Dr. Richard Neubauer: It is my pleasure to introduce our next speaker, Dr. Neil Farber. Dr. Farber is clinical director of the La Jolla Internal Medicine Group and Professor of Clinical Medicine, UCSD, San Diego, California. He and I have worked together on the American College of Physicians Ethics, Professionalism and Human Rights Committee over the past several years. Dr. Farber has also been our guest at grand rounds in Anchorage in the past, where he has discussed his original research on physician attitudes and how it influences their practice of medicine. Dr. Farber recently moved to southern California from the East Coast.

Dr. Neil Farber and his wife

Dr. Neil Farber: How many of you, as a physician, have had a patient who happens to be a physician, or had a patient whose caregiver is a physician? Almost everybody. Not quite, but almost everybody. And how many of you, upon hearing that, thought to yourself either, "Aha, this is going to be easy," or "Oh my God"?

I will argue the point at the end of my lecture that basically either of those are not quite what we want to do. The basic take-home message is that patients who are physicians are patients, and caregivers who are physicians are caregivers, and we have to approach them as such. Yes, a little bit special situation, but we have to approach them as such.

What I want to do is talk a little bit about general communication issues and then get into some specific issues that are a little bit more touchy, into how do we deal with communicating with patients who are physicians and physicians who are caregivers.

Are Physicians Different?

The first thing is, is a physician different than any other caregiver? The answer is, well, physicians obviously have more education and training in the area we're talking about, but their emotions are the same as anybody else's, and they're placed in the same situation as anybody else, and it's important to recognize that, so that we're dealing with a special situation when we're talking about dealing with a physician. The other thing is, you can't assume that a physician is knowledgeable in that field. They may not know everything. Generalists may not have detailed knowledge of specific conditions, and specialists may have knowledge only in their field, not general internal medicine, for example.

I will give you a story, and I'll talk about this as a theme throughout. I became involved in this and interested in this because of the fact that I have had an interest for a long time in communication issues and in medical ethics. Eleven years ago, my wife, who is with me, was diagnosed with brain cancer. I'll talk a little bit about some of the stories that happened along the way, but you need to hear that so you can understand where the stories are coming from.

How many of you know the details of what an anaplastic oligodendroglioma is? Yeah. That's what she had. I didn't even hear the word before it was told to me, so I had not a clue. This is sometimes what we're dealing with. I've had patients who are nephrologists. They've forgotten their general internal medicine and don't remember about statins. So it does happen.

Talking to Everyone in the Room

In terms of assessing the information from the patient, there's a tendency to talk to the physician in the room. When we're dealing with the patient, either the physician is the caregiver or the physician is the patient, the tendency is to talk to the physician. That's normal, because we can talk a little bit easier with one of our colleagues. But it excludes the non-physician from the discussion. It can either be the caregiver in the room, i.e. if the physician is the patient but brings their spouse, you're ignoring the spouse, or conversely, if the physician is the caregiver, you can talk to the caregiver about the details of the medical condition and forget that you're really dealing with the patient.

There's also a pitfall in assuming, as I said, that all the information is known. As I said, I didn't know anything about anaplastic oligodendroglioma, and the neurosurgeon that we saw assumed I did. So you have to be careful about that.

One of the other pitfalls is, there's clearly a tendency to use more jargon when the physician is the caregiver or the patient. If the physician is the patient, there is first of all a denial of the patient status of the physician. If you're dealing in jargon with a physician, you're talking technospeak, you're talking medical speak. And it denies the fact that that physician is actually a patient. It's almost as though you're talking about a colleague, about someone else, rather than you're talking with that person who is the patient in front of you. And it also excludes the lay caregiver from the discussion, from understanding what's going on.

Alternatively, if the physician is the caregiver, it leaves out the patient, and also, again, it denies the status that the physician has as the lay caregiver. We'll talk a little bit about this this afternoon.

What does this say?

