Doctor-Patient Communication for People With Metastatic Disease
Timothy Pluard, M.D.
March 26, 2018

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Timothypluard

Dr. Timothy Pluard is medical director at the Saint Luke’s Cancer Institute and the Koontz Center for Advanced Breast Cancer in Kansas City, Missouri. A medical oncologist, Dr. Pluard specializes in offering comprehensive care, including treatments that use advanced genomics and immunotherapy to women diagnosed with metastatic breast cancer. He also incorporates nutrition planning, spiritual counseling, exercise physiology, massage, yoga, palliative care, and emotional support into patient care. He also advises patients on participating in clinical trials on leading-edge treatments for advanced-stage breast cancer. Many of Dr. Pluard’s patients have praised his communication skills.

Listen to the podcast to hear Dr. Pluard discuss:

  • how he tailors his communication to each individual patient and that person’s unique situation
  • how he talks to patients about disappointing news, such as cancer progression or a treatment that stops working
  • what makes someone a good communicator
  • his tips on how to make doctor-patient communication the best it can be

Running time: 18:47

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Jamie DePolo:

This podcast is made possible by the generous support of Lilly Oncology.

Hello, everyone. Welcome to this edition of the Breastcancer.org podcast. I'm Jamie DePolo, the senior editor at Breastcancer.org. Our guest today is Dr. Timothy Pluard. He's medical director at the Saint Luke’s Cancer Institute and the Koontz Center for Advanced Breast Cancer in Kansas City, Missouri. A medical oncologist, Dr. Pluard specializes in offering comprehensive care, including treatments that use advanced genomics and immunotherapy to women diagnosed with metastatic breast cancer. He also incorporates nutrition planning, spiritual counseling, exercise physiology, massage, yoga, palliative care, and emotional support into patient care. He also advises patients on participating in clinical trials on leading-edge treatments for advanced-stage breast cancer.

Many of Dr. Pluard's patients have praised his communication skills. Today, he's going to talk to us about how people diagnosed with metastatic breast cancer can ensure that their communication with their doctor is the best it can be. Dr. Pluard, welcome to the podcast.

Timothy Pluard: Thank you. Glad to be here.

Jamie DePolo: You specialize in treating women diagnosed with metastatic breast cancer and I'm sure these people are experiencing a wide range of emotions, including fear, disbelief, shock, anger. How do you approach talking to a newly diagnosed person?

Timothy Pluard: Well, a couple of approaches. I think, one, it's always helpful, and I usually ask patients before we start a conversation what's their understanding of the situation. That just helps me gauge where they are, what they know, and what they're thinking. So, if a patient says, you know, “I have metastatic breast cancer and I don't have long to live,” that's a different conversation than, “I understand I have this cancer, but it's treatable.” So, I can kind of gauge where they are in their level of understanding and their emotional response to the diagnosis, and then that gives us a starting point for the conversation.

Jamie DePolo: Do you find that you have to communicate differently with someone who is experiencing a metastatic recurrence versus someone who is diagnosed de novo, the first diagnosis is metastatic disease? I'm assuming those two people would be in very different places.

Timothy Pluard: Absolutely. Very different places. So, the recurrent situation, you know, patients have a previous experience with breast cancer and may have had chemotherapy as part of their treatment and may have experiences that they're drawing upon. And one of the big issues that we often see in women with recurrence is they're wondering did I do or what did I not do to make this come back. And there can be some guilt associated with that, and I always try and explain to patients that it's been there the whole time. You know, the cancer didn't leave and come back. It's been in your body the whole time, and you've been living with it. And so our goal moving forward is to continue to treat you to allow you to live with your cancer as long as possible and to try to do so in a way that preserves your quality of life and your ability to carry on and do those things that are important to you. So, in contrast, a newly diagnosed woman is often a little more frightened, maybe not in every case, but certainly there's more shock to it, I think, because they probably had no idea that they even had breast cancer or possibly even were at risk of breast cancer, and now they're diagnosed and they're already metastatic. So, it's a little bit different perspective that they each bring, and so I think it's important that we recognize that and we tailor our conversation to them.

