DR LAWTON: You asked earlier in the day about other things that we could do for patients. From the time I entered this field I thought that every patient with a diagnosis of cancer could use help from a psychiatrist or a psychiatric evaluation.

However, any time you mention psychiatry to patients, especially in the age group I deal with but also in younger patients, the response is, “I’m not crazy” or, “Are you insinuating that I’m crazy?”

The reality is that it isn’t just this diagnosis; it’s the whole body of relationships and families. So many things are involved that only somebody who looks at a person from all of those different perspectives can really be helpful.

How do we encourage the patient to even be willing to listen to someone — a psychologist, psychiatrist, nurse practitioner, etcetera? It’s a huge challenge, but if we can break through, we can help a lot of patients.

DR SHUMAN: Many men would benefit from that type of addition to their therapy, but many men may not want it. As a physician, it is important to pick up on who will and who won’t, and then refer them accordingly.

I probably would not recommend psychiatric consultation for most patients; I think nurse practitioners and psychologists tend to be more practical and more results-oriented.

After I had my surgery, I wasn’t aware of it, but I was angry. My wife pointed it out to me on occasion, and I denied it. She is a pediatric therapist and she located a nurse who specializes in patients with cancer and HIV. I was resistant to therapy, but eventually I began to see that I was angry so I went to see this therapist.

Her approach is focused on meditation, which I wanted to totally dismiss and go back home. I’m not a meditation- type person, but I decided, “I’m here, and I’ll try it.”

Surprisingly, it’s made a huge difference in my life. It became a great way for me to deal with stress and with my anger, and I think it’s had a positive impact on my life — not only from the perspective of having prostate cancer, but just putting things in perspective.

It was something that I needed that I didn’t receive from my caregivers — my primary care physician, my oncologist, my urologist. As a patient, I had a different perspective of these caregivers.

When a patient comes into the office and the doctor says, “How are you?” what that question may mean is, “I’m incredibly busy today. I hope you’re doing well, and unless it’s a really serious problem, don’t tell me about it.”

DR LOVE: Can you tell us about the meditation? How often do you do it? How do you do it? How long does it take?

DR SHUMAN: It’s called guided imagery. Basically, you loosen your tie, take off your shoes, relax, breathe deeply, close your eyes, and put yourself in a pleasant place. Imagine somewhere where you would enjoy yourself.

My first reaction was, “What is this BS?” But I allowed myself to do it, and I could even do it right now. I could close my eyes and be out of this room. I can do it in an elevator. When I’m feeling angry or stressed — which occasionally happens at work — it’s incredibly useful. It’s something that I learned and continue to practice, and it’s made a big difference.

DR LOVE: How long would it take to teach someone to do that?

DR SHUMAN: It took me a few sessions. It probably sounds like self-hypnosis, but it isn’t hypnosis. I continued going back to this nurse for about eight months because I wanted to really establish it as something in my everyday life. She is a nurse psychologist and her visits were incredibly inexpensive.

DR LOVE: I’m curious about the anger. I was recently interviewing a nurse for our oncology nursing series, and she said, “They always send me all the angry patients, because I know how to deal with them.”

And I said, “Well, what’s your take on angry patients?” She said, “Anger is just another expression of fear.” What was your take on why you were angry?

DR SHUMAN: Good question. I did have some fear, as all of us do, but I think it was more than that. One thing I learned from this, which has been incredibly important for me, is to really appreciate and take each day by itself. I do not look forward or think about tomorrow or next week or next month. I think about today and getting my maximal enjoyment out of it.

DR LOVE: Another thing this oncology nurse said was that the angriest people are the attorneys and the physicians and other people who are used to being in control. I’m curious what your experience has been from that point of view. As doctors, people always listen to what we’re saying. All of a sudden, we have to listen to what other people are saying. Alan, I see you sort of nodding your head.

DR ROBERTS: One size doesn’t fit all. I don’t think everybody who goes to a shrink needs to have his head examined, but I do think that every situation has to be taken as an individual situation. One thing I have learned from my experience with having prostate cancer is that I’ve become a far better listener and a much more humble individual than I was before. I can help my patients now in a way that I couldn’t before.

Nobody knows what it’s like to go through what their patient goes through unless they’ve gone through it themselves. You can try to imagine it, but you can’t. Nobody knows what it’s like to be castrated until they’re castrated.

Our patients would probably profit from more of us having cancer. A humbling experience is a wonderful thing, and as a result, we can take better care of our patients.

