Giving Bad News

Recently, someone close to me was diagnosed with cancer. Due to a series of missed phone calls on both sides, he had not heard the results of his biopsy prior to his follow up appointment. When his young doctor walked in, he started with “so you know you have cancer, right?” I just wanted to scream “what the hell!” when hearing this story. It is never easy to give someone bad news, but this obviously was not the way to do it.

This experience took me back to a patient of mine early in my practice. She was a young, fit woman with short brown hair that framed her face. Because she was healthy, I had only seen her twice in the couple years I knew her - for her annual check up and a birth control refill. On her most recent visit, I asked if she was dating anyone. She shook her head, “no, the last guy was a loser. I’m taking a break.” Quickly she was animated and smiling again as she went on to tell me about a work trip to Vancouver soon. The only wrinkle was that her old boyfriend would be there too, but she shrugged it off.

I swung our discussion back to today and her check up. “This is a good time to be tested for STDs since you are in between relationships.”

“Sure, if you think so, but I’m not worried. He wasn’t THAT much of a loser,” she chuckled.

Within a week, I received her lab results. One page was flagged… HIV POSITIVE. I felt like someone had punched me in the stomach and I couldn’t catch my breath. How many times have I tested patients for HIV just as standard protocol? Even early in my career, too many to count and this was my first patient who tested positive. How could she look so strong and healthy and be carrying this deadly virus?

I was about to pick up the phone to call her when I remembered she was in Vancouver. Now what? Do I call her now, while she is away? If I wait until she comes back, what if she meets someone on the trip and has unprotected sex? She may expose someone else. If I were her, how would I feel hearing this news over the phone while on a work trip? So many questions were rumbling around my head - there were no good answers.

Is there a right way to give bad news?

When I get a patient’s pathology report of breast cancer on a Friday afternoon, should I wait until Monday to call her to let her have one more weekend “cancer free?” What if I do call and I’m transferred to voicemail? Do I leave a message to call me back? The office may be closed when she returns the call. Then she is left to ruminate over the weekend.

When I get the pathology results from a surgery and it shows cancer, do I wait until their post op visit to tell them in person or call right away? It is usually just a matter of a couple days. If I tell my staff to make her appointment sooner, won’t she guess it is because I have bad news? On the other hand, it gives her the chance to bring someone with her for support to the appointment.

When I receive a PAP report revealing precancerous cells, but I am post call and tired, do I wait another day to inform her? Knowing the patient well and knowing how she will react to the news, I may not have the patience and energy to be there for her as I would want to be and as she would need.

These are not rare scenarios-- these issues arise frequently. After so many years in practice, you would think I would have this down. But I don’t; every time it is difficult. Every time it’s heart-wrenching. Every time I envision how they will take the news, wondering who they have to support them, and how to best tell them. Understanding that once I say cancer or herpes or whatever diagnosis, they probably won’t hear much of anything else I say. I always end with “you are welcome to call me back or come in once the shock has passed and you need to talk more.” Many call me back quickly, some return for another appointment, sometimes with their partner. I called a patient’s husband recently while she stood next to me in the office because she didn’t know how she could tell him she had cancer. I have learned that each patient responds differently and has unique needs in these moments.

In the end, I called my patient the day I received her HIV results. I didn’t want her passing the virus on, as small as that risk was, and I thought she would want to know as soon as possible. It was one of the toughest phone calls I have made. And although I was just the messenger, I felt the heaviness of altering her life forever.

I hope that young doctor that informed my friend learns a better way to inform his patients of cancer. In that instance, he lost a patient forever. I know that I have blundered sometimes when giving patients bad news and understand how he could have spoken the way he did. I try to remind myself though, before I open my mouth, the impact my words will have to my patient in learning of a grave medical issue.

Andrea Eisenberg blogs at www.secretlifeofobgyn.com