“Is there somebody who’s willing to hold their hand at the edge?” - Bringing the Patient to the Center of Physician-Patient Communication and Decision-Making on Bone Marrow Transplantation

Abstract

Medicine is beginning to appreciate the value of “patient-centeredness”—healthcare attentive to the unique characteristics, needs, and values of each patient—and a wide body of evidence shows that physician-patient dynamics can have real effects on patients’ health. The patient-centeredness movement has led to calls for more equitable physician-patient relationships, shared decision-making, and more individualized models of care. But building all those requires fundamental shifts in the language physicians use to communicate. I analyzed 20 conversations between patients and physicians specializing in bone marrow transplantation for the physician-patient relationships that their communication produces, and the effect of those relationships on patients’ decision-making ability. My findings revolved around the “data dump”—that is, the physician’s nearly ubiquitous, depersonalized, extended monologue on the biology and history of the patient’s disease, the array of options available to treat it, and the risks and prognosis associated with each. I found that “data dumping” can have one of two effects: leaving patients confused and unable to decide on a treatment path, or silencing patients and preventing them from actively choosing their treatment. Silencing and disempowering patients can in turn prevent them from voicing clinically relevant information, and even from healing as well as they would if they were empowered. I also found that physicians and patients often had very different definitions of a “cure” and goals for their care; while the transplant specialists were focused on the cancer, patients had their minds on their lives as a whole. Taken together, these encounters showed that patients need treatment options to be individualized, contextualized, and delivered in a way attentive to their uniqueness, autonomy, and ability to process information. The physician is the only person in the encounter capable of fulfilling this need. Thus, drawing insights from a communication theory known as Motivational Interviewing, I offer recommendations on how physicians can humanize their information delivery and support their patients’ decision-making. If put to practice, my analysis and recommendations can make medical information delivery and decision-making more effective and equitable in a wide range of contexts.