DR LOVE: We recently completed a survey of 250 women with metastatic breast cancer. As we began the survey, several of the women started talking about what they look for in their doctor. The patients actually constructed a scale of qualities in their physician. The scale included everything, even sense of humor. We had about 15 different categories and we asked the women to rate the importance of each category using a scale from one to five.

The number one item selected, which was rated as 4.97 on a scale of five, was listening. I doubt that it would be much different in prostate cancer.

DR LANGE: I have always loved the quote from Franz Kafka: “It’s easier to write a prescription than come to an understanding with the patient.”

In our current healthcare system, writing excessive prescriptions is discouraged. And, if anything ought to come out of these kinds of ruminations, it’s a determination to resist that trend. If you go to Canada or to Europe in the socialized system, the trend is even worse.

We all have nurses and administrators telling us about our profiles and how much time we’re spending with each patient, etcetera. I’m worried, because — maybe more so than whether patients are treated with seeds or laparoscopic radical prostatectomy — time is a very important thing.

DR LOVE: I have noticed that things don’t change unless people really raise hell. We saw that in breast cancer. One example I can think of was a woman, Rose Kushner — I don’t know if any of you have ever heard of her — she was a breast cancer survivor who raised hell about mastectomy back in the early eighties.

She would just walk into medical meetings and interrupt them. It was incredible. People finally started to listen to her. It takes a lot to create change, which is why it’s interesting that we have this group of you here.

DR SHIMM: You see the same advocacy in AIDS.

DR MOUL: I don’t want to beat up on my own specialty, but part of the problem is that too much attention is focussed on this technique or that technique, rather than on being a comprehensive doctor for the patient.

We’re willing to spend all these extra hours to do this robotic or that robotic, which takes a lot more time, and the health system is accepting that, yet they’re giving us a hard time about actually spending extra time with patients in the office.

If we reallocate the extra time that we’re spending on a four- or five-hour operation, which we could do in two hours, and put that back into spending time with patients, we’d probably have better-satisfied patients. And we’d make more money, because these days you make more money in the office than in the operating room.

DR LOVE: I’m curious about how your personal experiences have affected the way you take care of patients and what you think about as you go through your day.

Some years ago I had community-acquired pneumonia, which my primary care doc missed. By the time I received antibiotics, I ended up spending a few days in the hospital. One thing I gained from that experience was an incredible appreciation for nurses.

Just the simple things they did were so great when I was feeling miserable. I’m curious how all the different experiences you’ve had have affected the way you take care of patients.

DR SCHELLHAMMER: I think many of the characteristics have been mentioned with regard to better listening, better understanding, better appreciation, and better communication with family members. I do not initially make it known to my patients that I went through this process, because I don’t want to overly influence treatment decisions. I was afraid if I say, “I did this,” then all thought processes might just be directed at what the so-called doctor did.

However, after a few meetings with the patient, I say, “I’ve been through this process, and I really can empathize. And if you have questions, I’m here to answer them, both from the book and from my personal experience.” I believe the bond that develops certainly makes a difference. As folks have already mentioned, it’s remarkable how patients like to interact in support of other people, and they find a good bit of healing of their own in supporting you and keeping tabs on how you’re doing.

DR MAGRINAT: I liked Alan’s earlier comment that, if more doctors experienced a major illness, not necessarily cancer, their patients would do better.

One thing that became clear to me was how unpleasant the little things are that don’t go away, such as a Foley — something that in the past, I just put in and I didn’t think about it. As a physician, it doesn’t bother you; it’s nothing.

As a patient, it was irksome for me to sleep with this tube in my bladder all the time. I became very irritable. I was a nasty person. I’ve become more sensitive to the little teeny things that I paid no attention to before, but the patient lives with 24 hours a day. For some of them, it’s a bigger deal than life or death. They don’t worry so much about living or dying, but this little thing that doesn’t let them sleep is a big deal.

RICHARD: Having been on the other side, one of the most powerful medicines is a sense of optimism by the person who’s taking care of you, and not just sort of brainlessly patting you on the shoulder, but a true, reasoned and genuinely felt sense of optimism. In oncology, we’ve perhaps shied away from doing that to the extent that we could.

I think surgeons actually do it better. It’s a powerful bond that a lot of surgeons have with their patients. Maybe it’s an internist/surgeon thing, but it’s a powerful part of taking care of people and it was a part of my experience that was very important.

DR LOVE: Optimism was also extremely highly rated by the patients in the survey I mentioned. Optimism and reassurance, which doesn’t necessarily mean we can cure this cancer. It just means a positive feeling about the future, which oncologists have learned how to transmit, even in the worse of circumstances.