"There is a bear in a plain wrapper on 78 doing flip-flops handing out green stamps."

Now it's plain English, but what does it mean? Anybody know?

The bear is a state trooper, because they wear the Smokey the Bear hats. In a plain wrapper, unmarked police car. On I78 doing flip-flops, anybody know what doing flip-flops is? That means straddling the median going on both sides of the road, handing out speeding tickets. In plain English, there isn't anything there you didn't understand, but you had not a clue what the meaning was. And that's what we do when we're talking about medicalese with our patients.

The other thing, there's a tendency to not keep open-ended. There's a tendency, especially when you have a patient who is a physician or a caregiver who's a physician, to ask more questions and especially in medicalese, and give more information, especially in medicalese, and again, that negates the patient/caregiver status of the physician. So we need to be more patient-centered, more open-ended. And that allows for more information back from the patient and the caregiver, and allows for some feelings to be expressed, and improves the relationship. The relationship, remember, is not with your colleague. It's with your patient.

Who Makes the Decisions and How?

Decision-making is critical. There really is a tendency to have the physician who happens to be the patient or caregiver make decisions. Again, the physician may not have knowledge in that area, and it puts an unnecessary burden on that physician. It really abrogates our role as being the physician involved in that patient.

Also, what we want to do is have a negotiator approach to the decisions. We make the decisions and we get acceptance from our patients.

When my wife went to see one of the neurologists at the institution where she was being cared for, because she had seizures after she had her treatment for her brain cancer, the woman looked at her, who knew I was a physician, looked at her and said, "So why are you here?" She said, "Well, my neurosurgeon said I should see you, because I have these seizures after all my treatment, and he felt it would be appropriate for a neurologist to follow me and put me on whatever antiseizure medicine is appropriate and take care of me."

She looked at my wife and said, "Isn't your husband a physician?" She said, "Yes."

The neurologist looked at my wife and said, "He's a general internist, right?" She said, "Yes."

The neurologist looked at my wife and said, "Well, he can take care of you. I don't need to do this." That's wrong. For a lot of reasons that we'll go into this afternoon.

Giving Patients Bad News

I want to shift just a little bit and talk about some of the specific nitty-gritty issues, like breaking bad news. We did this study looking at physicians, about their experiences, about how they gave bad news. We found that basically, only about a quarter of the physicians we interviewed had any kind of training in how to give bad news. That's not uncommon. It is only now that medical schools are beginning to do this. This is not what we want to do.

This was my wife's case. She presented to the neurologist. I unfortunately was in denial. I will admit that. I thought it was simply migraines, because I was in denial. When he kicked it up a notch, then I got in gear. But anyway, she went to a neurologist. She had focal seizures and headaches. The neurologist (this is a different neurologist than the one who said that -- we already left him, you'll see why in a minute -- the other one wasn't much better) took a history, performed a neurologic exam that was normal, and he ordered an MRI and performed it two days later. He called my wife on the phone. I was at work, about 15 miles away. I don't remember the drive home, and I'll show you why in a minute.

The neurologist said on the phone, "Mrs. Farber, your MRI shows something white in the brain." She said, "I don't understand. Is this is a joke?" He said, "No, I'm sorry, there is something abnormal, and you need to see a neurosurgeon right away." She said, "Is it a tumor?" He said, "I don't know, just see the neurosurgeon as soon as possible." And that was the conversation.

I got told about this and drove home probably about 90 miles an hour. I don't remember it. She went and saw the neurosurgeon with me in the room this time. The neurosurgeon again took a history, examined her, put the MRI up in the light box, and said, "Here's your tumor in this view and in this other view." Notice this is the first time anybody actually said "tumor." "It's in the right frontal lobe and it does enhance so it's probably a grade III or IV astrocytoma. We can biopsy it, but I recommend we remove it and give you another one or two years of life."

(She's in the room now. It's 11 years later.)

So I got interested and found that there is a better way.

