One summer afternoon some years ago, I stood studying the brain scan of a 40-year-old woman who had previously had a mastectomy. Even to my then-amateur eyes as a medical student, it looked bad. The tissue was studded and pockmarked, as if showered by meteorites.
With new weakness and garbled speech, the patient had just been admitted to our hospital's neurology ward. Her husband's pleading look said it all: Please, don't tell me her cancer has spread.
My next memory of the case is of a huddle at the patient's bedside: a tired but beautiful woman with searching eyes, her husband and a young neurology professor. Medical students flocked to this professor because of his lively personality and style of teaching. Then, however, he was holding the patient's hand and speaking almost in a whisper. "It doesn't look good" is all I heard him say. What I'll never forget was the sadness on his face.
You could say I was lucky. Although my first experience of a doctor breaking bad news was heart rending, it was also inspiring. What a sacred duty, I thought to myself at the time.
Over the years, however, I've learned that breaking bad news is a duty many doctors dread and some downright bungle.
Consider, for example, another incident involving bad news, this one courtesy of my friend Liz. Although it happened some time ago, anger and shock still color her voice when she tells the story.
Back in the 1980s, after months of abdominal pain and weight loss, Liz's father was diagnosed with stomach cancer. He went to surgery. Two days later, the surgeon stopped by to report his findings. After quickly revealing that the cancer was not fully removed, thus crushing any hope of cure, he edged toward the door. Liz, her mother and her sister trailed him down the hall, desperately pressing for details.
Finally they followed him into a crowded elevator to ask: What next? That's when he told them further treatment was pointless.
To be fair, breaking bad news is difficult. There's never enough time and information to answer every question. It's emotionally draining, and near impossible, when those who need to hear the news aren't ready to receive it. But none of these truths cancel the bottom line: In medicine, giving people bad news goes with the territory.
Throughout my medical education and internal medicine residency in the 1970s, we had no lectures or reading assignments on breaking bad news. Our generation learned by watching--in the ward, the emergency room, the ICU. Our mentors ranged from fellow greenhorns to gray-haired chiefs. Age notwithstanding, some doctors were skilled at breaking bad news, some inept, just like now.
Today medical schools are more enlightened--or so it seems. In their second and third year, medical students frequently role-play scenarios involving bad news. From time to time, professional societies and journals even publish guidelines on delivering bad news. Their points are eminently reasonable:
* Ensure privacy and adequate time.
* Discuss bad news directly with the patient.
* Prepare the patient and yourself.
* Provide information simply and honestly.
* Encourage patients to express their feelings.
* Discuss treatment options.
* Acknowledge personal shortcomings and emotional difficulties in breaking bad news.
Unfortunately, there's just one problem with role-playing and guidelines: They train the mind to speak, not the heart. In breaking bad news, you need both. And how do you learn to speak heart-language? For most people, medical or lay, I believe the learning comes through pain and loss. Doctors are hardly immune. But some use their professional role as an armor against the pain, both of others and their own.
Last month, we had a profound loss in our own family: a father and his 6-year-old child were killed in an accident. Among the many sympathy messages we received, the notes that moved us most deeply often began: "There are no words to express . . ."
Doctors must use words to share bad news--simple, clear ones--but they should also share their wordless grief, their empathy and their humanity. And when the exact right words don't come, the language of the heart can still fill the silence. A touch, a meeting of the eyes and moments of quiet are forms of solace that everyone needs eventually. After all, doctor or patient, someday bad news awaits us all.
Claire Panosian Dunavan is an internist and infectious diseases specialist practicing in Los Angeles. Readers may write to her at firstname.lastname@example.org The Doctor Files appears the fourth Monday of every month.