Judd, I was thinking about the interview that I did with you when you were talking about what had happened with your father-in-law. What do you say to a urology resident or med student who asks the question, “What can I do for somebody who’s beyond all active therapy?”

DR MOUL: Common courtesy, for one thing. I know it sounds corny, but things that we all should have learned as kids can make a difference to patients. Some institutions have such pyramidal training programs that breed such competitiveness and cutthroatness that then translates into patient care.

I’m not saying they necessarily breed all “badness,” but they have a tendency to breed some physicians who may have forgotten a lot of the things that our parents taught us. Common courtesy and respect for everyone as a fellow human being — those things go a long way.

DR LOVE: Colleen?

DR LAWTON: When I meet a patient, very often I meet their significant other and sometimes their children. I try to take all of them into consideration. I learned from my own experience that they are important parts of the patient’s support system and treatment.

My mom would call me and tell me things that were going on. My brothers would call me and tell me things that were going on. That has been helpful.

I run our residency program and I teach our residents this all the time — that sometimes the only thing you have to give is TLC.

Fear is an overwhelming emotion and it becomes tantamount in patients who have metastatic or refractory disease for which few options are available. Sometimes just coming in, talking to the patient, and trying to alleviate some of their fears is helpful, even if their fears are, “Am I going to die a painful death?”

You can explain to them that we have all sorts of things to help with pain. That is sometimes enough to really make their day.

DR LOVE: A lot of comments have been made about the issue of the spouse and the different perceptions of the spouse and the patient. One story I hear a lot is the wife wants every possible thing done and is not as concerned about side effects or toxicity. Maybe the patient is not quite so much in that camp. Is that something you’ve observed in your patients or that you experienced in your own situation?

DR LAWTON: In general, and, at least in my practice, the women (significant others or wives) say, “I want him around. I don’t care if he’s sexually functioning. I don’t care about the litany of side effects. I just want him around.”

Sometimes the patients think, “If I’m not sexually functioning normally, or if I’m not the same person that I’ve always been, I won’t be loved.” And that’s just a misperception.

DR FAGAN: That’s very true, and that happened in my case. My wife is 20 years younger than I am and she’s led the whole charge. She’s been wonderful, absolutely wonderful.

DR LOVE: Are there times when she wants you to do something more active or aggressive than you wanted?

DR FAGAN: Oh, yes.

DR LOVE: Judd, I’m curious about what we can do to improve patient education.

DR MOUL: Two years ago, the first time you did an audio interview with me, we talked about biochemical recurrence. I actually went back and listened to that recently. I’ve been doing a lot of traveling between Washington and North Carolina, so I’ve had a lot of time on the road, listening to the tapes, and you’re obviously a good interviewer. You are able to really question people, and that has turned out to be a great educational tool.

After I did that program, I started to think about a similar program for patients. I think the majority of the patients that I’m counseling for biochemical recurrence would actually be able to understand most of what I said on that program.

Some of these modules that you do for physicians are basic enough that we would be able to use them, almost unedited, as patient education tools.

Perhaps you could have one side with the interview module, and on the other side you’d ask questions to bring it down a little further to the patient level.

DR LOVE: What other forms of support can be helpful to patients in terms of nutritional counseling, stress reduction, etcetera? What are some of the things you’ve experienced that have been helpful to you or that you’ve seen in your patients?

DR LANGE: I was rather skeptical of alternative medicine strategies, feeling that it took a long time to get out of the medicine wagon and cough syrup era and into evidence-based medicine. After I had my own experience, I found myself walking into an alternative medicine store I had passed many times before.

I went in just out of curiosity, when only a few people knew I had prostate cancer, and I walked out with a couple of bottles with pictures of pretty cherries on them and peaches and whatever — I suddenly understood something that I hadn’t before.

We talked a little bit about PSA anxiety — taking the pressure off and giving the patient more control. I think that regardless of its scientific merits, we’re beginning to look at this in a scientific way — empowering the patient to do something and not ignoring the “placebo effect,” which is a nefarious term to most of us. It’s something bad. It’s something that we have relegated to the chiropractors and naturopaths. And the question of how we can use it in a way that’s honest yet hopeful is intriguing.

DR DEETHS: I don’t know what I’m taking, but my wife puts four medicines in front of me every morning. If I don’t take them, they are there at night to take. I honestly don’t know what they are, but I see the bill every month from the health food store!