Jamie DePolo: I assume or suspect that most of your patients are women. Do you treat any men?

Timothy Pluard: We do have a few men that we treat with metastatic disease in our center.

Jamie DePolo: Are those conversations different? Do you find yourself communicating differently with women and then with men?

Timothy Pluard: To some degree, I would say, you know, while everyone is different in general, men tend to ask fewer questions and really want the nuts and bolts, and I would say tend to probably, as a group — and obviously there are variations — but probably do less independent research often. And that's a limited sample size, but you know, it's a different conversation. Men and women tend to communicate a little bit differently, and the men tend to be a little bit more reserved. So it takes some effort to oftentimes to get them to open up.

Jamie DePolo: Well, that's a perfect segue into my next question, which is I'm wondering how you handle someone who is hesitant or afraid to ask questions. And I realize that the shock of the diagnosis can be very overwhelming for a lot of people, and so they may be just kind of sitting there in stunned silence and not know what to ask. But how do you kind of handle that for somebody who's hesitant but they seem kind of upset or like they want to know some things but you're not sure what.

Timothy Pluard: Yeah. So, that's... you're right. There's a shock value. And we know from studies that it's very difficult for women, on their first visit in this setting of metastatic disease, to be able to process information and to recall it later. But oftentimes you can sense that someone has something on their mind. And I think it's important to give them permission to ask it and to just say, “You know, it looks like there's something on your mind and you're maybe not sure how to ask it. Just put it out there, and we'll figure out what the question really is and go from there.”

So, I think it's one, giving them permission. And it's interesting because a lot of patients will come in and have written questions down and then will apologize for having those questions. And I always… I actually prefer a patient who's engaged in being a partner in their care, because I think that they will probably do better because they're actively participating in treatment decisions. And you know, all women with metastatic disease are invested in their outcome, but I enjoy patients who are engaged and ask questions.

Jamie DePolo: That seems very strange to me. What is the reason for the apology? That it's taking too much time that they wrote down questions?

Timothy Pluard: I think it's some of that, and I think that there's perhaps a perception amongst patients that they shouldn't be asking or challenging the doctor. And I don't see it that way at all. I see it as one of our primary roles is to provide information and education to the patients and their family, and somebody who has taken the time to thoughtfully write down their questions I think is a benefit.

Jamie DePolo: I completely agree with you. To your mind, what makes someone a good communicator? And I guess I should probably split that out. What makes a doctor a good communicator?

Timothy Pluard: Well, I think the first thing is to be a good listener and observer. You can tell a lot by the nonverbal communication that occurs, the body language. And so I think listening and observing, and you can really get a lot of information about what to ask and what maybe the patient is thinking about but not verbalizing. And then, I think, the second aspect of that is, you know, it's always a struggle to not talk in medical jargon and to really try and explain in terms that are understandable to the patient and the family and not fall into the medical jargon.

Jamie DePolo: Definitely. I know that's something that some of our site visitors talk about quite often, that they have to go home and then look things up. So, I certainly agree with you that a doctor who can explain things in easy-to-understand terms is automatically a good communicator in my book. I'm assuming, too, that some of the conversations you have with patients are similar. And I'm wondering, do you find yourself tailoring sort of these conversations that may be the same to individual patients or is there a sameness to it?

Timothy Pluard: There's a certain amount of similarity in the conversations, you know, the topics that are addressed. I will say I try and oftentimes use a fair amount of analogies so that we can relate the discussion to something the patient is more familiar with. And so I may, you know, if we know what they do for work or travel, hobbies, or whatever, I can sometimes utilize that for an analogy to make the concept that we're trying to convey a little more reachable for the patient, to translate something that may be medically complicated into some understandable terms.

Jamie DePolo: Sure, and it sounds like, too, you make a very strong effort to get to know your patients. You know what they do, you know their hobbies, you know what they like, so that allows you to, in a way, it's like you're talking to somebody that you know so you can bring up things that they're interested in.

