One of my patients came to clinic a few weeks ago for a routine visit. She had previously undergone therapy for a rare kidney disease. (Systemic diseases, from lupus to hepatitis, can affect the kidney, and we often use aggressive medication not unlike that used in chemotherapy for cancer. We even use terms like "remission" and "relapse" to describe the course of disease.)
My patient’s appointments were straightforward, because she had responded nicely to the medications.
That is, until this particular visit.
Later that day, I found myself faced with lab results that showed that the disease was coming back. And now, instead of my usual cheery post-visit phone call, I was going to have to give her bad news.
The part of giving bad news that has always been hardest for me is that period of time between when I learn the news and when I come to tell the patient. I don’t know if this is selfishness or empathy, but I feel a much greater burden when I am the only one who knows. After that moment, we are in it together; before that, I’m dealing with the news all by myself.
I had some formal training in this particular aspect of medical care (now more medical schools are employing actors to help students practice this skill), and I watched many experienced physicians deliver bad news. Some did it well, some did not. One thing I promised myself was that I would always think ahead about how to say it.
I go over it in my head. What will I say? When? Over the phone, or in person? If I call someone in to the office who hadn’t expected to come back for a month, they must worry that bad news is coming. But can I really give someone bad news during a casual phone call and then leave them to deal with it on their own?
For me, this anticipation is worse than the actual encounter. I have
seen a lot of different reactions, from hysteria to anger to stoic
acceptance—and once I see the reaction, I can try to respond
appropriately.
In the early days of HIV, when a diagnosis was like a death sentence,
there were a few cases of people committing suicide after finding out.
This led to a new practice: All HIV test results—positive or negative—had to be related in person. (Once HIV became treatable, this
recommendation was relaxed.)
Of course, we send out thousands of other kinds of tests, many of
which end up showing nothing remarkable, so we can’t plan face-to-face
meetings for every result. The phone has to play a role in this
transaction. So more often than not, when unexpected bad news turns up,
we give some news over the phone, and then invite the patient to come
in and discuss things in more depth. Sometimes we stall: "The final result isn’t
available yet, but there are some concerns…" or, "The result was not
normal, but I want to repeat it again…" and so on.
For my patient, we told her the news over the phone and then had her
back to clinic to discuss it further. She was scared and had many
questions, some of which I could answer and some of which I couldn’t.
We made another appointment to keep talking about what to do next.
I am curious, though, whether there’s a better way to organize
medical care so that the long, uncertain time between test result and
action plan—for both me and the patient—can be shorter.
Comments (5)
Although I know that all doctors work very long hours, and added to that, make calls to their patients to share info on test results and other information, they should set aside time during the week to see patients, who they know have unfavorable findings. That way they can give them time in the next day or so to discuss their results and what the next step should be. Also, let them know to bring someone with them they trust to be there so if they are upset, there will be someone to ask the important questions. And also reassure them by telling them that you are available to answer questions whenever they may have them.
I was given the “bad news’ about my husband over the phone. The doctor said he was sorry, that he hated to have to tell me the “bad” news. We were sitting in the living room, there was no where for me to go to react to the news other than right there in front of him. I do not think ‘bad” news should be given over the phone. I was the one that had to tell my husband that he had 18 to 3 years to live if we were “lucky” .
This doctor was a personal friend of my husbands. I was very confused at the way it was handle in every turn of the time we dealt with him. We are all human, we react to difficult things in many different ways.
Maybe it was better that he hear it from me, I know the learning the “bad” news, then having to tell my husband was one of the hardest things I have ever done in my 49 years of life.
I am sorry for the mistake Steve had 18 months to 3 years to live, he made it 16 months after the “bad” news.
I was told about my brain tumor over the phone, while I was driving. I’m glad the doctor told me sooner rather than later, but I wish he would have asked a few “light conversation” questions that would have revealed I was driving. He could have said, “Call me back when you get home, or come by the office if you’re close.”
The good news: no car accident, even though I was stunned.
The great news: the tumor was benign and has been sucessfully removed! (I had a skilled doctor and LOTS of friends that pray!)
The author of the article above, is seeking a better way to reveal such news. I’m not sure there is a better way that is practical. If there was a visit for every test result, that would drive up medical costs and spread thin the time doctors spend with patients. I think the phone is appropriate. If I could change anything, it would be that the phone call was pre-planned and scheduled. That way the person could be surrounded by family/friends if bad news was suspected. Also, the person could be sure to be in a safe environment, not driving on the road.
Over the phone? Why not just send a singing telegram? I have been the recipient of bad medical news two times in my life (cancer and Hep C). In both situations, I was told in person and was given the opportunity to bring someone with me. Both times….I went it alone. I think I did this because I felt that the doctor was the ‘best friend’ to have there at the time. I have always been picky about my doctors. If I don’t feel that I have good communication and a rapport…………I leave and find someone else. One time, I got a call from a scheduler who was calling to arrange a colposcope…oh course, I had no idea why I needed this treatment and neither did she. AHHHHHHHHHHHHHHHHH! After a stressful 5 hours until the doctor could call back, I blew up at the doctor who was rather blase about it….’didn’t you get my letter?’ Uh, no. As consumers in the medical profession, I think we need to shop a bit and not only get knowledge and training……but, personality and empathy.