Choosing
“watchful waiting”

Generally, watchful waiting is appropriate for men who meet one or more of these criteria:

• Short life
expectancy

• Have significant other illnesses

• Have small tumors, a low Gleason score, and a low PSA level

• Any man fearful of treatment, regardless of age or health, also may choose watchful waiting.

Effectiveness of watchful waiting If you meet the criteria for watchful waiting, you may avoid the discomfort and possible side effects of treatment by choosing this option. If you have limited remaining life span or other serious disease, watchful waiting may enable you to maximize your quality of life and avoid prolonged recovery and other complications.

Risks
of watchful waiting

The major risk of watchful waiting is that without treatment, prostate cancer can grow and spread outside the prostate capsule before your next doctor's visit.

Even small, slow-growing tumors may become rapidly growing tumors if left untreated. And sometimes prostate cancer that appears to be small and slow growing may be larger and more aggressive than originally thought.

The structure of the consultation




Silverman et al¹ provide a detailed description of the structure of a medical consultation which incorporates the approaches outlined above,
and the skills required at each stage.







Initiating the session






• Establishing the initial rapport


• Identifying the reasons for the consultation






Gathering information






• Exploration of the problems


• Understanding the patient's perspective


• Providing structure to the consultation






Building the relationship






• Developing rapport


• Involving the patient






Explanation and planning






• Providing the correct amount and type of information


• Aiding accurate recall and understanding


• Achieving a shared understanding: incorporating the patient's perspective


• Planning: shared decision making


• Options in explanation and planning
  
  
  
  • If discussing opinion and significance of problems
  
  
  • If negotiating mutual plan of action
  
  
  • If discussing investigations and procedures
  
  
  
  






Closing the session

Reflective activity 4 - cultural differences




What cultural differences have you identified or experienced with both patients and doctors in terms of:





• Health beliefs?


• Concepts of the doctor's role?


• Concepts of the patient's role?


• Expectations of the consultation?


• Expressions of distress?


• Concordance?






Examples might include:




• Health beliefs: different beliefs about the causation of illness; self-treatments; urgency and when to seek medical attention;
  different delivery systems for medications; recovery paths
  


• Concepts of the doctor's role: authoritarian or partnership approach; disease or whole person focused; team member or head
  of a hierarchy
  


• Concepts of the patient's role: passive, active participant, or consumer


• Expectations of the consultation: admission to hospital; a prescription; unlimited or constrained time


• Expressions of distress: stoic or demonstrative; physical presentations of emotional distress


• Compliance: doctor's "orders" must be followed, or doctors provide advice which the patient may choose to follow or not.

Communication and outcomes for doctors

Effective communication also has many positive outcomes for doctors such as more accurate and efficient consultations^{1 2}; increased doctor satisfaction, and decreased frustration.^{1 2}

Reflective activity 3 - patient's concerns

Reflective activity 2 - the environment

Identify some of the differences in the consulting environment between a private consulting room and an emergency room cubicle.
How might these impact on communication?

Symptom relief and physiological outcomes




A number of different studies have demonstrated an association between doctor patient communication and physiological measures
such as:






• Resolution of chronic headache²
  


• Post-surgical recovery and decreased length of hospitalisation^{1 3}
  


• Post-myocardial analgesia²
  


• Blood pressure and blood sugar measurements^{1-3 9}
  


• Improved symptoms and function of patients with rheumatoid arthritis and peptic ulcer disease^{1 9}
  


• Perceived health status and daily functioning³
  


• Duration of sore throat,¹ and even
  


• The possibility of improved survival rates from breast cancer.¹

Reflective activity 1 - doctors' tasks




Doctors' tasks include, to:





• Diagnose and treat disease


• Promote health and help prevent illness


• Educate patients


• Relieve suffering


• Support patients who are suffering


• Counsel


• Participate in and sometimes lead a team of other healthcare professionals


• Administrate


• Advocate for patients while providing a gatekeeper role to services


• Ensure ongoing professional development, so that knowledge and skills are up to date


• Care for oneself.

我是TD来的，失业，就意味着0收入。不过日子过得还行，听我来818：

衣服：社区领取的，美国的社区居民有捐献旧衣服的传统，一般由社工之类的负责，我到处领取一次，衣服都有7、8成新，款式以休闲型为主。出国前我住
在中国西部，年收入5万，穿的衣服品质没有现在好。内裤当然是穿新的，这点后面再说。我经常把多余的衣服卖给不识此路的其他偷渡客，每月可收入200美
圆，。

食物：超市免费领取，美国的超市在食品过期前一两日会免费派放，这些主要是罐头类食品，肉食和菜食都有，打烊前几十分钟有免费面包派发。我每天转悠
到几大超市领取免费食物，将其中一部分转手卖给不愿出门的社区居民，每月收入大约800美圆。呵呵，在国内我是长跑运动员，我能跑。

住宿：主要住在各个教会提供的免费宿舍，条件不错，水电齐全，可以洗澡，还有免费洗衣房，有些条件好的还有小型图书馆。不过只能住一宿，每天得排队
领号，竞争激烈；我反正失业，每天早早排队，基本上能领到号。有时候排不上号，就住地铁站或地下过道等，挺干净的，就是没厕所，起夜不方便，凑合吧。天气
好的时候我就把教会宿舍的床位卖给其他领不到号的人，一次5美圆，在地铁站就帮那些卖唱的张罗生意，卖个吆喝，收个钱啥的，以分点小钱。这两项相加，每月
收入大概100美圆。

交通：前面说过，我是长跑运动员，主要是跑几大超市，直径在20公里之内，完全能胜任。我打算2012年参加奥运会。有赞助商看中我的潜力，每月支
付我100美圆，直至2012年。条件是如果我能参加2012年奥运会，就替他们免费做一年广告。赞助商是卖内裤的，免费提供新内裤。

生活用品：0费用。教会宿舍免费提供，有时顺手带点牙刷牙膏啥的，以备地铁站之用。

吸烟：0费用。自制卷烟，公园里有烟叶，采摘后烘干作为烟丝，卷烟纸垃圾桶里找，每月卖给其他失业者、流浪汉、卖艺人等若干烟卷，收入约30美圆。

报刊书籍：纽约所有的公共图书馆，全部免费。藏书极为丰富，一有空我就去读书，我感觉我快成著名学者了。

社保医保：根本没必要买。我是偷渡，社保指望不上。公立医院看病不要钱的，有次急病，躺医院门口昏过去了，医院收治痊愈后，分文不收，哈哈，美国政府专门拨款替无力偿付医药费的代付了。

健身：0费用。有时候在公园教美国佬打打太极拳，收点指导费，每月收入120美圆。钱不多，但都是些老头老太，他们钱也副富裕，将就吧。其实我啥拳都不懂，蒙他们的。

卡拉OK：0费用。我很喜欢唱歌，但一直找，纽约就是找不到这玩意。中国城也找不到。

桑拿：0费用。冬天教美国佬练完南拳北腿之后，去土耳其浴室。

通信：0用零。我用根长线捆住硬币打电话，从来不用付一分钱。美国人好愚蠢，他们的自动电话亭很好作弊。

上网：0用零。哈哈，图书馆，免费的。电脑很新，速度超快。

饮水：费用零。大街上到处是免费饮用水。