Timothy Pluard: Well, I think one of the keys to good communication is to always remember we're talking about and talking with a person and not a disease. Sometimes we tend to think about the mechanics of the disease from a medical standpoint and get too focused on that as opposed to the person in front of you.

Jamie DePolo: Do you have a particular way — this kind of follows up on that question — I'm sure you have to talk to patients about disappointing information, say a treatment has stopped working or the cancer has progressed. Do you have a particular way of communicating that type of information?

Timothy Pluard: So, two things I would say. One is, even at the outset, I try and prepare the patients for what might come in the future and probably will come in the future. And so we kind of lay out that this is going to be an ongoing, chronic process, and that we're going to encounter times when the cancer has adapted to our current treatment and we're going to have to respond to that by changing our treatments, so that they know that that's kind of par for the course. So, we normalize it, in essence.

Secondly, I think at any time that there's progression of disease or a change in therapy is required, we have a plan. So, I don't go into the room before I have a plan: “So, this is what's happening. This is what we're going to do,” or “This is options of what we can do.” Because I think that is critical so that we don't have this, you know, “Things are getting worse. We're going to have to figure out what to do.” I think if you have a plan, that is hugely important for the patients.

I would say the other aspect that we try and do is not have a gap between getting scans and visits. So, we try and do it within a day of your visit to get the scans. That way, there's not the uncertainty that the patients experience between the time of the scan and finding out the results.

Jamie DePolo: Oh, that's great because I know some people — well, it's even become a word now, scanxiety, where they sit at home, wait for the results of the scans for 3, 4, 5, 6 days until they get the results. So, you're talking about at your clinic, you do the scan and then it's the next day the person would get the results?

Timothy Pluard: Correct.

Jamie DePolo: Oh, that's wonderful. I'm sure that would ease a lot of people's tensions. Are there certain topics that patients don't bring up that you wish they would?

Timothy Pluard: I'm sure there are a number of topics that they don't bring up, and I think any topic that they think about bringing up and then feel that they shouldn't bring up, I wish they would. Oftentimes we don't do a great job at this, myself included, but I think providing that safety net and telling them, “If there's anything you want to ask, if there's anything you want to ask in private without your family here, you know, we can do that, and there's really nothing that you should be afraid to ask about.” Conversely, there's often times the family wants information. So the family will ask a question. You know, “How long do you think mom has to live,” or something of that nature. And I think one of the things I always do is I always ask the patient, “Is this something you want to hear? Because if it's not, then we can have this conversation outside the room or at a later time when you're ready to hear it.” But I think they have to control the information flow.

Jamie DePolo: That's very insightful and very thoughtful. I'm wondering, too, to sort of give our listeners some advice and to conclude, would you have one or two recommendations for people who have been diagnosed with metastatic disease to make sure that when they're talking with their doctor, they're getting their needs met? Are there kind of one or two things that people could keep in mind, whether it's writing down questions or not being afraid to ask questions? Anything like that?

Timothy Pluard: I think those are two excellent points right there. The third one I would add is — so for our initial consultations, we actually video record the consultation and give the patient a CD of the consultation so that they have it at home and can review it. I think it's perfectly reasonable for patients to ask to record the conversation on their iPhone or whatever device they would like, because it's difficult in the time, the stress, to recall later what was said.

Jamie DePolo: Oh, I'm sure and I'm curious, too. That's amazing that you do that. And I'm wondering if you know, just roughly, a percentage of the number of people that then came back to you and said, “I'm so glad you gave that to me because I didn't remember X, Y, and Z from the conversation.”

Timothy Pluard: So, we're trying to pull together some data around that, but anecdotally, we've had several patients remark upon that. And we actually had a patient who we did it and we had a technical issue and her disk ended up being blank, and she asked us to recreate the consultation, which was challenging. It's somewhat live TV, but we went through it.

Jamie DePolo: Dr. Pluard, thank you so much. We really appreciate your insights on this, and I'm sure your ideas and thoughts will help a number of our listeners. Thank you again.

Timothy Pluard: Well, thank you for having me.

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