Anthony L. Back, MD
Having Difficult Conversations About Cancer
SCCA’s Dr. Anthony Back has a tough job: He teaches other doctors how to have “difficult conversations” with their patients—how to tell a woman that she has cancer; how to tell a man that his cancer is not responding to treatment and that he will soon die.
For doctors, he says, giving bad news is “one of the most stressful things they do.” And, depending on when and where they were trained, they may never have been taught how to talk with their patients.
Good communication with doctors is important to people with cancer, Dr. Back says, “because they need to get more than ‘technical’ medical assistance when they go to the doctor. They should expect more. Patients should feel confident going into an appointment that their concerns will be discussed.”
Dr. Sam Whiting, MD, PhD, an assistant professor at UW School of Medicine and assistant member at Fred Hutchinson Cancer Research Center, who works closely with Dr. Back, says, “Doctor-patient communication is a difficult and supremely important aspect of all medicine, not just oncology. But communication is taken to the next level in oncology because of the importance of the topic and the complexity of the situation.
“While a patient is trying to listen and learn and plan with the doctor, he or she is simultaneously experiencing fear, hope, and confusion; thoughts of mortality and loss; frustration and sometimes anger—all mixed together to what can be an overwhelming extent.”
Dr. Back says cancer patients need doctors who understand what they are experiencing and who are not afraid to talk about it.
Doctors benefit as well
Doctors who know how to have these difficult conversations with their patients are less likely to burn out, he says. Also they are better able to help their patients make the right decisions about cancer treatment. “Medicine is actually a relationship business,” he says.
Doctors who are good communicators listen to their patients, Dr. Back says. They show empathy. They don’t rush through difficult conversations. And they acknowledge their patients’ emotions.
Dr. Back trains doctors in a number of settings. He made a presentation at Grand Rounds at University of Washington Medical Center titled “Difficult Conversations: Talking About Life-Threatening Illness.” He organizes retreats for oncology fellows that are sponsored by a grant from the National Cancer Institute (NCI), and is working on improving communication at SCCA.
He also mentors young doctors-in-training, including residents and fellows at SCCA and its parent organizations, UW Medicine and Fred Hutchinson Cancer Research Center.
“Tony is not only an excellent communicator himself, he is an excellent and dedicated researcher and teacher of the process,” says Dr. Whiting. “I think that everyone who works or trains with Tony benefits both from watching him and from receiving his teaching. I think his impact on the skills and practices of the next generation of oncologists is, and will continue to be, important and relatively unique.”
In addition to training doctors, Dr. Back does research on communication between doctors and patients and has published a number of papers on this topic.
Dr. Back is also working with SCCA’s Dr. Julie Gralow on a new study to find out why older people do not enroll in clinical trials in significant numbers.
"Sometimes patients don’t want to be in clinical trials because they are worried they are going to be treated like guinea pigs or just numbers in a study," Dr. Back says. "But being in a clinical trial ought to mean that you have better conversations with your doctors and nurses, and that they get to know you better.'
Talking to his own patients
Dr. Back also treats patients at SCCA. His patients include people with colorectal, liver, pancreatic, and stomach cancer.
He suggests that his patients bring a written list of the their questions to each appointment. He uses the lists to help prioritize his time with patients and make sure that all of the patients’ questions are answered.
He doesn’t tell his patients what to do. “Communication between Tony and his patients is always a two-way street,” says Dr. Whiting. “He never dictates to or talks ‘at’ people.” Rather, he and his patients make treatment decisions together, focusing on finding the right answer for each patient. “He encourages active involvement in the decision-making process,” says Teresa Crossley-Hill, a registered nurse who is the clinical nurse coordinator for Dr. Back’s oncology team.
“He communicates in a manner that shows his genuine concern and compassion for his patients and their families,” she adds.
Debra Jarvis is a staff chaplain at SCCA. She says, “I've been with Tony as he's given difficult news and here is what impressed me: If it's clear that a patient does not understand or is not realizing what he is saying, he will say it a thousand different ways to make sure that he or she is hearing it.
“He is always very gentle, and he listens way more than he talks. Paradoxically, he is also not afraid to laugh in a situation like this. I've heard patients make jokes about their prognosis, and he'll respond to the joke and then very gently steer the conversation back to what he was saying.”
She adds that Dr. Back has “a deep appreciation for spirituality, knowing that medicine is not simply about drugs and surgery and cures.”
Bringing culture change
Dr. Back was born and raised in Vancouver, Washington. He is a graduate of Harvard Medical School and did his residency and an oncology fellowship at University of Washington Medical Center, followed by another fellowship at Hutchinson Center.
He joined SCCA in September 2004 as a medical oncologist and director of the Program on Cancer Communication. He is also an associate professor at the University of Washington.
Dr. Back says the death of his mother from aplastic anemia when he was a college sophomore was a “wake-up call” that helped make him the doctor he is.
“I feel that my calling is to be a healer in this world,” he says. “And in my research, there is a little piece of culture change that I’d like to make happen in oncology: Really good communication—the kind that would make patients feel heard and respected and informed—because it is one of the ways that physicians can be healers.”
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* Physician's Directory listing for Dr. Back
Anthony L. Back, MDDr. Back treats patients with colorectal, esophageal, liver, pancreatic, and stomach cancer.
Patient Care Philosophy:
Dr. Back has become the resident expert in communication between physicians and patients and acts as a mentor for many new physicians.
- Clinical Research Division, Affiliate Member Fred Hutchinson Cancer Research Center
- Professor, Oncology Division and Adjunct Associate Professor, Medical History and Ethics, University of Washington School of Medicine
Oncology, Ethical issues, Palliative care
Education And Training
- MA: Harvard Medical School, Boston, 1984
- Residency: University of Washington, Seattle, WA, 1984-1987
- Fellowship: University of Washington, Division of Oncology, Seattle, WA, 1988-1989
- Fellowship: Fred Hutchinson Cancer Research Center, Division of Oncology, Seattle, WA, 1989-1991