Breaking Bad News: Six-Step Protocol

• Getting Started: Physical and Support Setting / Starting the Conversation
• What the Patient Knows
• What the Patient Wants to Know
• Aligning and Educating
• Responding to Patient Emotions
• Planning and Follow-Through

This is a six-step protocol from Robert Buckman, which most people believe is probably the best way of indicating how to give bad news to patients. It's basically six steps about getting started. First finding out what the patient knows and what the patient wants to know, then what he calls aligning and educating, responding to patient emotions, and planning follow-through. The basic core of this is what we call patient-centered. That is, starting from where the patient is and moving from there.

Getting Started

Some of the issues about getting started: meeting in private, in person. Obviously you can't always meet in person. Sometimes it does come out on the phone. But as much as possible, in private. At a time that's convenient to the patient and the family, having a support person there if possible, holding your telephone calls, holding your beeper, having somebody else hold your beeper. He doesn't include this, but I do. I advocate not wearing a white lab coat. I don't know how many of you do when you see patients. But if you usually do, I advocate not doing it. The white coat is a barrier, and you want to be aligned with the patient at that point. Sitting next to the patient, not across the desk. And beginning by asking how the patient is feeling.

What the Patient Knows

The real first step is finding out how much the patient knows. What we want to do is get an understanding of the medical situation, and sort of a style of their statements. Are they medically savvy or not medically savvy? And obviously, this is important in a physician's case, knowing how much they know about the situation. I know this. I've been practicing 29 years. If you asked me, when I saw what she was having, "What do you think is going on?" I would have said, "Oh, well, she's had migraines before, this is just her migraine transforming." That was because I was in denial. So you need to hear that from the physician. Are they in denial, for example?

You also want to find out the emotional content of their statements, and you find that out from their verbal and nonverbal statements that they're using. You want to assess the level of communication. For example, if the physician is the patient, how much have they shared with the caregiver? How much does the caregiver know what's going on? If the physician is the caregiver, how much did he or she share with the patient and share their feelings? Denial is a very powerful thing. I did not tell my wife that basically the possibility was this was a tumor. First of all, I was in denial and wouldn't accept it myself, and even when I got kicked out of gear and said to myself, "My God, she probably has something going on," I didn't want to hear a word.

What the Patient Wants to Know

We have to assess the different levels of information in terms of diagnosis, treatment options, prognosis, and we have to decide what we're going to discuss with the patient. Buckman advocates finding out what the patient wants to know, at what level, how detailed, and leaving the door open for denial. This should be done, I advocate, before you ever get to this stage, where you're actually giving bad news. You should know ahead of time. But if you haven't, then it's important to ask, because not all patients want to know.

Aligning and Educating

He then goes on to talk about aligning and educating, and that includes deciding on what your objectives are during that meeting. Remember that once you give bad news to somebody, they don't hear anything else. I can tell you, sitting in the neurosurgeon's office and actually hearing, "This is a tumor," I don't remember the rest. I didn't remember the rest at that point. So what we want to do is align and start from the patient's point of view, and then bring the patient's and the caregiver's point of view closer to where we are. You do that by giving a warning shot, something like, "I'm afraid I do have bad news for you." Giving information in small chunks, usually a *narrowing of events. Avoiding jargon, that we talked about. Checking reception frequently, making sure the patient and/or the caregiver are hearing what you're saying. Reinforcing and clarifying the information. Listening for the patient's concerns and the caregiver's concerns and blending your agendas.

Responding to Patient Emotions

Then responding to patient emotions. We do that by identifying and acknowledging their emotions and encouraging them to actually express their feelings. The use of therapeutic touch and the empathetic response. Remember that any type of emotion can occur when you're giving bad news, and that can be anything from denial to anger, sadness, relief. Don't be surprised what occurs. For the physician who is the patient or the caregiver, rational thought and emotions are very separate. You need to deal with each.

