It happened today.
It\’s a sinking feeling in the stomach.
The patient comes into the office with a chief complaint and set of symptoms that worrisome, or the x-ray comes back with a \”suspicious area\” on it. It sounds like cancer. My mind explores the possibilities, hoping for a diagnosis that is not so bad, but the elephant just won\’t leave the living room.
Having practiced for many years, I have had to give bad news many times. It does get easier, but it never is easy. I am standing at a major turning-point in a person\’s life. The words that come out of my mouth will hit them like a sledgehammer, shattering what is \”normal\” and leaving an uncertain future.
There are a few things that I have found are most helpful in this setting:
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Don\’t beat around the bush – most of the time they already suspect something is wrong. It does no good to use euphemisms. If it may be cancer, then say \”it may be cancer.\” It is extremely important that your wording is specific, not vague. - Give a specific plan – It is extremely important to give patients something to focus on in the immediate future. Answer the \”what now?\” question. I usually call the specialist in person and get an appointment right away. I don\’t leave the scheduling to my nurse or referral coordinator. It is extremely important for people to walk out of the office with a plan. Their lives are suddenly full of uncertainty, so it\’s not right to add to it.
- Don\’t conjecture – I try to stick with what I know for sure. I try not to answer questions like \”how long will I live?\” or \”will I need chemotherapy?\”. My job is to get them to the next step. A \”mass\” is not the same as \”adenocarcinoma.\” If these questions are asked, I tell them that the specialist will make the diagnosis and then the longer-term plan will be more clear.
- Don\’t make them wait – If more tests are needed, don\’t schedule them for two weeks – even if it would not matter clinically. It is simply cruel to tell someone they might have cancer and then make them wait to know what it means. If necessary, I schedule the scan myself or talk to the radiologist to get it scheduled. If an oncologist or surgeon schedules an appointment for two weeks (or even 3 days), I call them personally and ask to get the patient in sooner. Today, if possible.
- Bring them in – It is awful to call someone and say, \”your doctor wants you to come in and go over your test results,\” but it is worse to give those results over the phone. As uncomfortable as it is in person, it is important that you are with them. It shows that I understand how earth-shattering this news is. To do it over the phone makes it seem like you don\’t care.
- Don\’t try to find \”silver linings\” – I have had many cancer survivors tell me that their cancer really helped them see what was really important in life. But that means nothing to someone who just got bad news. Once you say the word \”cancer,\” any thing you say to try to make things better will fall on deaf ears. What people need is your sympathy and a clear plan – that will comfort far more than any platitude.
- Give comfort – Sympathy literally means to feel pain alongside someone. You feel pain. The pain you feel giving bad news is shared with their pain receiving that news. I also will give these people special access to me if they need anything – my cell phone or a back line number. They need to know where to get answers. Also inquire about support systems – do they have family in town, or a church they belong to?
- Follow up – I don\’t just pass people over to the specialist. I want them to still be my patient. I either ask them to call when they know what is going on, or I call them myself after a reasonable length of time. If necessary, I even schedule them to come in simply so I can hear what is going on. This makes people feel less isolated and gives a chance to ask questions.
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One of the great honors of being a doctor is to be there at the critical times of a person\’s life. Not all of those times are not happy. I think people need you most as a comfort and help at these times. It is very hard for a doctor to cause pain by their words. But the way in which bad news is given can either add to the pain or start the healing process.
This is a good post. I hope more doctors read it. I was once in an emergency room where I was “attended” (or should I say ignored) by a surly physician. I was so shocked by his bad behavior that I told him. His answer: “I’m not here to make you feel better emotionally. I’m here to make sure you don’t die on the table, and to get you out of this emergency room. That’s it – that’s my only job.” (Then he walked out). I have a witness to this, also.
This is a good post. I hope more doctors read it. I was once in an emergency room where I was “attended” (or should I say ignored) by a surly physician. I was so shocked by his bad behavior that I told him. His answer: “I’m not here to make you feel better emotionally. I’m here to make sure you don’t die on the table, and to get you out of this emergency room. That’s it – that’s my only job.” (Then he walked out). I have a witness to this, also.
There are so many good things about this post, I could go on for miles. I’ll just say this: I love reading your posts. That is all.
There are so many good things about this post, I could go on for miles. I’ll just say this: I love reading your posts. That is all.
