It’s that part of the job that I've never gotten used to. I hope I never do. I saw a man recently with an unexpected finding on his exam – a “lesion” that should not have been there. I was seeing him for his diabetes and blood pressure, and was doing my “ritual” physical exam, when the “lesion” blared into my vision.
I say “ritual” exam because the exam itself had little to do with his medical problems. It is just my practice to do a cursory exam of the head, neck, chest, and lungs of most everyone who comes to the office. I guess it’s the “laying on of hands” part of the practice of medicine that makes me do this; there is something about the human touch that makes a doctor's visit different from a visit to the accountant.
I got a sick feeling in my stomach when I saw it. I like to make people better, I like to make them happy; now I had to give some bad news.
When broadsided like this by an unexpected finding, it’s work to keep a calm composure. I was surprised and very worried, but I tried not to show it on my face. Why do I feel the need to keep calm? My visceral reaction would be to exclaim, “Oh, no! What is that??” but even a small amount of shock and surprise could have a negative impact. I suppose it’s because people need to face hard things with confidence, and my reaction will have a big influence on his own outlook and perhaps even the outcome of his disease. I am sending him off toward one of the hardest things in his life, and I want him to go with the best possible mindset.
“So, have you noticed this before?” I asked, fighting to keep a calm expression.
“Yes, it has been there for a few months and since I had this appointment scheduled, I waited to see what you thought”, he replied while looking into my eyes, gauging my level of concern.
I took a breath and calmed myself.
“Well, I have to say that I am worried about this and I think you need to see a specialist for further evaluation. It very well may be cancer, and if it is I don’t want to delay things. There is no way to know if it is something serious, but I always err on the side of caution. I am very concerned about it.”
As I explained, his expression changed little. He kept studying my face, measuring just how much he should worry. I wanted to convey to him the urgency and gravity of the situation and yet not over-state things. Fifteen years in practice has taught me that sometimes “sure things” are not what they seem. I don’t want him to skip the specialist visit and delay diagnosis and treatment, but I also don’t want to paint such a hopeless picture that he will think, “what’s the point?” I craft my words as carefully as I can.
In his book The Anatomy of Hope, Dr. Jerome Groopman discusses the role of hope in a person’s battle with disease – in his case from the perspective of an oncologist. One section of the book that I thought was especially important was his discussion on how to give bad news. We are not taught how to do it in medical school, nor does our society prepare us to do this daunting task. I did have a very good oncology rotation in residency, with a strong emphasis on our personal interaction with our patients, so I do have some examples to work by. But overall, my method has been self-taught.
We physicians are not made differently than other people; we don’t have a stronger emotional reserve or innate knowledge on how to handle difficult situations. I want people to like me. I want people around me to be happy. I don’t enjoy throwing emotional grenades into the lives of people I’ve cared for over many years. Yet this is part of what I must do, and in doing so I have learned a number of things.
1. Stay Calm – The person has put their confidence in me enough to make me their doctor, and so I need to honor that trust. They want me to think clearly and make good decisions, which can be undermined by strong emotion. The want me to be their guide and to take the situation in hand while they are overcome by emotion.
2. Stick to facts – I start out with saying what I know. “I see a lesion that has me worried” is a statement of fact. “It could be cancer, but we don’t know until the specialist analyzes it” is also straightforward truth. When I am asked “what kind of cancer?” or “how serious is it?”, I stay away from conjecture. I answer: “I don’t even know it’s cancer now, and we won’t know until the biopsy is done.”
3. Don’t cloud things – I think it is important to use words like “cancer” if the concern is enough. That is the patient’s worry, so my exclusion of the word just leaves room for reading between the lines. The human being in me makes me want to surround my words with others that cushion the sharp edges of a word like "cancer", but doing so serves only to confuse the person, not help.
4. Give a clear next step – Saying words like “cancer” is like dropping a bomb; people won’t hear much else in the visit after you say that. But what they need to know is what the next thing they need to do. Bad things like cancer make people feel powerless and scared; giving them a plan on how to approach it is one of the most important things a doctor can do.
5. No delays – I immediately got on the phone with the specialist while this man was in the exam room to make sure he could be seen right away. One of the worst things I see doctors do frequently is to say things like “you may have cancer” and then leave the person to fight through the system on their own. I could have just sent it to my referral coordinator, but who knows if the specialist may have a 2 month wait? What’s to guarantee that my staff won’t fax to the wrong number or just forget to do the consult? I need to do everything in my power to get the process going. This makes the patient's feeling of powerlessness as short-lived as possible.
6. Personal after professional – My first reaction is often one of empathy for someone who I know facing a difficult hard time. But my duty is that of doctor first, and that emotion should not stand in the way of it. Once I have handed the person off and made the plan, however, I think it is appropriate to show compassion. I can’t make things go away, and I can’t fix the situation, but I can offer support and sympathy. My relationship with my patients goes beyond the chart, the numbers, the studies; it goes to the human being across the room from me. I think better care comes when there is some emotion shared between doctor and patient, although I always keep in mind that they are paying me to be their doctor, not their friend.
The image of the “lesion” hung with me for the rest of the day. I had to put most of it down and clear my mind when I entered the next exam room. I need to offer my best to each patient, and allowing a hard thing to cloud my head could lead to mistakes. But the putting down of hard things is never complete. I still carry visions of "lesions", of difficult conversations, of strong emotion that are many years past.
Yes, it’s “just my job,” but at one moment I have the opportunity and responsibility to play a huge role in one of the most important moments of a person’s life. That is a great honor as well as a big responsibility that I accepted when I agreed to be their doctor. If I do my job right, they leave me with understanding of the situation, with a clear plan of action, with knowledge that I know they are hurting, and most importantly, with hope.