Anger can often be one of the components of what occurs. It can be fate or God, or family members, physician and medical establishment. For physicians as the patient or caregiver, it may often be turned on themselves. "I should have known better, I should have realized what was going on." That's especially true when the patient is the caregiver. I can tell you, I had those feelings.

In terms of dealing with emotions, it's important to anticipate and prepare yourselves ahead of time, and recognize and acknowledge the emotion, discuss it, apologize and make a plan of action, and I'll go into each of those. I don't mean exactly apologize, just so you know.

Okay, you're giving somebody bad news, or we'll see some of the other kinds of sensitive discussion we're talking about. Be ready. There's going to be emotion, so you have to prepare yourself for it. Again, remember that anger is not always directed at you, and don't take it personally. Highly emotional patients can make you highly emotional, and that can escalate. There's something called limbic resonance, and the way it works is basically, it's actually a structure in the brain, it's in the limbic system, along with specific nerve transmitters, and it's a protective device. You've all seen a mammal or bird go crazy trying to protect their young. Have you ever seen a snake do it? A snake sees its little snakelings get eaten by a bird, and they just slither away, because they don't have this. So it's a protective mechanism, it's a survival device, but we have emotions that resonate off another person.

You've all had the feeling of going into a room and having somebody literally just about ready to jump out of their skin. How do you feel when you go in that room? You get really anxious. You feel your skin crawl. Or you go into a room and somebody's really pissed off, and you're suddenly feeling yourself get really angry. That's what's happening. And when that happens, it continues to escalate, so we want to try and defuse that.

If you're unsure of the emotion that the patient has, you might ask, "Are you feeling upset about this?" or "How does this make you feel?" That helps you to understand where they're coming from emotionally. You want to acknowledge the emotion. So something like, "You really seem upset." I tend to use "upset" rather than "angry," because "angry" is a little pejorative, and people get a little bit angry about hearing that they're angry. So I'll say, "You really seem upset," or "You really seem frustrated," or something like that. And again, try not to react to the emotion, either with your body language or verbally. Verbally, try and listen to it rather than defend it.

So you want to elicit the patient's perspective. Eliciting their perspective is not the same as agreeing with them. You want to ask, "Can you tell me why you're so frustrated?" or "What were you hoping would happen today?" and then say something like, "I can see how you would be so upset about this. It makes sense." You don't want to interrupt unless the patient is getting out of control. You want to let them let off steam and recount their grievances, and as I said, validating their emotion is extremely important.

The "apologize" is not really an apology. It's basically a statement of sympathy. "I'm sorry you're so frustrated. I wish that you didn't have cancer." Something along those lines.

Planning and Follow-Through

And then lastly, after dealing with the emotion, Buckman advocates inquiring and addressing the patient and caregiver concerns. You can't assume that your concerns match those of the patient and the caregiver. Remember that the physician is acting in that role, as a patient or caregiver, not as a physician. So their concerns may be very different from your concerns. Your concern may be, "How can I get this patient to the oncologist for chemotherapy?" Their concern may be, "How am I going to tell this to my 13-year-old son?" So they can be very different.

You do want to make a plan and explain it. I advocate avoiding specific statistics, as does Buckman. You want to not talk about numbers of survivors or amount of time left or any of those kinds of things, except in very general terms. It's okay to talk about general terms of survivorship, i.e. the months, the years, or many years, or whatever, but don't give specific statistics. Physicians will try and go there. Try not to if you can.

Part of that is providing some kind of hope. Hope can be different kinds of things. It can be, "I will be there with you. I'll make sure I get the best care for you. I will go to the experts and find out how to get the best treatment, the best palliative care, whatever it might be." Both your individual support as a health care provider, as well as support groups, are important. Most physicians are unaware of support groups, so you may need to investigate that. Individual support as a physician is important, but don't make promises you can't keep. If you're planning on leaving the state in four months, and the physician who is the patient is in a vulnerable position at that point, don't say, "I'll be with you the whole time," if you're going to be gone. And you don't want to give specific statistics, not even to physicians. You want to deal in generalities.

