Monday, May 28, 2012

Bad news

Breaking bad news to a patient is an experience unlike any other.

It's a necessary part of the job.  Remember - this is internal medicine.  There aren't many fairytale endings here.  It's generally a one-way street that eventually culminates in death.  Feeling chipper today?  Then don't read on.

It sure feels like I blog a lot about this kinda stuff - probably because I do.  I'm really not a pessimistic person by nature - a realist, yes - but not a pessimist.  I'm trying to portray a realistic picture of the work of an internist, which by now you can probably tell isn't full of sunshine and roses.  And yet I still enjoy my work tremendously.  There's something about caring for people in their state of poor health that brings me satisfaction.  But lest you think I am altruism personified, you should also know that I do enjoy the perks of being a doctor.  Recall that I am incredibly human and enjoy the same things that you do.

Back to the topic at hand - bad news.  Part of being an internist is delivering bad news.  And I mean bad news. 

Take Mr H, for example.  He's a 45 year old M who came to the ED this week because of swelling in his legs and abdomen.  He has a history of hypertension but is otherwise pretty healthy.  I can tell right away that he is a bit socially awkward - he tells me he was diagnosed with Asperger's in childhood.  He's incredibly nice and likes to talk.  He lives alone and has a full-time job as a security guard.  He smiles a lot and seems happy with his life.

Before I went to see him for the first time on the medical ward, I looked through his chart.  The ED physician notes bilateral lower extremity swelling, protuberant abdomen that is tense, but nontender.  There is a significant amount of recent weight loss.  He has a notable microcytic anemia - commonly seen in slow gastrointestinal bleeding.  CT scan of the abdomen and pelvis was ordered.  I pull up the scan and on the very first image I see an enlarged liver that is chalk full of metastatic lesions.  There's a large mass in the transverse colon.  Within 2 minutes of starting my chart review I had essentially made the diagnosis of metastatic colon cancer.  Damn. 

With this fatal information in hand, I went to see Mr. H.  It was late afternoon and the sun was going down.  He was alone in his hospital room with the blinds down and the lights off.  The sunlight that made it through the curtain filled the room with a dim, dull yellow color.  I offered to turn the lights on and open the blinds, but he said he had always preferred enclosed, dark places.  Ok, whatever you like.  I'm about to ruin the rest of your life, so you should be as comfortable as you can be. 

He sits up on the side of the bed as I pull up a chair.  It usually isn't a good sign when your doctor pulls up a chair - either you've lucked out and he's got incredible bedside manner, or you're about to get some shitty news.  It's kinda like the casino.  Either you just hit the jackpot or you lost it all. 

I try to keep the chit-chat to a minimum before I break bad news.  There's nothing worse than going from a chipper banter back and forth about something insignificant to telling someone they have a fatal disease.  So I try and avoid that.  But I try not look like the grim reaper either - I've learned that puts off an air of mistrust from the get-go.  I try to take the middle road of being very professional, but not too rigid as to foster mistrust.  If I don't have a patient's trust within two minutes, the conversation generally doesn't go well.

I shake his hand, sit down, and introduce myself.  I ask the usual questions about how he ended up in the ED.  He talks quickly and nervously and doesn't like to make a lot of eye contact.  He smiles and jokes about his abdomen getting bigger - says he's been trying to lose weight and it's coming off his face and arms, but his gut just gets bigger.   

As he talks, I see his mouth moving but I'm not hearing much of what he is saying.  I already know the diagnosis.  So I let him go on until his words have exhausted themselves, nodding as if I'm listening intently.  In the back of my mind, I'm wondering how he is going to take the bad news.  I can see the pain and suffering that he's about to go through.  His days are numbered - this terrible disease will eventually kill him in some horribly unpleasant manner.  Yet I continue to smile and listen to him talk.  For a moment I feel like a complete charlatan, pretending to not know what is going on while listening to him talk. 

The strange part about breaking bad news is that I'm not afraid of doing it.  And to be honest, I really don't mind doing it, either.  It sounds strange as I type that, but it's the truth.  I don't enjoy it, but I'm not averse to it.  Some of that is probably selfish - there's nothing that makes you appreciate what you have until you see someone who is about to die.  There's something very sacred in that moment.  All my first world problems disappear and I think about the things that are really important to me.  I drive home with a new resolve to be a better person and appreciate the precious time I have on this earth. 

Unfortunately that profound effect only lasts for a few days.  I'm disgusted at my own ability to remember these moments.  That strong desire that caused me to reevaluate my life the night before instantly flees at the first yelling match between by young kids.  You'd think after having hundreds of these moments that the feeling would just stick.  But it doesn't.  Don't forget - I'm incredibly human.

Back to Mr. H.  His words exhaust themselves and he sits silent, waiting for my next question.  Instead of a question, however, he's going to get some bad news.  Some really bad news.  I've learned to be direct in these conversations.  If you talk too much, patients don't understand.  And once you say the word cancer, it doesn't really matter what you say, because they're not listening.  I take a deep breath and begin.

"Mr. H, I know why your belly and legs are swollen and why you have been losing weight." 

"Ok..." he says, sensing that the conversation was changing for the worse.  His eyes are now fixed on mine and his nervous fidgeting has stopped completely.  He looks scared.

"There's no easy way to say this.  I'm have some very bad news.  You have cancer."  I got goosebumps over my entire body as I said it. 

It's always interesting to see how people respond when confronted with bad news.  Everyone reacts differently.  Mr. H's reply took me by surprise.

"Whoa," he muttered, eyes still fixed on me.  After a few seconds of silence that felt like minutes, he then said rather nonchalantly, "Well, at least I know.  That's cool.  I've always kinda been a fatalist, so I figured something like this would happen sometime." 

He smiled innocently and then asked, "Is it treatable?"

