You don’t have to solve everything in one visit. Sometimes you learn things in one visit that open the door for you next time.
Michael J. Fisch, MD, MPH
Just asking patients “Is there something else you want to address in the visit,” rather than “Is there anything else you want to address in the visit today,” dramatically reduced patients’ unmet concerns during a primary care visit, according to a 2007 study.1 That learning can be applied to talking to cancer patients about pain.
“If you say ‘anything else’ or if your hand is on the doorknob, you are sending a little message, ‘Are we done yet?’” Michael J. Fisch, MD, MPH, told The ASCO Post. Lead author of a cancer pain study recently published in the Journal of Clinical Oncology,2 Dr. Fisch is Chair of the Department of General Oncology at The University of Texas MD Anderson Cancer Center in Houston.
Asking open-ended questions during—and not just at the very end of—a visit, and letting patients offer enough clues about what is troubling them can provide the information physicians need to help patients manage cancer pain. “I think that is a skill that can be learned,” Dr. Fisch said.
He suggested the following open-ended questions:
• Take me through your day. What are things like for you these days? You may have to prompt patients by saying, “You wake up and have a cup of coffee and then what happens?” By using that line of questioning, physicians might find out that a patient gets tired from a short walk or needs somebody to bring food because leg pain is preventing the patient from standing up to use the stove. “By the time you take me through your day, I have a pretty good sense of your functional levels and limitations are,” Dr. Fisch explained.
• What was your life like before you started cancer treatment? This question can provide a sense of what functions patients have lost and how that affects them. For example, a patient might say, “I was the kind of person who was very busy. I did it all. I had lots of energy. Now I can’t do anything. I can’t remember things. I hurt all the time.”
These questions and the conversations that flow from them can help physicians understand what patients think is really important to their lifestyle and quality of life and build trust.
“You don’t have to solve everything in one visit,” Dr. Fisch advised. “Sometimes you learn things in one visit that open the door for you next time. In real time, that ‘something else?’ question may not have done much more than plant the seed, but that seed can help you understand the patient in the most robust way, as a whole person, so you can figure out how to help in all possible ways, not just during chemo or when the next scan is ordered. It is saying to the patient, ‘That’s not all I am interested in.’”
Not all the talking needs to be done by the oncologist. “The oncologist can set that tone, and then the midlevel providers—the other people in the office—can pull together these clues about the patient that inform you how to focus the care and get better results,” Dr. Fisch said.
“That is an integrated systems and team work issue, using your own systems, your own personal clues, and the people you consider your own microteam over time, and figuring out what you can do to help the patient,” he added. “You shouldn’t just go through your own agenda, your predetermined check list, because patients do not experience things in the linear and limited way that you wish they would. If you accept that you are dealing with complex issues, then you have to let your techniques inform how you can be successful in the face of that complexity.” ■
Disclosure: Dr. Fisch reported no potential conflicts of interest.
1. Heritage J. Robinson JD, Elliott MN, et al: Reducing patients’ unmet concerns in primary care: The difference one word can make. J Gen Intern Med 22:1429-1423, 2007.
2. Fisch MJ, Lee J-W, Weiss M, et al: Prospective, observational study of pain and analgesic prescribing in medical oncology outpatients with breast, colorectal, lung, or prostate cancer. J Clin Oncol 30:1980-1988, 2012.
In 1994, a landmark study of pain among oncology outpatients prompted a host of pain management initiatives.1 More than 18 years later, a recent study among more than 2,000 cancer outpatients has found that “one-third of the patients who had pain or used analgesics received inadequate treatment for ...