How timing shapes one of the hardest conversations in medicine
New research shows that a different kind of breast cancer awareness starts with better communication
A newly diagnosed breast cancer patient sits across from her surgeon to discuss her course of treatment. Moments after the surgeon starts laying out the options, she cuts in to say, “I want both breasts off.”
Surgical guidelines actively discourage this treatment for early-stage, one-sided breast cancer patients with no family history or genetic mutations related to breast cancer. In these cases, removing a healthy breast doesn’t improve survival odds and can raise complication risks.
But it’s also, unmistakably, what this patient wants.
Chase Raymond (left), a CU ǸԹ associate professor of linguistics and a member of the clinical faculty in Family Medicine at CU Anschutz, and Virginia Teas Gill (right), professor of sociology emerita at Illinois State University, collaborated on research studying how surgeons and breast cancer patients communicate.
In that moment, the surgeon faces a dilemma. Follow the evidence and risk overriding the patient’s autonomy or honor her request and allow her to forego the treatment option backed by decades of medical research: lumpectomy plus radiation therapy.
This tension plays out in exam rooms around the world every day for breast cancer patients in need of life-saving care. It is also at the center of from Chase Raymond, a ǸԹ associate professor of linguistics and a member of the clinical faculty in Family Medicine at CU Anschutz, and , professor of sociology emerita at Illinois State University.
October, which is , is a fitting time to examine that push-and-pull through a new lens.
“Our approach is to look at real recordings of actual consultations, with prior consent, of course, and then we can see what surgeons and patients are really doing,” Raymond says.
In studying the moment-by-moment mechanics of how doctors and patients reach treatment decisions, their paper sparks valuable discussions about patient advocacy and how providers can navigate the balancing act between competing mandates.
A black box, finally opened
Raymond and Gill’s approach relies on Conversation Analysis (CA), a tool used for uncovering the interactional structures that underpin every ordinary conversation.
“This is language and social life—the interactional mechanics that we use to get the activities of everyday life accomplished with one another,” Raymond says.
Gill was drawn to breast cancer surgical consultations for this study because of a historical trend concerning that patient population.
“Historically, breast cancer patients did not have a say in how they were treated. Really, through the 1970s in the United States, this was a decision that was made by physicians,” she says.
For years, radical mastectomy (removal of the breast[s], chest muscles and nearby lymph nodes) was standard treatment even for small tumors.
Today, researchers understand more about what factors influence a patient’s long-term outcomes and which treatment modalities represent the best chance for remission. Treatment options have expanded, giving patients many more choices for their care, including the option to have less-extensive surgery. However, many early-stage patients are now expressing a desire to have both breasts removed.
Yet, what happens between patient and provider in the exam room has largely remained a mystery.
“What goes on when the surgeon and patient talk to each other has been kind of a black box,” Gill says.
“The challenge at issue is, how can patient preferences be balanced with best practice guidelines in this setting?” asks researcher Virginia Teas Gill. (Photo: Unsplash)
She and Raymond wanted to open it.
“We want to understand this process of how surgical treatment options are presented and negotiated, and Conversation Analysis gives us the tools to do that,” Gill adds.
Two mandates
The challenge for physicians isn’t simply whether to make a recommendation for a particular course of treatment. Gill and Raymond note that doing so is often medically necessary.
“The challenge at issue is, how can patient preferences be balanced with best practice guidelines in this setting?” Gill says.
In cases where surgeons and patients may have different perspectives, “both sides are looking for the right thing to do, but figuring out what exactly that is doesn’t happen in an instant. The surgeon and the patient are going to take turns back and forth to ultimately arrive at a decision,” Raymond says. “The sequencing and the ordering of the parts of this conversation are incredibly important.”
‘OK, then you need to hear me out’
In one consultation Raymond and Gill studied, a surgeon walks this tightrope on the record. When the patient asks for both breasts to be removed before being presented with complete information about her options, the surgeon neither grants nor denies the request.
She instead asks the patient to wait and hear the full picture first, including the survival and recurrence statistics associated with all her options.
Gill and Raymond use this example to illustrate how this surgeon works to help the patient make not just her own decision, but a decision that is informed by medical evidence.
“Before granting the request, the surgeon asks the patient to first listen to information that she might not know,” Gill adds.
The duo likens the interaction between patient and provider to stocking a metaphorical pond.
They note that every patient enters the room with “their life experience, their preferences, their values, what they’ve heard from other people and all kinds of media sources.”
Physicians have their own pond filled with information, and the two don’t always fully overlap.
Before a final decision is made, Gill says, the surgeon’s job is to close this information gap. In this case, that means presenting clinical trial data on survival and recurrence, so that the patient has access to the information in their pond. It also means giving the patient an opportunity to ask for more information and express her concerns to complete the surgeon’s picture of what matters to the patient.
That’s why understanding these conversations is so important. There’s a lot at stake, and everyone is trying to achieve the best outcome."
Raymond says, “The patient is thereby reassured that the decision is hers, and will remain hers, but some additional information will be shared before that final decision is made.”
Working both ways
Patients, Gill says, can use the same strategy in reverse, asking to hear more information before accepting a surgeon’s recommendation, or before any medical decision is made.
Raymond notes that physicians are given a limited window of time to convey a tremendous amount of information, with patient satisfaction and complication risks on the line. But no outcome feels good if a patient goes through with a treatment they later regret or leaves the office without understanding all their options.
“That’s why understanding these conversations is so important. There’s a lot at stake, and everyone is trying to achieve the best outcome,” Raymond says.
Conversation Analysis is one way researchers can peek behind the curtain and identify patterns that can help both sides communicate more effectively.
The researchers believe the observations made in their study are important for negotiations beyond the surgical consult room, too.
“This is a dynamic that happens in a lot of contexts. It’s a balancing act that plays out in many different settings, both in and out of medicine,” Gill says.
In the exam room or elsewhere, timing matters. If information can be given before final decisions are made, these priorities don’t have to be in competition. For Gill and Raymond, the study is also a reminder that how patients and doctors talk to each other still matters.
Did you enjoy this article?Passionate about linguistics?Show your support.