What to do when the patient gets in the way of the surgery.
It took her a while to walk into my consultation room. She shuffled very slowly, inch by inch, and finally sat down with a deep sigh.
The whole time she was breathing hard, she had a dry cough that made her face crinkle in pain from deep down inside her chest.
Donna* seemed lost in my large consulting room. Her eyes barely met mine, and when they did, all I could see was anger.
Walking next to her was her tall partner, her pillar of strength, literally.
Silent and resigned, he settled down to observe the exchange between this 75-year-old lady and me.
“I don’t want to be here,” she said. “We had to walk a long way from the car park. I can hardly breathe. Can we get this over and done with?”
I had to take a moment to think. The referral letter stated that she had two large skin cancers on her back, occasionally bleeding, which I examined.
We have all been there, unremitting coughs causing deep lower chest and upper abdominal soreness. They are the worst. No control, and no peace – two critical things for life.
I took a deep breath before I spoke.
The most important thing, Donna, is to help you breathe again,” I said. “That is the most important thing.”
Her demeanor changed. She sat up, her eyes widened, and she said, “Yes, that is the most important thing.”
I am going to contact your GP,” I continued. “You should see your doctor as soon as possible to get a cocktail of medications and physiotherapy so that your lungs open up and you don’t have to suffer during these cold winter months.”
Finally, a tentative smile from Donna.
˜What about these sores on my back then, can you fix it?”
“Of course, I can,” I said. “Once you feel a little better, we will get you back to the hospital. I can cut those nasty cancers out and put you back together again.”
This encounter got me thinking about empathy and asking questions about it.
I first learned the difference between sympathy and empathy from my Catechism teacher, when I was 13.
A simple example, when someone is hungry, ‘sympathy’ feels for them, but ‘empathy,’ shares a sandwich with them. My life was never the same, and I developed and honed a sixth sense to tune in to the other person’s psyche, immensely helpful when I started looking after patients.
While Donna was at this appointment to have a consultation about her skin cancers and needed my expertise is in surgical oncology, that wasn’t the space she was in at the moment. I needed to pivot, so that her feelings and her pain were the most important thing in the room.
We run a risk in our earnestness to ‘manage’ patients and deploy our technical skillset, made so much more difficult by our ‘busyness’. The risk of not listening and failing to connect on a deeper, emotional level – that just makes it all that much harder for patients to trust us enough to let us help them.
These are two qualities patients need from a surgeon, perhaps in equal measure and simultaneously: empathy and cognitive problem-solving. (1)
And there is a perennial tug-o-war between emotional intelligence and technical ability. Sometimes, we have to stash our feelings away to focus on the diagnosis (i.e. the ‘case’ in front of us). That can be counterproductive because, without meaning to, we alienate the patient.
Empathy, is it teachable? I think it is.
Sometimes it’s just about using simple phrases to respond to a patient, that demonstrate you are listening and you care like: ‘I can imagine how difficult that is.’ ‘Sounds like what you’re telling me is…’ or ‘It sounds like you were really frightened when you got that news about the cancer’. (2)
Empathy and telehealth, what does this look like? With lockdown after lockdown, how can a surgeon be empathetic during a consultation without seeing the patient face-to face?
When Donna was in the room, I was instantly able to pick up the vibe of her being distracted, in pain and furious.
I don’t know that I would be able to do that by phone. So much of the information is missing when you can’t read facial expressions or see how a person is reacting to what you are saying in real time.
We have to work extra hard, put in even more effort to connect without the benefit of face-to-face communication. (3)
I met Donna again in the anaesthetic bay just before being wheeled into the operation theatre. This time she looked at me as a friend. With trust. Clearly, the ‘breathe first’ strategy helped her.
The third time I saw her was a week later, in my consultation room for a post-operative review. I swear she skipped into the room, wounds healed beautifully, squamous cell cancer excised with good margins, absolutely delighted. There was only one person happier than Donna, and it was not me. It was her stoic partner. He winked at me as they left, with a parting shot.
“No more daily dressings doctor!”
‘Dura est manus cirurgi, sed sanans. The hand of the surgeon is hard, but healing.’ – Walter Map
* Names have been changed
Dr Sandra Krishnan is a surgical oncologist at Northern Surgical Oncology, Sydney Adventist Hospital.
- Omar SH, Adam W Why Doctors Should Be More Empathetic–But Not Too Much More, Scientific American; April 26, 2011
2. Coulehan JL, Platt FW, Egener B, et al. “Let me see if I have this right … ”: words that help build empathy Ann Intern Med 2001;135(3):221–227.
3. Elisheva TAN, David RU, Karen MD The Art of Surgery: Balancing Compassionate With Virtual Care J Med Internet Res 2020; 22(8):e22417.