How Do Physicians Deliver Bad News?

So we want to find out how physicians do give bad news. We asked 1,000 practicing internists in the United States about different factors they use in giving bad news, and we asked both items of structure and time, as well as emotional support, and these were all the items we did in terms of structure and emotional support, dealing with fears, etc. Generally, physicians did pretty well by their self-report, except there were some things they didn't do as well as they should have.

For example, they didn't avoid wearing a beeper. They didn't refer patients to support groups, probably because they didn't know about them very much. And they didn't avoid wearing a lab coat. Generally they did pretty well on emotional support, but notice they fell off in terms of giving specific statistics. I would advocate that's probably not what we want to do.

Physicians' Emotions: To Share or Not to Share?

So this is the seventh step. Do we share our own emotions with our patients, and how do we do so? Well, there are different ways of doing so, of dealing with our own emotions. We as physicians are going to have much stronger emotions dealing with a colleague's illness or a colleague's significant other's illness than with the average patient. We share them often times with colleagues in terms of things like valent groups, small groups that get together and talk about emotions and patients that they've had various emotional issues with. They may talk about significant others. They may talk with their medical or non-medical friends.

The question is, is it okay to cry with a patient? We did this survey of residents and their patients in a residency program, and we gave seven scenarios in which bad news was given, and we looked for a concordance between physicians and patients in terms of when was it okay to cry. We found that there was a lot of concordance, that it was better to cry in a life-threatening situation than in a non-life-threatening situation. Both patients and physicians agreed with that. And that basically, if the patient cried first, it was okay for the physician to then cry, not the reverse. Again, both patients and physicians had concordance with that.

But generally speaking, the patients were more accepting than the residents of the physician crying with their patient. Women, either patients or residents, were more accepting than men, just to let you know.

So the bottom line is that it is okay to cry with patients, as long as you're doing it in an appropriate setting and when the patient is crying first.

Advanced Directives

Another issue is advanced directives. And again, you'll see that the other topics I'm dealing with all sort of echo Buckman's principles about giving bad news. It's all patient-centered, and that's one of the important aspects. Again, the steps are introducing the topic of advanced directions, engaging in structured discussions, documenting patient preferences, reviewing and updating, and applying it if needed. Not all physicians know about advanced directives. Not all physicians have advanced directives. So we can't assume that the patient who is a physician, or the caregiver who is a physician, has talked about this and understands the details about it.

We want to make sure that we're straightforward and routine, and reassure patients that we're not talking about this because the patient is terminally ill, unless they truly are. But physicians will routinely assume that it is because the patient is terminally ill, either themselves or their loved one. We had a really funny circumstance. It wasn't about advanced directives, but it highlights this. Our youngest daughter was in a car accident, and wasn't seriously injured. The airbag went off, she doesn't remember what happened, she got bounced around and was frightened. But she told the paramedics when they came that she must have lost consciousness because she didn't remember. So they looked at her and decided that they would helicopter her to the trauma center. She was fine, she wasn't bleeding or anything. I said, "Is this really necessary?" They said, "Well, she lost consciousness, our opinion is she needs to go to the trauma center, so we're going to take her."

So my wife and I went down there and followed. They had her in the back. We're sitting there waiting, and I told them I was Dr. Farber, could I go back? "No, the ER people are dealing with her, you can't go back yet." So we're sitting there waiting, and the chaplain walks in. And he introduces himself and says, "I'm Reverend So-and-so, I'm the chaplain, so-and-so." And the first thing, I looked at him and said, with tears in my eyes, was, "I'm a physician, my interest is in patient-physician communication, especially giving bad news. Just tell me how bad this is." And his immediate response was, "Oh, no no no, they just send us in all the time." I went back and my daughter's sitting there and smiling, and the ER physician said, "This is the least injured patient I ever saw helicoptered in here." But I immediately made the assumption. So you're going to see that. You can talk about advanced directives, talk about anything like that, physicians usually jump to an assumption.

