A friend of mine plays a mean game of poker. She comes out ahead in Atlantic City, finishing near the top in hold ’em tournaments. She is a poker savant. Not long ago I asked her secret to playing the game so well.
“I learned to play cards when I was being trained to treat cancer.”
“Oh,” I said, “the discipline, memorization, patience and statistics?”
“No, that is when I learned not to show my feelings.”
Now, you may be saying, “Boy, she must be a cold fish. I’m glad she is not my oncologist.” You would be wrong. She is bright, caring and connects deeply with patients and their families. She is greatly admired, has received numerous awards and, frankly, could take care of my family or me anytime.
Read again; “I learned not to show my feelings.” She did not say, and definitely does not believe, that she should not have feelings or that she should ignore the emotions of her patients. Rather she believes that to display them in an unfiltered, spontaneous way around patients is a bad idea.
In the third year of medical school, students get their first real and extended contact with patients. Usually, patients like to talk with trainees and share their medical stories. One of the reasons patients are open to students, is that the students are not a threat. They do not know too much and are not allowed to give good news or bad. In other words, whatever happens, a student is not likely to ever give a patient The Look.
The Look happens in that fraction of a second when a doctor first learns something bad and by grimace, sideways glance, sigh or gesture, signals that the patient is in deep trouble. Patients go to great length to avoid The Look. They cancel appointments, dominate conversations or alter what they tell the physician. They will disengage and stare at the floor and, in the extreme, throw tantrums and storm out of the office.
Families too try to prevent The Look by flooding medical interviews with distracting questions and observations, or pulling the doc aside to request information be withheld. I have seen entire medical records from outside medical centers, which have been altered to hide the truth.
The Look is the reaper of hope, like a needle thrust into a balloon instantly deflating the spirit. The Look can bring a functional doctor-patient meeting to an end, as the patient drifts into despair. The patient may withdraw or slip into deep denial, undermining a physician’s opportunity to educate, plan and give the patient the tools to cope. Therefore, my friend is right. Skilled oncologists learn to avoid the “tell,” the “slip,” the “oh, damn” and, most of all, The Look.
A wise teacher told me that when you must give bad news, be prepared, consider, have a plan. “If you are going to take, be ready to give.” That is an excellent theory, be ready, but often you are sitting in front of the patient and they hand you a report, or the computer screen glows, or a voice on the phone informs, and suddenly, in a microsecond, you know things have changed for the worse.
Experience and training have taught you that if the let your eyes bug, mouth drop open and you start to mumble, then the patient is going to dissolve. You know if you are going to help the patient, organize the next steps, give that patient what they need to move forward, than you must get ready, consider, have a plan. Therefore, you do not let yourself display The Look.
This is not about denying the impact of the news, nor is it a lack of empathy. Quite the opposite; you absorb the impact of the blow, so you can start teaching slowly, step-by-step. Give the patient the time needed to absorb the news and adjust. Suppressing The Look is an act of mercy. You take the pain, for a while, so that when you can deliver the news carefully. It is not about denying a patient’s right to dignity, control or transparency. Rather, it is about teaching them gently so that the ability to cope is not lost.
Does this poker face undermine trust? Does it mean that you can never be sure what the doctor is thinking? Should you worry that the truth is hidden? The ability to teach gently and carefully, by giving news in mentally digestible pieces, is not a substitute for total and honest communication. Rather, it is a tool that makes it possible. If a patient finds, when the interview is over, and the doctor walks out the door, that complete information has been deliberately withheld, then its time to get another physician.
Learning how to suppress The Look is an absolute skill for any physician who takes care of seriously ill patients. The patient and doctor depend on that learned buffer. Nonetheless, I wonder if it is good for the doctor, as a person, to be a carved totem. What price do they pay? When they return to loved ones, can they be spontaneous, open, honestly warm? They must recover natural emotional expression; turn The Look on, as well as off. Still, I wonder whether that connection to a vulnerable, honest, human reality, is ever fully regained.
James C. Salwitz is an oncologist who blogs at Sunrise Rounds.