Friday, July 27, 2012
How to deliver a cancer diagnosis to patients
When I see patients in the office, I try to guess their occupations from their demeanor and mannerisms.
Salesmen are the easiest to ID. In general, they are gregarious males with manly handshakes. They laugh loudly and like to tell jokes. Teachers are more reserved and often give their narrative in a logical and chronological order, as would be expected. Another clue that the patient is an educator is that their appointments are usually in late afternoons. I have a solid record picking out the engineers and scientists. (For physician readers, I estimate that with regard to engineers, my sensitivity and specificity are 60% and 90% respectively.)
Engineers can be tough patients for gastroenterologists to treat. They operate in a computational universe, where numbers add up and problems have concrete solutions. Doctors, particularly gastroenterologists, function in an entirely different milieu. Our world is nebulous. Engineers see mathematical truths, while GI physicians see fog. When they see us with chronic nausea and abdominal pain, they are frustrated when we cannot provide them with a satisfying diagnosis.
I recall an engineer I saw some time ago. He was neatly attired and related his ominous symptoms in an intellectual manner, as if he were giving traffic directions. He was having trouble swallowing his food and was steadily losing weight, a presentation that generates the highest level of physician concern.
I scheduled him for a scope examination of the esophagus, and found the expected cancer. Afterward, he was seated with his wife as they awaited the news of my findings.
These minutes when we physicians know the bad news, and the patient doesn't, are ponderous. We wish we could hold on to the secret and spare patients from the knowledge that will change their lives so brutally and irrevocably. Subconsciously, we stall. During those minutes, hours or sometimes days, physicians are in a different dimension, a medical twilight zone. Once we relate the news, however, we are hurled back to earth. Once the patient knows, then we are enveloped by an aura of cold reality.
How should physicians give bad news to our patients? Should we be blunt? Do we front load the heavy news or lead to it after several introductory sentences? Should we use euphemisms like 'growth,' when cancer is the right word? Should we spin the information with hope and optimism, even if the medical facts contradict this assessment? Do we tend to sugarcoat for our own benefit as well as to soothe the patient? Should serious medical news ever be delivered on the telephone? How do we respond if the patient asks, "Am I going to die?"
There is no standard strategy of how to do this right. In addition, patients are distinct human beings and must be approached individually. See First, a blog that emphasizes the importance of communication between physicians and patients, writes that false hope for patients may be the wrong prescription. Medrants, an academic physician and thoughtful blogger, speaks for all physicians when he writes, "Breaking bad news may be the most difficult and important part of our profession."
I have spent 4 years in medical school, 3 years in an internal medicine residency followed by 2 years of fellowship training in gastroenterology. During those 9 years, I don't recall a single lecture on how to deliver bad news to patients. Yet, I remember memorizing biochemical equations, the names of minute nerves and muscles, the function of microscopic components of cells, hundreds of medications and the natural history of arcane diseases that I have never seen in my career.
The astute medical interns and residents I admired were those who could spew off the dozen or so medical explanations for an elevated calcium blood level. I wonder if medical training, at least in my day, had proper priorities for training physicians. Doc Gurley, a physician and folksy and irreverent blogger, recalls a single lecture she heard as a medical student on how to deliver bad news to patients. It impacts her practice to this day, two decades later.
Delivering bad news is a very difficult and unavoidable responsibility of a physician. Do I do it well? I think so, but I'm not really sure. I gave the news to my patient and his wife after I had made arrangements for him to see the necessary consultants in the coming days. I think that patients' stress in these situations is eased when there is a plan that we physicians put in place. He listened without demonstrating emotion, and thanked me for my time. He then left with his worried wife. The news was still in his analytical left brain, where he stores his facts, figures and formulae. What happens when it crosses the Rubicon over to the other side?
This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.
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