The new graphic medicine story in the Annals of Internal Medicine, “Betty P,” left us feeling dismayed. Great graphic style, yes. Wisdom about end-of-life care, no. What we object to: the story’s assumption that the absence of a do-not-resuscitate order was the big problem. While all too common, it is unacceptable that no one – not the primary care doctor, the hospitalist or the oncologist spoke to the patient about her medical condition and goals. They might have found out that her first grandson was supposed to be delivered in two weeks and she was willing to try anything, even if low probability, to see his birth. Or they might have learned that her priority was to be at home with her family and that hospice was the treatment that best matched her goals.
We also worry about the depiction of the attending physician’s formative experience as an accomplice to an assault. While this will motivate him to talk to patients, it will not necessarily lead to patient-centered conversations. He (and his resident) need evidence-based skills in order to talk to patients about these difficult topics. The conversation should focus on what, given the medical reality, is important to the patient and how the medical system can help him achieve these goals and avoid interventions that will not achieve the goals and cause distress. The real core of high value medicine is not about unilateral physician decisions—it is about matching treatments to patient values.
Luckily, things are improving. VitalTalk, the not-for-profit we founded, has trained over 400 educators over the last five years to go back to their home institutions and develop educational programs for their clinicians. We have developed and taught programs for hospitalists, oncologists, intensivists, nephrologists, geriatricians, cardiologists and palliative medicine physicians about how to talk honestly and compassionately to seriously ill patients at institutions ranging from community clinics to the Veterans Health Administration.
Our hope is that five years from now, an attending would grab the resident and say, “Lets go talk to Mrs. Hoffman about her condition and what treatments best match her goals. I learned how to do this as a resident and it helped me be a better doctor. I can help you learn these skills.”