See one, do one: Learning to deliver bad news

Short White Coat is a blog about learning to be a doctor. Posts appear here as part of White Coat Notes. Ishani Ganguli is a third-year Harvard medical student. E-mail her at shortwhitecoat@gmail.com.

As part of my outpatient month on medicine, I spent the morning with an oncologist at Dana-Farber Cancer Institute’s lung cancer clinic on Friday. I had learned the stats on the leading cancer killer in the US, but watching this doctor deliver bad news to patient after patient was much harder than I had imagined. He would chat with each patient before addressing the elephant in the room, using her reactions to guide his discussion of the next steps.

Minutes after clinic ended, I crossed Binney Street to complete my third-year OSCE (objective structured clinical exam) -- one in a series of annual tests of our bedside manner. The topic of this observed exercise, appropriately enough, was giving bad news, something of a follow-up to last year’s practice run.

We prepared by reading the scenario: a 66-year-old woman with a history of breast cancer was coming in for low back pain. The reason, a bone scan revealed, was that the cancer had come back to invade her spine. My job was to tell her.

I visited with a patient-actor as my evaluator watched me through a two-way mirror and a video camera in a corner of the room made permanent impressions of my every empathic hand gesture and turn of phrase.

When we were finished, the evaluator came in to grade me on my interpersonal skills and my discussion of next steps. Her main critique was that I had hedged the results -- that I did not definitively tell the patient that the news was bad, reminding her instead that women do make it through such a recurrence (though really, the numbers are low).

Then she pointed out the unfortunate clincher: my response when the patient-actor expressed her hope that the technicians had looked at the wrong patient’s bone scan in coming to their decision. "I hope so too," I quickly responded before realizing what I had said. It was a slip borne out of my overwhelming desire to reassure this sad-eyed woman. In that exquisitely scrutinized moment, I had let that desire trump my primary responsibility.

Realistically portraying a patient’s chances and the risks and benefits of treatment options is a critical task, one on which some doctors may fall short: Recent studies have demonstrated patient concerns about receiving inadequate information about their breast cancers to make decisions.

I had seen that morning just how individually patients respond to bad news -- whether it’s by making aggressively cheerful jokes about the X-ray technician, doggedly aligning themselves with the latest second opinion, or shrugging away signs of their growing disease burden. I also discovered something about myself later that day: I have to balance my instinct to comfort with realism (but not hopelessness) when I deliver that news.