Take-home Message

Cognitive intervention

(Fictional narrative by the doctor)

James Fleck, MD, PhD: Anticancerweb 25 (06), 2020

After years in the daily clinical practice, I had already realized the importance of the information provided to the patient. The information helps to create a positive attitude when facing cancer. Influenced by a pedagogue mother, and father with artistic talent, I have always worked under the perspective of cognitive psychology and creativity. I have always believed that the doctor-patient relationship should require clear and understandable communication. I used to be uncomfortable with the word patient as it referred to a passive attitude. In my opinion, the patient should always actively participate in the assessment, as all recommendations must be submitted to the patient's consent. Furthermore, consent will only be validated if the patient fully understands what has been previously informed.

The physician must include a cognitive and social function in his assessment, supervising and encouraging the patient in the active search for technical information. This will help the physician to reinforce and develop positive attitudes in the patient, improving resilience.

Alex's request was aligned with the interactive approach.

In addition to technical efficiency, the physician must develop the skill of a coach, understanding the patient's psychology and preparing him to face adversity. He needs to be attentive, anticipating and correcting any attitude of the patient that could jeopardize the result.

I was excited about the idea and set up a task force to develop a tutorial. I was looking for something that would be accessible to all patients, regardless of their educational, social, or economic status. For this reason, I produced the tutorial in print and electronic format. The method would be similar to athletic training. The athlete already has the ability, but the coach is the one who makes the result possible.

I realized that this task would not be easy. As a teacher, I knew that the best result was obtained when the student actively sought information. Although I taught lectures in our clinical oncology fellowship program, my greatest satisfaction was with the daily rounds on the wards. I used to encourage my students to actively seek out information and then get their critical feedback. As a result of this interaction, knowledge was better understood, supported by evidence, and better transferred to the patient care program.  

The tutorial would follow the same strategy. I would have to identify the ideal time for the application. Some patients actively sought information, as Alex did. They represent a more favorable group in which the tutorial could be recommended in the first appointment. Others were not so proactive and I should be more cautious. However, I had observed that even when this curiosity did not manifest itself spontaneously, it was present as a subliminal idea in most of my patient's mind. Sometimes the search for information would express itself clearly only after a few consultations.

Let's go back to the comparison with the coach. He knows the right time when he should or can work with his athlete, both physically and emotionally. It is an exercise in mutual trust, essential for obtaining the best results. The dynamic can easily be transferred to the doctor-patient relationship.

I had to identify the best time to apply the tutorial. I also anticipated that the best tutorial result would occur in patients who already expressed resilience.

Resilience consists of a set of attributes that help the individual to face adversity, overcoming physical and emotional distress. Resilient patients promote a cooperative attitude with the doctor, usually at the first visit. They seek a clear understanding of medical thinking and how it will lead to diagnostic and treatment evaluation. They are optimistic and curious, persistent and effective. The ideal situation for any doctor would be the appropriate combination of a resilient patient with a well-structured training program (tutorial).  

However, not always a quick and spontaneous expression of winning behavior occurs. Sometimes it is necessary to break down a barrier imposed by an inappropriately protective family or even rescue self-repressed attitudes by the patient. Most of the time, the repression is due to the fear of the unknown or to the fantasies of an association between cancer and death. Rescue is possible whenever minimal signs of resilience are observed in the patient's behavior. It must be actively pursued, even when it is subtle and veiled. Resilience represents the basis for a winning behavior and must be worked up with a combination of interpersonal trust and accurate information. 

The biggest challenge occurs with patients who do not express any sign of resilience. In the coach's analogy, this is a situation of an undisciplined, unmotivated or even incompetent athlete. The challenge becomes huge. The doctor will have to search in greater depth for individual, family or social limiting psychological factors. Unfortunately, in this group of unmotivated patients, the physician does not have the time to work out the lack of resilience before starting the interventions. The doctor will have to work in both directions, at the same time. The patient needs to be treated and assisted in parallel with all his emotional limitations. A reasonable strategy is to restrict the information, explaining only the intervention that is being immediately proposed. The physician must make sure that the patient has fully understood the provided information. A positive feed-back should be permanently exercised. It is similar to a student who requires special care, with an individualized tutorial, specially adapted to his personal needs.

To be continued in PLOT 3 (conflict) …

* Attention: The story 6 will be published sequentially from PLOT 1 to PLOT 6 and you will always see the most recent posting. To read Story 6 from the beginning, just click in the numbered links located at the bottom of the homepage.  

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James Fleck, MD, PhD: Full Professor of Clinical Oncology at the Federal University of Rio Grande do Sul, RS, Brazil 2020