I knocked, introduced myself, and got the HPI. The patient had classic symptoms of unstable angina. Chest pain? Check. Shortness of breath? Check. High cholesterol? Check. Family history? Check and check.
This was going to be so easy, I told myself. I'd probably have to look at an EKG and tell the patient he likely needed to get an echocardiogram, with the possibility of a reflex cath, if it were abnormal. This I could do. So I started going through the motions. Finished the interview. And then set the stage. "Well sir, it looks like we did some tests and labs. Let me get those results, and we can figure out what the next step should be."
I opened the door and grabbed the lab tests that were sitting in the folder outside. Oh your physical exam was unremarkable and your EKG was normal - so good news, you're not having a heart attack! And your chest xray shows ... oh...a 3.4 cm lung mass... indicating...ummmm, cancer.
My fake patient went into hysterics.
And I agree. That was probably the worst way ever to tell someone they have cancer. True, I should have read the results outside before coming in. True, I should have gone through the 6 step protocol on "how to deliver bad news." And true, I should have done all sorts of things that I didn't do. Instead, I essentially said, good news! you're not having a heart attack! Bad news! You have lung cancer! I'm sure the way I said it - hesitantly and all drawn out - only made the situation inherently more awkward.
Fast forward to my sub-i, and I have a 40 year old guy who comes in with what seems like indigestion, only to find out that he actually has metastatic cancer of unknown origin. Someone in the ED had told him, but had not gone about it properly. "Hello sir, well it doesn't look like you have gallstones, but we need to admit you to find out where your cancer is coming from." "My what???"
It was a rough morning that day, as he became a part of my team's census, and I was assigned to his case. It was rough seeing his wife and father jump on the first plane out so that they could be by his side. And it was rough seeing him break down, every time he thought about how he should have spent more time with his family when he had a chance.
They teach us how to deliver bad news in med school, and they even have us practice it. But the truth is, reality is so different from those structured exercises. How are we supposed to set the stage and determine how much the patient wants to know? What are you supposed to say? "Sir, your CT results are back...but first, why don't you tell me what you want to know?" Honestly, what is a patient going to say to that?
I dunno what I'm gonna do or say when it comes time for me to personally break bad news to a patient first. Heaven knows I completely botched it for a fake patient, what will happen when it happens to a real person? With real feelings and real families and real everything?
