Delivering the bad news

Short White Coat is a blog written by second-year Harvard medical student Ishani Ganguli. Ishani's posts appear here, as part of White Coat Notes. E-mail Ishani at shortwhitecoat@gmail.com.

There’s not one right way to deliver bad news to a patient, one of a doctor's most difficult tasks. And I can imagine hundreds of ways to get it wrong.

The Patient Doctor II course directors at Massachusetts General Hospital decided eight years ago that it wasn’t enough for medical school admissions committees to select compassionate applicants -- some of these skills need to be taught. So they began taking their students to the Wellness Community, a wood-paneled oasis in Newton, where cancer patients and survivors come together to share their experiences and enjoy each other’s company. Our task was to talk with members of the community, role-playing those life-changing moments when a doctor first says the C word.

I screwed up my courage and volunteered for the second of three role-plays before my classmates and teacher, pulling up a chair to face a lung cancer patient with whom I’d made small-talk moments before. Drawing from that morning’s reading assignments and from somewhere deep in my gut, I reassured this lovely woman that I’d give her more information at the very earliest I could get it, that there were promising treatment options for her non-Hodgkin's lymphoma, that we’d fight this battle together.

Such skills are tested on next month’s Step I Boards (preparation for this qualifying exam has quickly insinuated itself into our every waking moment). Computerized practice questions pose elaborate scenarios in which you, the doctor, must give your patient a terminal diagnosis. What do you do if family members are in the room? How should you weigh cultural context when telling a Korean man, or a Latina woman, such news? Board review books offer formulaic approaches to such questions, tidily encapsulated in chart form, and one of the seven or so multiple choice options will usually stand out as a bit less stilted than the rest.

It’s nothing like doing it in person.

When the patients gave us feedback, we knew it meant a great deal. When another patient critiqued my classmate’s nervous assurance that he wouldn’t die, this man had learned the hard way just months before that false hope could quickly fester into distrust.

Knowing that my lung cancer patient had gone through it before, that the tears in her eyes were residual and not the product of acting school, touched me in a way I hadn’t expected. I’ll remember those eyes every time I have the unfortunate task of telling my own patients what neither of us want to say or hear.