I thought this was a wonderful post, too. I must say I had the same experience as Lauren in an ER once. It is so nice to read a post like this so I can understand that that particular experience may have been an anomaly. Your patients are very fortunate to have you.
I thought this was a wonderful post, too. I must say I had the same experience as Lauren in an ER once. It is so nice to read a post like this so I can understand that that particular experience may have been an anomaly. Your patients are very fortunate to have you.
Us family docs have been all over this topic (during my residency, which included a 6-semester diploma program, we had a specific course on “breaking bad news” one semester). here’s a detailed approach from the American Family Physician, always a treasure trove IMO.
One of the most important things is to find out what the patient already knows and bridge the gap between his/her knowledge and yours, IMO.
Us family docs have been all over this topic (during my residency, which included a 6-semester diploma program, we had a specific course on “breaking bad news” one semester). here’s a detailed approach from the American Family Physician, always a treasure trove IMO.
One of the most important things is to find out what the patient already knows and bridge the gap between his/her knowledge and yours, IMO.
I will never forget the appointment I had with my PCP after the melanoma. She was mortified. It had been found, removed and all taken care of in the 6 weeks between regular appts with her. She was upset and saddened that I ‘d not called her to let her know about it.I learned something that day … PCP’s do care … and to include them in important things. ;o) (this was a different doc than the one I just changed from)
I will never forget the appointment I had with my PCP after the melanoma. She was mortified. It had been found, removed and all taken care of in the 6 weeks between regular appts with her. She was upset and saddened that I ‘d not called her to let her know about it.I learned something that day … PCP’s do care … and to include them in important things. ;o) (this was a different doc than the one I just changed from)
EXCELLENT! Now that is the way to handle it.
“the way in which bad news is given can either add to the pain or start the healing process.” I wish I’d had you when I was given “the news”. The way it was done to me was inexcusable, and you know I’m usually on the side of the physician. I’m glad he no longer practices.
EXCELLENT! Now that is the way to handle it.
“the way in which bad news is given can either add to the pain or start the healing process.” I wish I’d had you when I was given “the news”. The way it was done to me was inexcusable, and you know I’m usually on the side of the physician. I’m glad he no longer practices.
Really, it is so good to read the doctor’s perspective.
Really, it is so good to read the doctor’s perspective.
You’re very right here.
One of the reasons that I am looking for a new primary doc is the way the last one handled telling me that I probably had cancer. (I did have papillary thyroid cancer.) He said, “Oh, that’s probably nothing. You should go see this other doctor if you’re worried though.” I trusted him, so I didn’t want to go, but my husband talked me into it. Imagine my shock when I found that the doc he had sent me to was a thyroid surgeon. Luckily, her office had fabulous staff who were able to help me set up a biopsy and an appointment with an endo – things he should have sent me to, according to them.
There are, of course, other issues, but the way that he handled my cancer diagnosis is the biggest reason I need a change.
You’re very right here.
One of the reasons that I am looking for a new primary doc is the way the last one handled telling me that I probably had cancer. (I did have papillary thyroid cancer.) He said, “Oh, that’s probably nothing. You should go see this other doctor if you’re worried though.” I trusted him, so I didn’t want to go, but my husband talked me into it. Imagine my shock when I found that the doc he had sent me to was a thyroid surgeon. Luckily, her office had fabulous staff who were able to help me set up a biopsy and an appointment with an endo – things he should have sent me to, according to them.
There are, of course, other issues, but the way that he handled my cancer diagnosis is the biggest reason I need a change.
I have always wondered how physicians approach their patients with news like this. IMO, I think you’ve set the standard on how it should be done. Let’s hope others follow your example.
I have always wondered how physicians approach their patients with news like this. IMO, I think you’ve set the standard on how it should be done. Let’s hope others follow your example.
P.S. Your blog is definitely in my top ten, too.
P.S. Your blog is definitely in my top ten, too.
Excellent post and one I wish every doctor would read and take to heart.
I can’t tell you how often I’ve heard someone complain to me, “The doctor told me I had cancer over the PHONE!“
Excellent post and one I wish every doctor would read and take to heart.
I can’t tell you how often I’ve heard someone complain to me, “The doctor told me I had cancer over the PHONE!“
Excellent post! People desperately need doctors who care.
