Take-home Message

Patient-centered communication

(Fictional narrative by the doctor)

James Fleck, MD, PhD & João A de Andrade, MD

Anticancerweb 13 (02), 2019

It was a summer afternoon when Theophilus came to my office for the first time. He was accompanied by his wife, Vilma. Theophilus was a 75 years old gray-haired and mild-mannered gentleman. From the moment I walked into the office, he remained very focused and was clearly measuring my body language and scrutinizing my comments. Vilma was a calm and collected 70-year-old lady who stared protectively at Theophilus during the consultation.

They struck me as a happy and loving couple.

They were naturally worried, since this was the first time Theophilus was facing a potentially severe illness. He retired from a successful military career and had always been careful and proactive about his health. He exercised regularly, never smoked and kept a healthy weight.

Vilma had never faced any major illnesses herself, so this was definitely new territory for her as well.  

They had built a large family, consisting of three sons and two daughters, who had already given them twelve grandchildren. Vilma knew the names, ages and personal preferences of all grandchildren while Theophilus simply refer to them by birth order. It was obvious, however, that both had great affection for their family.

Six months prior to visiting me, Theophilus started having urinary problems.

His sleep was interrupted every two hours by the need to urinate. On occasion, he felt an urgency to urinate many times during the day and recently he began to have occasional urinary incontinence. 

Theophilus knew that aging alone could bring up many of those symptoms.  Indeed, they are often caused by a benign disease called prostatic hyperplasia, but they can also be a sign of a more serious issue such as prostate cancer. He used to have regular check-ups with a general practitioner who requested a blood test called PSA, which stands for “prostate specific antigen”. Upon receiving the PSA result, the clinician alerted him that the value was above the upper limit and recommended an appointment with a urologist.

PSA is a marker of prostatic tissue health that can be measured in the blood. The level of PSA may be above the upper limit in benign prostatic hyperplasia (BPH) or prostate cancer as well as other conditions such as bacterial or fungal prostatitis, urinary retention and even ejaculation. Specifically, a rise in PSA level could be detected in any circumstance related to increased PSA production and/or rupture of the tissue barriers between the prostatic tissue and small blood vessels. 

Theophilus PSA level was 9 ng/mL, which falls within a grey zone where both BPH or prostate cancer are possible. 

He was appropriately concerned with the meaning of the results and was very frustrated by the lack of precision and clarity. 

Being an engineer that worked on robotics and artificial intelligence, he was used to deal with very precise and reliable results. When he questioned the general practitioner why the test was ordered, he response he got was that he would need to be checked by a Urologist. He was far from happy…

As I listened to his narrative of the sequence of events that brought him to me, I felt that this was my first opportunity to step in. He came across as a rational and inquisitive person. In fact, many of his frustrations with the state of prostate cancer screening tools are shared by physicians! I felt that I would have to try to meet his expectations for precision and proceeded to give him more details about the process. 

I explained that in Medicine we often have to integrate many sources of incremental information before a diagnosis and a plan of care can be developed. The digital rectal examination (DRE), associated with a transrectal ultrasonography or more recently with multiparametric magnetic resonance image would help us understand the meaning of the results of a PSA test. I explained that the PSA can have a high degree of false positive results (which we call “low specificity”) for cancer, but that it would be very useful for treatment monitoring if cancer is confirmed. In addition, the performance of the PSA test as one attempts to differentiate BPH and prostate cancer declines among those patients with urinary symptoms compared to testing an asymptomatic population. Unfortunately, an even more refined genetic test (PCA3) performed in urine after vigorous DRE does not have 100% sensitivity or specificity for prostate cancer. I stressed the fact that the diagnosis of prostate cancer requires a comprehensive consideration of all signs, symptoms as well as complementary advanced testing such as image-guided biopsy.   

Theophilus smiled and asked me to try to empathize with the fact that it was very difficult for an engineer to deal with such degree of imprecision!

Vilma touched his hand. 

He added that for the first time in his life he was understanding “how doctors think”!

I smiled back, and proceed to ask more details about his medical history.

Feeling more at ease, he reported what happened during the consultation with the urologist.

The urologist performed a DRE and identified enlargement of the prostate (around 90 g) and a firm nodule on the surface of the right lobe. He requested a transrectal ultrasonography, which confirmed the finding of the clinical examination, adding information of a single nodule with extra-capsular extension, which means that it had already gone beyond the prostate. Seeking to better define the tumor extension, the urologist requested a multiparametric magnetic resonance imaging.

Theophilus shared his frustration with Medicine with the Urologist. All new findings were followed by requests for further investigation in what seemed to be a circular, tiring and everlasting process. He asked for a second-opinion, even before the Urologist had a chance to explain his approach.

The consulting Urologist, who was a very well qualified and able physician, obliged and immediately gave him the names of a few colleagues that would be able to give him good advice.

This is how I got involved.

He told me he did not want to delay the investigation, but he was still uneasy about the proposed diagnostic plan.

At that moment I realized that the patient had made every effort to understand the medical reasoning, but it was very difficult for him to have closure, since he was coming from the point of view of the exact sciences. He was hoping to find an approach that followed the same rational and predictable method that he was familiar with. 

He was almost rejecting Medicine as a science!

I made the argument that Medicine, although sometimes more an art than a science, would surely help him, but it would be necessary for us to try to speak the same language. The medical rationale might seem incomprehensible to him, just as it was difficult for me to understand advanced mathematics.

I started our dialogue by asking him to tell me about his expectations. I wanted to know more about how his thought process was “wired”.

He seemed to like this approach and challenged me to solve an old game called Tower of Hanoi. He told me that by solving the game, I would be able to gain some insights into his mind and how it operated.

I accepted his challenge and in return, proposed a task: I had developed a tutorial meant to give patients an insight into how a physician thinks and makes decisions. I asked him to read and critique it as honestly as he could!  

We gave each other 48 hours to complete our assignments. 

*       Attention: The story 2 will be published sequentially from the PLOT 1 to the PLOT 6, however it will appear backwards. So, you will always see the most recent publication. Just browse in numbered pages located at the bottom of the homepage and start to read the story 2 from the beginning. 

To be continued in PLOT 2 (rising action): Commitment 

© Copyright 2019 Anticancerweb

 James Fleck, MD, PhD: Full Professor of Clinical Oncology at the Federal University of Rio Grande do Sul, RS, Brazil 2019

Joao A. de Andrade, MD: Professor of Medicine and Chief Medical Officer, Vanderbilt Lung Institute, Vanderbilt University Medical Center, Nashville, TN – USA 2019 (Associate Editor)