Tuesday, November 14, 2006

Breaking Bad News

We had our first-ever class on how to break bad news to a patient this week. I say "first-ever" because I actually think I might have benefited from having such a class earlier in my training, followed by a refresher course now. The class didn't really contain any instruction; instead, a standardized patient (SP) sat in the front, and two student volunteers each attempted to break the news to her that a routine chest x-ray revealed a lung mass suspicious for cancer (confirmed by CT). The first student did an excellent job; the only thing I would have done differently is that I wouldn't have interrupted the patient's questions to read things like "pleural effusion and right pleural mass" off the CT findings. The second student didn't really have a chance. The SP changed her tactics: instead of being quietly shocked and tearful, this time she was fuming mad from the get-go. "Some idiot called me and said there was a mistake on the x-ray, and instead of repeating it I got some cat scan thing, and all I wanted is your signature so I can go get my new job!" The poor student, flustered from the beginning, struggled to do his best, but the SP wouldn't give him any ground. At one point, he looked at the audience and the instructor and said "Can I call a friend?" He was given no lifelines, however, and literally ran out of the "patient's room" at the end of the encounter (amongst much laughter, including his).

I, fortunately, was not chosen for this encounter, and studiously avoided the instructor's eyes when she asked for volunteers. During both students' attempts, I squirmed in my chair, especially during the second. All I could think was "Thank GOD that isn't me up there!" It's one thing to deliberately enter an encounter that is guaranteed to be uncomfortable; it's entirely another to do so in front of a room of your classmates. I do think it might have been nice to have a little more instruction, like "What NOT to do when breaking bad news", or "How to pass the SP interaction on Thursday".

My extreme discomfort showed me that I have an awful lot to learn about this topic. I was present when my senior resident confirmed that the "head mass" seen CT was indeed most likely cancer for the family of the fifteen-year-old patient, and it didn't feel so awkward, just sad. But I didn't really have to talk. I've never had to break that news myself. I'm really not looking forward to the "practice session" on Thursday, where I will get my own SP and I will have to tell them something bad. However, I think this is something, like the rectal exam, that I'd rather practice on someone who's getting paid before I have to do it for real.

I do have a fear about breaking bad news, and that is that I will cry. I don't know if a patient or their family would be offended if their doctor cried while delivering bad news. Would it be a sign that the doctor cared, or would it make the encounter more about the doctor than the patient? Is it a sign of weakness?

On a slightly related tangent, I expect to have to use my new-found knowledge during this year, because one of the oddities of being a third year medical student is becoming a "patient advocate". We really get the most time to be with each patient, since we have (far) fewer duties than any of the actual MD's or nurses: we generally only carry 3-4 patients at a time, and we are only marginally useful in doing actual work, AND we are inefficient at conducting H&P's, so the combination gives us the most time to spend with the patients. I've had patients tell me I'm the only person who answered their questions. Most residents and doctors I've worked with cared about the patients, answered questions, and tried to keep patients informed. Yet, the perception was one of confusion and lack of information on the part of the patients. As I'm getting ready to go back to the county hospital for internal medicine, I'm trying to get back into that mindset, to remind myself that it's so busy at this place that questions get lost and patient care may be cursory. We'll see how well I do.


barbie said...

i'd be OK if my doc cried. but only if i cried first.

frectis said...

It's weird for me. I'm a midwife so usually the news I have is good but let's say I attend a birth that makes for adrenal depletion and PTSD I keep it together and run it completely professional. When I'm doing peer review is when I fall apart.