Excellent post! People desperately need doctors who care.
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Thanks for your post! Every word told by a physician to a patient is a worthy chance to help, or a terrible pitfall trap for both if things are not done well. Sometimes, and unfortunately, we physicians discover it, when we become patients.Thanks again. I´ll try to improve my skills in this matter, and i hope i remember your advices every time i open my mouth in my daily tasks.
Thanks for your post! Every word told by a physician to a patient is a worthy chance to help, or a terrible pitfall trap for both if things are not done well. Sometimes, and unfortunately, we physicians discover it, when we become patients.Thanks again. I´ll try to improve my skills in this matter, and i hope i remember your advices every time i open my mouth in my daily tasks.
This is my story, I hope it’s an aberation.
After a surgical biopsy which resulted in a 3 day hospital stay, and although suspected to be cancer, I didn’t get definitive word of my diagnosis until the 2nd day. And it wasn’t by the surgeon, but rather by a resident I had never met before. He told me the bad news standing in the doorway, then turned around and left with no opening for questions. He was there maybe 10 seconds.
This is my story, I hope it’s an aberation.
After a surgical biopsy which resulted in a 3 day hospital stay, and although suspected to be cancer, I didn’t get definitive word of my diagnosis until the 2nd day. And it wasn’t by the surgeon, but rather by a resident I had never met before. He told me the bad news standing in the doorway, then turned around and left with no opening for questions. He was there maybe 10 seconds.
[…] Agosto 2008 por mariagps El Dr. Rob ofrece en su blog algunos consejos sobre cómo dar malas noticias a los pacientes: It happened […]
In her “Breast Book” Susan Love suggests that giving the biopsy results over the phone gives the woman a chance to fall apart before the appointment so that she’s hearing the plan without being in the middle of a huge emotional response.
Hopefully the patient has met with the surgeon before the biopsy and he/she has outlined the things that might happen in the future so it’s not a totally cold call with the biopsy results.
It may well depend on the person and how they cope, but I think that’s a good way to deliver bad biopsy news.
In her “Breast Book” Susan Love suggests that giving the biopsy results over the phone gives the woman a chance to fall apart before the appointment so that she’s hearing the plan without being in the middle of a huge emotional response.
Hopefully the patient has met with the surgeon before the biopsy and he/she has outlined the things that might happen in the future so it’s not a totally cold call with the biopsy results.
It may well depend on the person and how they cope, but I think that’s a good way to deliver bad biopsy news.
My internist delivered the news that I almost certainly had ovarian cancer (I did) exactly the way you describe it should be done. After my surgery, my gynecologic oncologist apologized for forgetting to remind my internist that I was in the hospital; I just laughed and said she didn’t need reminding. And indeed she didn’t; she stopped by to see me a few hours later, called me at home the morning before my first chemo appointment to wish me luck, and has followed me very closely in the 4 years since.
My internist delivered the news that I almost certainly had ovarian cancer (I did) exactly the way you describe it should be done. After my surgery, my gynecologic oncologist apologized for forgetting to remind my internist that I was in the hospital; I just laughed and said she didn’t need reminding. And indeed she didn’t; she stopped by to see me a few hours later, called me at home the morning before my first chemo appointment to wish me luck, and has followed me very closely in the 4 years since.
Can I just add one more little thing to your excellent post? Try not to give them the bad news last thing on a Friday. I was once told I had a very serious disease over the phone on a Friday afternoon. I immediately set about adding my newly revised life-expectancy to my children’s ages and generally had one of the worst weekends of my life – this was pre internet, BTW.
I didn’t have the disease at all in fact – the diagnosis was plain wrong and based on misinterpretation of a result on a screening blood test. The experience has probably turned me into a bit hypochondriac – but a very well-read one.;-)
Can I just add one more little thing to your excellent post? Try not to give them the bad news last thing on a Friday. I was once told I had a very serious disease over the phone on a Friday afternoon. I immediately set about adding my newly revised life-expectancy to my children’s ages and generally had one of the worst weekends of my life – this was pre internet, BTW.
I didn’t have the disease at all in fact – the diagnosis was plain wrong and based on misinterpretation of a result on a screening blood test. The experience has probably turned me into a bit hypochondriac – but a very well-read one.;-)