Making Choices in Clinical Practice

ORLANDO, FL—Most sessions at the ASCO Annual Meeting are devoted to scientific data that inform clinical decisions and practice. In a Special Session called “Frankl's Choice: Reflections on Professional and Personal Choices,” however, clinicians and cancer-care community members related the need most people have to find meaning in their lives.Figure: Lidia Schapira, MD: “We all agree that good communication is important. But what ‘good communication’ is may have different connotations depending on our personal beliefs and the setting in which we practice.The session was designed to explore the values that each physician or practitioner holds and how such values impact medical practice. “We all agree that good communication is important. But what ‘good communication’ is may have different connotations depending on our personal beliefs and the setting in which we practice,” said one of the session's co-chairs, Lidia Schapira, MD, a medical oncologist at Massachusetts General Hospital Cancer Center. There are three aspects of communication, she said: The first involves information and evidence about what effective communication is. The second is the skill set required to put that knowledge into practice. Both of those, Dr. Schapira said, can be taught in various settings. But the third aspect, the role of an individual's values and beliefs, is harder to teach, and is often not discussed. “We may be theorists or very knowledgeable about the science of communication but, in fact, a lot of what we do is informed by who we are and what we believe in,” Dr. Schapira said. Interface between Personal Choices & Professional Choices Oncologists Make with Patients The session was designed to explore exactly those issues, and the interface between personal choices and the professional choices oncologists make with their patients. The session included the documentary film Frankl's Choice, which was written and produced by the session's other co-chair, Ruth Yorkin Drazen. Ms. Drazen lost her husband 18 years ago to prostate cancer and has been making movies about illness, cancer, and the medical community ever since. The film, which was released in 2001 and is available on the ASCO Virtual Meeting Web site as part of the session, explores the life and philosophy of Viktor Frankl, MD, PhD, a famous Viennese neurologist who believed that people need a sense of meaning about their life in order to have an internal comfort or satisfaction. “People are so busy doing, that they forget that they are recipients of their own great life,” Ms. Drazen said. “It isn't enough to do what you learned and protect your patient. You must have that internal space inside yourself of joy that you share only for yourself—that way you will never burn out, because you will never find that there isn't something new to live for, for yourself, your children, your spouse. Life is very rich.”Figure: The film includes scenes of Balfour Mount, MD, describing his own battle with cancer and talking to patients with late-stage disease about what it means to be sick and at the end of life. He said that by paying attention to a person's inner anguish, by honoring that, one can lessen the experience of symptoms and sometimes even the symptoms themselves.Figure: The film “Frankl's Choice” explores the life and philosophy of Viktor Frankl, MD, PhD, a famous Viennese neurologist who believed that people need a sense of meaning about their life in order to have an internal comfort or satisfaction.The film features interviews with patients and physicians, including Balfour M. Mount, MD, the Eric M. Flanders Professor of Palliative Medicine at McGill University in Montreal, who also spoke during the ASCO session. In one scene in the film, Dr. Mount described an incident from his own battle with cancer in which he was lying in the recovery room when a group of residents came in. Although one of them read off his vital signs, no one addressed him as a person, and when they were leaving the room they talked about him as if he wasn't there. During the discussion that followed the film, an Australian physician asked how the medical profession could improve medical training so that young physicians do not become solely focused on the disease at the expense of seeing a patient as an individual. Dr. Mount said that the students are reacting to the system that they work in, including the emphasis on billing only for tangible treatments. In contrast, he thinks it is important to emphasize to students how critical a physician's individual person can be to a patient, and the need for physicians to be aware not just of the pathophysiology of disease, but of the whole person. The film also included scenes of Dr. Mount talking to patients with late-stage disease about what it means to them to be sick and at the end of their life. By paying attention to a person's inner anguish, by honoring that, one can lessen how they feel their symptoms and sometimes even the symptoms themselves, said Dr. Mount and other panelists. Not ‘Touchy-Feely’ After the film the audience and panelists engaged in an animated discussion. At one point, someone suggested that some of the issues being considered were “touchy-feely,” to which Dr. Mount strenuously objected:Figure: In response to a question about whether empathy can be taught, Edwin Hughes Cassem, BD, MD, PhL, said that he believed it couldn't, but that practitioners can learn to be more empathetic by looking at each of their patients as unique individuals.“It is not touchy-feely, warm and fuzzy—It is a practical part of our role,” he said. “This is part of seeing a patient as a whole person and recognizing what we can do, whether it is modifying the natural history of the disease or not.” Audience members asked about the role of religion in meaning, issues of loss of control for both the patient and doctor, and whether empathy can be taught.Figure: Jimmie C. Holland, MD: “In order to feel a sense of meaning in one's life, it is important to identify one's values and then live a life that follows and honors those values. For many of us in the medical community, giving is a big part of it.”In response to the question on empathy, Edwin Cassem, BD, MD, PHL, a Professor of Psychiatry at Massachusetts General Hospital and a Jesuit Priest, said that it cannot be taught, but that practitioners can learn to be more empathetic by looking at each of their patients as unique individuals. To do that, he suggested, physicians or practitioners can ask themselves “Who was this patient when she was at the top of her game?” or they can ask the patient questions that extend beyond the disease, such as “What are some of the things you are most proud of?” Added pioneering psycho-oncologist Jimmie C. Holland, MD, of Memorial Sloan-Kettering Cancer Center: “In order to feel a sense of meaning in one's life, it is important to identify one's values and then live a life that follows and honors those values. For many of us in the medical community, giving is a big part of it.” Dr. Cassem said that to identify one's own core values, he thinks in terms of questions such as “When freedom, fame, money are stripped away, what is still me? What does it stand for? What does it mean?” Balancing Personal Care with Time Demands of Busy Oncology Practice One of the audience members asked how a physician can balance this sort of very personal care with the time demands of a busy oncology practice. Panelists agreed that such an approach actually doesn't always take a lot of time, but rather an awareness of who a patient is and having an interest in that person. An oncologist in the audience from Indiana mentioned a study in which the researchers found that when physicians spent just five minutes on patient-centered questions, patients felt more attended to. Another audience member noted that listening to patients was key, not just asking the question. An oncologist from Mexico City thanked the panel for including such an important session in the ASCO program, saying, “Sessions such as this can really help redirect our thinking, help us distinguish between the science of medicine and the art of being a good doctor.” Conference Listings on OT Web Site A comprehensive listing of oncology-related conferences and courses is available at www.oncology-times.com under the “Conferences” link. To include a meeting in our listings, send the following: name of the event, sponsor, date(s), location, contact information including phone number and e-mail address, and Web site. There is no charge, but items should be submitted at least three months before the event. E-mail the information to [email protected]

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