As I said, determine their familiarity. Not all physicians may know about advanced directives. Explain the process. Determine the comfort level they are at about discussing it, and then determine the proxy. If the patient is not the physician, don't assume the physician will be the proxy. It may not be. The patient may want someone else. The physician may not want to be the proxy. There are many different situations.

You need to engage in structured discussions, the proxy decision-maker should be present, and describe scenarios and options for care. A list of the patient's values and goals, and then check for inconsistencies. In terms of their education, you need to define the key medical terms and explain the burdens and benefits of treatment. Remember that when we're talking with physicians, and I'll show you this in a minute, life support can be sometimes only short-term. We can withdraw or withhold life support of any kind at any time if that's what the patient or their surrogate wants. And some physicians have difficulty with this. Remember that any intervention can be refused and recovery cannot always be predicted.

One of the ways of getting around this is asking about their past experiences. Have they had past experiences with friends, family -- in the case of the patient who's a physician, ask the physician what their experiences with end-of-life care have been.

Hospice Issues

Hospice is another area that is kind of tricky. Again, you want to sort of approach it from Buckman's point of view, determining what either the patient or the family knows of the prognosis, and again, many physicians have mixed perceptions about hospice. There are many myths about hospice -- that the physician won't be able to continue the care, that you have to be ready to die, that there are no treatments available, etc. So we often times need to reeducate physicians who are either patients or caregivers about what hospice means. And we need to reeducate them about the prognosis too.

Again, we need to determine what their goals of care are, determine what the patient and the family know of hospice, and then dispel the myths and educate them about the benefits, respond to emotions, and establish a plan. You see this very much mirrors what Buckman is talking about.

So these are some of the misperceptions: that the primary physician no longer has contact with the patient when they're in hospice, which is not true; that they can only stay in hospice for six months, and that's not true. At the beginning, the patient has to be certified by the attending physician that his understanding is that they only have six months left to live, but that can continue. They can be recertified and recertified. There are people who lived four to five years on hospice. The other myth is that people deteriorate faster when they're in hospice, and actually the reverse is true. People live longer when they're in hospice.

Caring for the Caregiver

We do need to care for the caregiver. This is an issue that's near and dear to my heart. There's not very much data on how physicians and caregivers interact. There was one study done in Japanese geriatric patients. That's about it. It was done by Deborah Rutter. It's pretty famous in terms of doing communication issues. They found that physicians used less partnership-building in triads, that is, where there was a caregiver and patient present, than in dyads, that is, where just the patient was present. The companion's emotional communication was lower than the patient's. So it's sort of the caregiver in the corner, and we'll talk a little bit about this this afternoon.

Twenty percent of the companions talked about their own health, and that was basically dropped by the physician. They didn't really pick up on that. We're actually going to be doing some studies looking at this issue.

Some of the emotional support that the physician needs to give to the physician caregiver is that the physician caregiver is a valuable member of the health care team, but not as a physician, rather as the lay caregiver. Listening to caregivers' needs, inquiring how the caregiver is coping, recommending bereavement counseling, and doing a condolence phone call or attending a funeral when the patient has died. Our community is going to be coming out with a white paper at some point in time in terms of dealing with caregivers.

There's some other support that we need to give to physician caregivers, and that is ensuring that they have competence in caring for the patient's needs. You can't assume that a physician has such competence just because they're a physician. I do not know the first thing about nursing care, and most of us don't, but we have to make sure that a physician is taught about that, for example. That the caregiver does care for their own needs. We are very much in tune with caring for everybody else. We don't care for ourselves at all. So when a physician is a caregiver, we have to assure that we are allowing the physician caregiver to give them permission to care for themselves as well, and that includes routine health care. That also includes outside social enjoyment and friends. These are vitally important for a caregiver of any kind, but especially for a physician, and again, informing them of outside resources.

