Confessions of an Intern

Week Twenty

Just more of the same this week. I have definitely had my share of experience giving bad news. For new doctors, the thought of telling a patient bad news is one of the more dreaded rites of passage we must go through. I've had my fair share in the last several weeks of having to break bad news to patients. There is maybe a disconnect in how we are taught, or maybe it is a subconscious rejection of an unpalatable experience, to handle sharing bad news. We have classes on how to tell someone bad news. It is always cancer that is used as the example of the bad thing we have to tell a patient. Undoubtedly, that is one of the most feared diagnoses out there, as there is often still a great deal of uncertainty as to whether treatment will offer a cure.

But I want to touch on some of the finer points we are not prepared for, you see. We all know Cancer=Bad in the most basic explanations. We are not prepared on the whole how to share bad news with someone who is cognitively impaired (many folks out there live alone and care for themselves and are barely considered to have a functional capacity for judgement and insight). We are not prepared to face a family who refuses to see the reality of a terrible situation and demand everything be done for their loved ones, although the whole medical team may be aware of the futility of our efforts. We are not prepared to understand that what is a relatively common everyday diagnosis may equate to devastating news for our patients. We cannot be taught how to be empathetic and patient and understanding.

I feel very blessed to have had so many years in the trenches dealing with the aftermath of the doctors dropping a bomb on a patient and/or family that I am well equipped to deliver bad news. I don't want to have that as a bragging point, more just a fact. I've seen so many things go wrong because of misunderstanding and misinformation, I vowed to do better. I've learned that when you don't get the answer you want, maybe you asked the wrong question. I know compassion and empathy cannot be taught, but I do believe we can all try to learn these things, or some semblance of them.

One of the first things I would say is don't drop the bomb and run. That is chicken-shit, pardon my French. If you are going to have to give bad news, be ready to hang out for awhile. There was nothing worse than being called in to explain what was going on after seeing the doctor all but run off the unit. Generally you knew the situation, but were not prepared to give options. As doctors we need to make time for the hard stuff.

Next, I would say always be honest. Those folks who ask questions are going to have a lot of them. If you don't know the answer, say so, but try to find the answer, or someone who knows. In the same vein, don't sugar coat the news or hide it in a broad generalization of what could be wrong, and fool yourself into thinking you told the patient the bad news. Recently, I had the experience where a patient came in with weakness, and in the workup it was found they had a brain tumor. I was told by the ER doc that he had told the patient about the tumor. I asked the patient going in what they knew was going on. I didn't get a straightforward answer, so I finished my history and physical and again, asked the patient what they thought or had been told was wrong. They said the ER doc told them a STROKE! Guess what? I got to break the bad news. And it wasn't a benign tumor, it was a big bad brain tumor.

Another thing I would caution future and present docs about is minimizing those diseases we see as common, everyday things. Take a step back and put yourself in the patient's shoes being told for the first time they had diabetes and had to inflict pain on themselves many times a day if they wanted to get better or remain healthy. Or the person diagnosed with high blood pressure and put on a new medication. Beta blockers are handed out like tic tacs these days, but they come with significant side effects. How would you like to be a 30 year old man and put on a medication that could cause impotence? The alternative threat a heart attack or stroke because of uncontrolled hypertension. While these are not usually death sentences in and of themselves, they can be devastating to the individual. So, don't be nonchalant about any of the diagnoses you give your patients.