"Treatable, perhaps, but not curable.  Chemotherapy can buy you some time, but it won't cure you of the cancer," I reply.

"Ok...well....let's give it a try," he says with another smile.  "If it doesn't work, that's ok."

That is the part that kills me.  Patients have no idea what to expect, so they try so damn hard to be positive and stay optimistic.  It's admirable.  It gets me every time though.  I'm so impressed with their determination and attitude, but at the same time my gut twists inside of me because I know how much pain they will go through before they die.  I hold back the tears and smile, trying to acknowledge his courage without killing his spirit. 

We talked a little bit more about chemotherapy.  I answered his questions as best I could.   I told him what to expect during the hospitalization and that I'd be by first thing in the morning. 

Breaking away from that conversation is always difficult - mostly because I feel bad about coming in there, dropping some unexpected bad-news bomb, and then just walking out.  I get to go home to my wife and kids and enjoy my life while he is still stuck in the hospital, left to drown in the abyss of bad news that I just threw him in.  I usually end up repeating some cliche phrase to try to cheer them up, which always sounds tacky and trite when it leaves my lips.  Nonetheless I still do it, because it's better than just walking out without saying anything. 

And so Mr. H left the hospital a few days ago with a diagnosis of metastatic colon cancer.  He went his way and I went mine.  I'll probably see him back in the hospital before long, and I would gladly care for him again.  Hopefully next time I won't have any bad news - maybe we'll find something enjoyable to talk about.  And maybe by then I will have learned how to stop forgetting these powerful moments and actually appreciate everything that I have in this world.  I really have no reason to complain, but I probably still will - at least until I have to break some more bad news. 

Stay tuned - exciting picture post about my workplace coming soon!


  1. I am writing this reply after being post-call in the MICU so I apologize upfront for the lack of brevity; blame it on delirium and thank you very much in advance for the haldol (although I discovered per Jacobi J, et al., Crit Care Med 2002; 30:119-141 that this is actually only level C evidence i.e. "Crap").

    I too am not afraid of giving bad news, and only until recently did not mind giving it either. There is something admittedly perverse/unsettling about a concept like not enjoying it but "don't mind...not averse to it" and it is something that I have thought about with some degree of guilt in the past. Because by simple elementary school logic (by this I mean with regards to the field of arithmetic), if one does not have negative feelings about something, by default and inarguably, one has either neutral and/or positive feelings about it. And given the severity of such a situation as delivering bad news, I feel compelled to debate that everyone doing it should only feel quite terrible about it.

    Mind you I preface this by saying that I am also very human (and subjectively probably more flawed than the average orangutan) and most of what I am arguing is primarily for the sake of discussion with a dabble of objective sincerity on the side. But here it goes.

    You state that these situations help you "appreciate" and prioritize things/events/people more and that this "profound effect only lasts for a few days." Although I "appreciate" the concept you are expressing and agree that it exists, consider this my dear blogger.

    Lets say I am a blooming gastroenterologist in a highly profiled academic center, and in my patient pool I am taking care of (a) my parents, (b) a tall lanky goofy-looking caucasian guy who is 6' 2", weighs about 11 stones (yes I used the British measurement for some playful confidentiality) and has a BMI of a very feminine ~20, and (c) a short spunky slightly aggressive South American female (I hope you dig the alliteration). Now lets say I also diagnose these individuals with some tragic ailment.

    (i) Now when I present the bad news to my parents, do you think any part of me, for any measurable amount of time (and certainly not days), will feel "appreciative" of the things I have etc, or rather would I be angry/shocked/depressed and all-in-all be an emotional wreck. This lack of objectivity is one of the primary reasons why we as physicians do not and should not take care of friends or family.

    (ii) Now lets say I go approach patients (b) and (c). They are complete strangers to me and most likely similar to your entry, it is the first time I am meeting them. I have not yet had any sufficient time to develop an emotional relationship with them that inevitably occurs with time (admittedly at different rates). Now is it likely I will feel appreciative of all that I have after delivering bad news to them - most certainly. Is it acceptable or reasonable for there to be this gross discrepancy, especially lasting for days? I am not so sure. I am not even sure it would be okay if it just lasted for minutes. Have I ever had a reactionary but nonetheless appropriate guilt spell after feeling "appreciative" after delivering bad news? Absolutely.

  2. (Continued due to character limit :)

    My second comment: I too have encountered and am initially impressed with patients' positivity and optimism especially after I have delivered such terrible news. However after also considerable thought, I would like to offer the firm suggestion that 100% of the time with 100% certainty this "good" reaction we are seeing is an absolute farce. My hands are getting tired of typing this but let me quickly reference both the undeniable instinct of self-preservation and the famed Kubler-Ross model. I strongly believe that any type of positive response to getting bad news is either (1) a lack of understanding, (2) a fleeting transient feeling that will soon be replaced by D.A.B.D.A (google my abbreviation), (3) an often documented paradoxical desire to please the physician so that we do not feel like failures after delivering bad news, or (4) a complex conglomeration of all three (I am sure I am missing some other situations here). Consider what I have said my friend and I look forward to reading yours/others thoughts.

  3. Excellent points as always, jyalpha. I would be completely unable to string any coherent thoughts together post-call, so mad props to you.

    The only way that I can explain the gap between what we 'should' feel and what we actually feel is that we are fallable human beings. Medicine is humbling in that we are constantly reminded of our inadequacies.

    In terms of optimism - you make a valid argument. There are, however, patients that fully comprehend bad news (ie not in denial, aren't seeking to please) and yet still stay optimistic. Just my experience though - perhaps yours has been different.

  4. Bravo! Way to distort, you two.

    Stick to your regular jobs and don't bother venturing into psychological analyses. Truly asinine.