Monday, May 4, 2015
On delivering bad news
Delivering bad news is part of my job, an important part.
It is fashionable nowadays to speak of the doctor-patient relationship as a partnership. In the sense that both doctor and patient have important roles to play for the patient to get good care, that's very true. But even in the best of times, it's a very asymmetric partnership. Even in a run-of-the-mill visit for a sinus infection the patient and the doctor bring very different skills, experiences, and expectations to the encounter.
The more unexpected and unusual the clinical situation is, the greater the asymmetry between doctor and patient. A perfect example is benign positional vertigo, which is common enough that primary care doctors see it all the time, but most patients have never heard about it. The symptoms are scary, but the prognosis is fine. Ninety percent of the time all that is needed is a careful examination and some reassurance. The patient and the doctor come to the encounter with completely opposite attitudes. The patient is terrified by the vertigo and has never heard of anything like this. Is it a stroke? Is it a brain tumor? For the patient, it's the first time he's had vertigo. For the doctor, it's the hundredth case he's seen. The doctor's job is just to rule out a couple of rare but serious possibilities and break the good news in a credible but reassuring way.
That's a picnic compared to delivering catastrophic news. That's when the ever-present asymmetry between doctor and patient threatens to be a gulf that cannot be bridged. The doctor and the patient couldn't be in more different positions. The doctor has been through this many times before and is not in danger. The patient has never been through this before and has a life-threatening problem. The doctor is thinking of a checklist of tests to consider, specialists to call, treatment options to weigh. The patient is barely processing the bad news.
Much has been written on the art of delivering bad news. There are entire books and classes devoted to the subject. I am certainly a continuing student, not a master, in this field. The key is the understanding that the patient cannot bridge the chasm of experience and expectation between him and the doctor; he can't even meet the doctor half way. He can't develop the perspective of seeing a dozen patients with the same illness go through treatment. He can't review the literature about his disease. He will only hear the words “cancer” or “stroke” or “Alzheimer's” or “ALS” and hear nothing else until the shock wears off. The doctor has to remember that his hundredth time of delivering terrible news is the patient's first time hearing it.
The surprising thing is the patient's response. I've seen brilliant successful patients retreat behind a fortress of denial, leaving all important decisions to their upset and bewildered family. I've seen emotional breakdown, of course. But surprisingly frequently, even when the family expects emotional breakdowns, I've seen courage, and calm, and even acceptance.
About 10 years ago, a middle-aged man who had been my patient for many years came to see me for some worrisome symptoms. I ordered a test and the following day called him with the results. He had a kind of cancer that usually had a terrible prognosis. A few days later, waiting for a procedure, he said to me “I have no regrets. I love my family. My family loves me. I've lived a good life.” He passed away within a month. He was not an old man. He would have been justified in ranting about the decades that were stolen from him. But instead he faced his mortality unflinchingly.
This week I told a sweet older lady that she has a life-threatening illness. Her son held her hand while I rubbed her shoulder. “Might this kill me?” she asked. I told her it might. We're taking it a day at a time.
The lesson I keep relearning is that delivering bad news is tough. That's probably a good thing. If it ever gets easy I should retire. The lesson patients keep teaching me is that they're frequently tougher than anyone expected.
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000. Holding privileges at Cedars-Sinai Medical Center, he is also an assistant clinical professor at UCLA's Department of Medicine. This post originally appeared at his blog.
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Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.
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Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.
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Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.
Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.
Dr. Mintz' Blog
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Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.
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Other blogs of note:
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Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.
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The Public Library of Science's open access materials include a blog.
One of the most popular anonymous blogs written by an emergency room physician.