institutional support of a clinical ethics program within his health care organization, which was not, at that time, associated with either a medical school or university. My colleague responded that one reason for this development was the goal that ethicists would be available to discuss death and dying issues with patients and their families, rather than having that function be the responsibility of the attending physicians.

Finally, I conclude this personal storytelling with a somewhat humorous event that nicely highlights the care that must be taken with the words we use in communicating with our patients. Many years ago, I was asked to cover for a colleague while serving as the on-service attending of the month. When I approached the bed of a particular patient, I found a rather angry individual who asked me to explain why his doctor was not available, having been informed only the night before that his oncologist was “on protected time.” The unquestionably indignant individual inquired of me: “Who is he being protected from…me, his patient?” One can only imagine my next hour spent trying to explain the inappropriate use of this colloquial clinical-academic language. 

It is not unreasonable to suggest that, in addition to an extensive understanding of the natural history of specific cancers and the most up-to-date thinking on therapeutics, skilled and experienced oncologists appreciate the critical relevance of their personal patient communication style. Further, it is likely that such clinicians will have developed their own strategies to deal with more difficult conversations.

In my experience, when initially discussing details of a relatively prolonged treatment regimen that is challenging for a patient to fully comprehend and accept, I have found that employing an analogy to another far more common life experience can be helpful. For example, I have attempted to very directly contrast the decision required of the patient with the process of buying a house and assuming a “monthly mortgage payment.” There is a legal obligation to continue paying that mortgage unless the property is subsequently sold, regardless of any feelings the owner may develop later for the home they have purchased. The very specific point I am making here is that the current decision to receive a chemotherapy regimen is not what happens when buying a house and assuming a mortgage, as the patient can simply elect at any time to discontinue the therapy based on experienced toxicity or other personal considerations.

A second approach I have found useful is to describe what I have labeled the “sleep test.” In a clinical setting where a patient is struggling to decide if a therapeutic option, such as receiving an extended adjuvant regimen that will hopefully optimize the chances the cancer will not recur but where available objective data are equivocal as regards benefit vs harm, it might be helpful for the individual to consider how their choice may affect, or has already affected, their ability to sleep.

It is reasonable to suggest that the degree of anxiety or emotional distress associated with the decision process may meaningfully influence an individual’s ability to achieve restful sleep. And if that is the case, acknowledging this effect may help a patient decide on an approach that minimizes ongoing discomfort as much as possible.

To be clear, there is nothing unique about the examples cited above, only that they have been of value to me over several decades in efforts to optimize communication with individual patients. Most knowledgeable oncologists will probably have their own experiences, perhaps somewhat humorous or even painful, that emphasize the complexity and difficulty of ensuring essential communication with their patients.

Finally, it is likely these clinicians will have developed their own strategies to help them successfully fulfill this vital goal. These approaches must always acknowledge the relevance of meeting patients where they are emotionally at any point in time in their own critical decision-making process.^1,2

References

1. Weeks JC, Cook EF, O’Day SJ, et al. Relationship between cancer patients’ predictions of prognosis and their treatment preferences. JAMA. 1998;279(21):1709-1714. doi:10.1001/jama.279.21.1709
2. Fridman I, Smith C, Barrett A, et al. Navigating disagreements on health information: how patients with cancer perceive health care providers’ approaches to discussing patient-identified information. JCO Oncol Pract. 2025;21(8):1193-1202. doi:10.1200/OP.24.00071