So the take-home message: all communication should be patient-centered. You need to start with the patient and the family understanding and their point of view, and then using empathy, therapeutic touch, and listening skills to communicate with the patient and caregiver who happen to be physicians, remembering that they are patients and caregivers first. Avoiding jargon and remembering that the physician can still be a patient or a caregiver, that's extremely important.

Audience Question-and-Answer Session

Q: How do you propose to determine "what the patient wants to know"?

A: The answer is that it's tricky, and that's why I don't recommend doing it. Buckman recommends doing it any time you're giving bad news to somebody. I think it needs to be done ahead of time. His example is saying something like, "If you were to ever get really sick, would you want me to tell you the information about that?" Well, you're giving it because somebody's just had a colonoscopy with a biopsy. You're sitting them down and you're saying, "If I ever had to tell you something really bad, would you want me to ..." - it's like, bing bing bing bing bing, "I've got colon cancer!" Right? So I advocate not doing it in that setting, but ahead of time.

Q: I think that's pretty difficult.

A: It is.

Q: Not a good answer.

A: It is, and there is no good answer. This is the one point that I disagree with Buckman on.

Q: You certainly can ask them as ...

A: As you go along.

Q: ... information is being communicated ...

A: "How much do you want me to know?"

Q: ...verbal or nonverbal cues, and go from there. But initially, they're there because they want to know.

A: That's right. And I agree with you.

Q: On the cultural aspect of this....

A: Yeah, I didn't get into that, because I was talking about the physician as patient or caregiver, but there are cultural differences. It was brought home best to me about 10 years ago. I had an interest, as I said, about different types of communication, including end-of-life care, and I was gung ho, talking about advanced directives, and we ought to have the talk with every patient about advanced directives, and ask them, "If ever you got sick or you were comatose, what would you want?" And this guy at this meeting I was at got up was presenting the work, had done this ethnographic study of Navajo Indians. Navajo Indians, in fact I believe all Native Americans, including -- I'm not sure about Native Alaskans, but I know Lower 48 Native Americans all basically have the belief that if you talk about something, the belief is it may come true. So you cannot ask a Navajo, "If you become comatose, what would you want me to do?" You have to say, "I know this guy who became comatose. Here's what happened. What do you think he would want?" So you're right, without going into the entire spectrum, there are many differences in terms of cultural aspects, which is an entire other four-hour workshop in and of itself, and we need to at least go to someone who knows about those kinds of issues, have somebody who is of that cultural group.

Q: In many situations, it's known right away that the patient is a physician. But increasingly, that's less common. As we get older, it's not clear. At what point do you tell a physician that you're seeing as a patient or a caregiver that you are a physician if they don't know?

A: So you mean ...

Q: Well, you come in with your child or whoever, and you're going to have a consult, and they start talking down to you and your wife, who's also a physician for 20 years, you're just going crazy, you say, "Well, we are physicians," because you're looking at your watch and you know they're going to be running out of here without doing a biopsy. At what point do you bring it up? Just quietly suffer through it?

A: Right, so you as the patient or caregiver, you mean.

Q: Yes, that's what I mean. I mean, in the older days, in a small community, everybody knew who you were. Now that's changed. And the older you are, the more retired you are, the less ...

A: So coming at it from the other point of view, what you might do is say it right away, but say, "Yes, I'm a physician, but you're my doctor." For example, I have no serious medical problems. I have gastroesophageal reflux, allergic rhinitis, and just recently diagnosed with hypercholesterolemia, and saw somebody. He knew I was a physician because I told him right away, but he said, "What do you want to do?" and I said, "You're my physician." But what I would have done if I was just seeing somebody for the first time, and let's say he saw the lab results and he started talking, then I'd say, "I am a physician, I do know about it, but I'm your patient and I want you to make the decisions." Something along those lines, is what I would have done. It's hard to recommend what to do, and each person, I think ...

