Delivering bad news

“I’m very busy today with patients so I don’t have time. But, it’s not like your mom will die from thyroid cancer in the next couple of days.”

This is the statement that the physician said to me and my mom before quickly exiting the room. The physician was seeing my mom in his clinic that day about a suspicious finding on a thyroid ultrasound.

The physician had no idea that we had recently lost a family member to a long hard-fought battle with cancer. The physician didn’t take time to think what his words would mean to us when we heard the word cancer again. The physician even missed the nonverbal cues from my mom that she was anxious, nervous, and shocked from hearing about the “suspicious findings”.

As a medical student, this is a prime reminder that learning the art of delivering bad news is essential in my medical training. It’s important to put myself in the shoes of the patient and remember that everyone has a story. Sensitivity towards the patient and their family/friends is crucial.

During medical school I’ve had the opportunity to extensively practice delivering bad news. During the preclinical years my peers and I attended lectures taught by faculty who, over their careers, had perfected their skills in delivering bad news. Through use of multimedia videos and active role playing of real life situations, we were exposed to the do’s and don’ts of this important skill. Then I had the opportunity to do practice sessions where I would deliver bad news to a simulated patient and then get feedback from faculty about my performance and what I could improve on. It was impactful to be able to evaluate myself after these encounters and hone in on what I did well to make the patient feel comfortable and what may have been perceived as insensitive to a patient. Central to all these lectures was the concept that a physician’s main goal should be to make sure the patient is comfortable at all times and the main focus.

 I learned that one of the most important things one should do is maintain eye contact. By making eye contact and sitting down, those extra 10-15 minutes makes a huge difference and puts the patient at ease at time that is likely to be extremely difficult. During my clinical rotation in general surgery, I remember a situation where I went with the surgical team to explain to the family members that the patient may have serious complications from the Whipple procedure (pancreaticoduodenectomy- surgery to remove the head of the pancreas). The attending surgeon immediately put the family at ease by sitting next to them and putting a hand on the patient’s husband’s shoulder, stating, “you’re doing an amazing job as a caregiver for your wife”. This simple statement put everyone in the room at ease. Then attending then calmly went on to explain the various complications of this high-risk surgery in a way that was not overwhelming, but also direct, so that there would be no miscommunication about the risks. As a student I noticed how the attending surgeon continuously made sure to pause during his explanation. He did this in order to assess whether the family was comprehending everything and also ensured he did not confuse the patient’s family with unnecessary medical jargon. That interaction had a great impact on me because here was an example of an attending surgeon, who was extremely busy, but still took the time to spend those extra moments to sit down, make eye contact, and help to alleviate the worries of the family members. 

Another vital tip that I was taught during my clinical years was the importance of asking about the patient’s support system. Many patients may be seeking treatment away from home or may not feel comfortable sharing bad news with their family or friends right away. As a health care professional and as the patient’s caregiver, it’s important to share information on other support systems that may be available, such as therapists, social workers, and home-care. During my internal medicine rotation, one of the interns on our team was inundated with 10 new patients on the service overnight and so she was trying to discharge some of the other patients. Unfortunately, in her haste to do that she missed the nonverbal cues from the patient who later complained to the social work team that the internal medicine care team was insensitive and hadn’t even asked if she had a home to return to. It turned out that the medicine team had not communicated effectively with social work who reported that the patient had been evicted from their group home and there needed to be time for arrangements to be made for another group home. As I watched these events unfold as a student, I remember thinking that it was quite easy to get wrapped up with trying to manage the floor as an intern/resident that sometimes we forget to take a step back and make sure that we consider holistically all the obstacles a patient may have in terms of their living situation, social history, support system, etc.

As I reflect on my mom’s appointment that day at the clinic, I often think that if the physician had taken just an extra minute to explain that our questions/concerns would be answered at a later time (since he was busy then,) it would have made this entire experience different. My experience in this scenario has certainly taught me to remember that the patient should always be my primary concern, no matter how busy things may get. As a future medical professional it’s important for me to remember that these skills I’ve acquired in medical school in delivering bad news will one day be indispensable and hopefully make me a more empathetic and cognizant physician.