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Giving bad news
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The patient and their family are waiting. The imaging study and pathology results are in your hands, and you review them one last time. It does not look good. Someone, you, must inform them of the results and explain what it all means. Taking one last deep breath, you enter the room.
Giving bad news is never easy. Doing so in an honest but empathetic manner is an essential skill in the art and practice of medicine. And yet, it seems few physicians receive formal instruction on how to do this.
I remember clearly one of the first rotations I had as a medical student. It was a general surgery rotation. The surgeon had a reputation for being belligerent and losing his temper. He had no problem berating nurses, students and even patients. The advice given to me by other students was to stay out of his way and not say anything to provoke him.
One day an elderly gentleman, the patriarch of a large Hispanic family, presented with abdominal pain. Imaging studies suggested malignancy. An explorative laparotomy confirmed widely disseminated stomach cancer.
The next day, the surgeon entered the patient’s hospital room with me tagging along behind. The man’s family had gathered expectantly at his bedside. The surgeon told them bluntly: “We opened you up. You’re full of cancer, and you’re going to die. There’s nothing we can do.” Then he turned around and walked out. At the time, I was inexperienced and did not have the courage to stay and do what was right. I regret that I too turned and walked out of the room. I promised myself from that day on, I would never ever be like that surgeon.
In my internal medicine residency, I was exposed to mentors who had a much more understanding and sensitive approach. It was these role models whom I tried to emulate.
Still, there was one attending who gave me the following advice: “Tom, you care too much. Patients want their doctors to care for them, but we can’t. Doctors have to become very good actors at pretending we really care.” Indignant at her cynicism, I suggested if that is how she truly felt, perhaps she should be in another profession. She smiled knowingly, “You’ll be different once you’re in practice; just wait and see.”
I practiced for several years as a general internist before I became an endocrinologist. There were many occasions to give bad news during that time. Despite that cynical attending physician’s forecast, I never changed or "pretended" I cared, instead of really caring. I am grateful that as an endocrinologist, I now rarely have to give bad news. Most endocrine disorders, if not curable, are at least manageable.
There is no one best way to give bad news. Every situation is unique. What has worked well for me, and what I advise my students, is to think of how you would like your own doctor to think and act. Imagine the patient is your own grandmother. Share and explain the facts without being cold or blunt. Look your patients in the eye. Be sincere. Offer hope when there is hope, but be cautious in encouraging unrealistic expectations. If your patient cries, that’s OK. If you need to shed some tears yourself, go ahead. A pat on the hand or shoulder, or even a hug, provides comfort far beyond words. Most importantly, reassure your patient that no matter how hopeless it seems, you will be there for them in the future, for any questions or anything else they may need.