Q: We had one dermatologist tell us, after 20 minutes of talking down to us and we finally commented we're physicians, tell us, "Well, I would never tell people that I was a physician, because I would just watch to see what they do." I mean, it's awkward.

A: It is awkward.

Q: Staff too, it's not just ...

A: But one of the things that's part of the history-taking is to know the social history too, and that would include being a physician.

Q: You as a physician-caregiver, I think, are in a unique position with your wife, and I've been there too, where when she doesn't like what the doctor providing her medical care is doing, you get blamed. That's correct.

(Laughter.)

A: She's looking at me, and -- the decision I have to make is, do I go back to the room tonight or not? Hm. Well, I don't think I could get blamed. Well, I shouldn't say that. There were a couple of times, yes, in the past, especially when I was younger and didn't know enough, where I had recommended somebody because they had been recommended to me and they turned out to be terrible, and I was new to the place and didn't know, etc. So that sort of -- "You heard what happened and you didn't know," and the answer is, yeah, I didn't, because I was new, and she recognized that. But there can be a tendency for someone to do that.

Q: In my case it was a missed mammogram ... it got missed for six months or a year. Fortunately she's still alive 12 years later. But it was -- the medical care broke down, and I felt guilt.

A: And that's one of the things I was saying, is we as physician-caregivers, or physician-patients, can have a lot of guilt and a lot of anger at ourselves that we missed it, that we blew it, it was something that we did.

Q: When you get the bad news about your patient, how do you bring them into the office without alarming them on the phone?

A: That's a good question. Generally what I do is, if I know that I'm looking for something and I'm worried, I will routinely make another appointment for them after the -- whatever the study is, so that I don't have to call them on the phone, because I know they're coming. And I'll say at that visit, "Once you have your colonoscopy done and the biopsy done, come back and talk. Both you and your husband come back, and we'll talk and figure out what's going on."

Q: And if something surprises you, that mammogram or whatever, and you don't want to give it to them over the phone ...

A: I'll call them and say, "Got the results from the mammogram, why don't you come on in, I like to talk to people in private, you know, in person, whatever," and usually you get, "Is it bad?" And then you end up doing it on the phone. That happens. That's why I said it's not 100 percent.

Q: As a physician, you're in a patient or caregiver role, and the physician that you're seeing is not terrible, but maybe you know something about the area in which they're treating you, and maybe you're not quite 100 percent in agreement with what they're proposing or planning, and then you're wondering, "Well, am I just being hyper because I'm a patient or I'm a caregiver, and how do I talk to this doctor about my question about their decision-making?" Dynamics like that. Do you have any comments about that?

A: Are you going to be here this afternoon? I'll talk about it this afternoon. The talk I'm going to give this afternoon is about the physician as the caregiver in the corner, and it actually applies to the physician as the patient in the corner too, and the whole issue of the boundary between being the physician and the lay patient or caregiver, and how much to do. I'll talk a little bit about that, and I'll answer that. If you still have the question after the next talk, raise it again and we'll talk some more.

Q: The concept of limbic resonance of course is fascinating, it's something we all know from experience, and it sort of rolls into, in my mind, a lot of the other components of the presentation. This limbic resonance, emotions, so forth, one of the real concerns we all have is how can it interfere -- optimal intellectual rational thinking?

A: It does. And I'll explain a little bit about that tomorrow. During the workshop tomorrow, we may do some role plays. Not everybody, but we'll do some demonstration.

Q: When you suggested being vague about prognosis, I'm a little uncomfortable with that, because it seems to me that the physician patient or caregiver, within 45 minutes after leaving your office, will get on the Internet and find some horrible information. Don't you have to discuss that?

A: What I generally do is give a range. And I may say, "If you go to the Internet, you can find lots of different studies, and they may say lots of different things, and that's why I'm giving you a range."