Breaking Bad News
Bad news is like a lump of red-hot coal that lands in your palm--and that you can't let go of, no matter how badly you'd like to.
I was tossed the burning coal over twenty years ago, when I was thirty years old and fit as a fiddle. Or so I thought. I also happened to be a first-year medical student, having my head filled with facts large and small about the human body.
Then something started to go wrong.
The first inkling came when I had to excuse myself from a two-hour seminar because of a sudden urge to pee. No big deal...and yet something about its urgency bothered me. The next time the seminar met, I took the precaution of urinating beforehand.
It didn't help. The same painless urgency interrupted the session once more. What was up?
Before long, I found myself using bathrooms a lot--in fact, more often than anyone I'd ever met. Within weeks, a one-hour class exceeded my endurance. So did the bus ride to school. And I certainly couldn't make it through the night.
Then the thirst began. A raging, playground-in-the-summer thirst that had me running back and forth from my desk to the kitchen, filling tumbler after tumbler with water or orange juice as I tried to study anatomy.
Clever fellow, I wondered whether it was the drinking that was causing the peeing. One night, to see what would happen, I went to bed thirsty. It didn't help.
Nowadays, as a doctor, I know that such symptoms mean only one thing. But back then, I couldn't assemble the disjointed facts I was learning into a clear picture. I assumed there could be a million causes for my symptoms, most of them treatable.
There was one piece of inside information that I chose to ignore as it flitted in and out of awareness: a cousin in his early twenties who'd developed an unquenchable thirst during a car trip--and landed in a doctor's office, where he was handed a diagnosis of diabetes, juvenile onset, and put on insulin right away.
When I thought about my unfortunate cousin, I wondered whether he had to inject the insulin directly into his veins, like a drug addict.
Luckily for me, I knew that I couldn't have diabetes.
How did I know? Because I was healthy. How could a person as healthy as me have diabetes? The logic seemed airtight.
The night that I had to use the bathroom five times, I finally decided to see a doctor. For some reason those five visits exceeded a critical threshold and convinced me that I needed help.
I had the good fortune to be covered under a student health plan whose office was in a red-brick building a few blocks from campus. An elevator took me up to a hallway, then I entered a waiting room.
Behind a sliding-glass window sat a graying secretary named Gladys, who greeted me and told me the doctor wasn't in. But after hearing my story, she made a call and described my symptoms over the phone. She listened, nodded and hung up.
"The doctor wants you to leave us a blood sample and come back tomorrow," she said.
The next day, I returned to the brick building filled with hopeful anticipation, like a pilgrim in search of salvation--or a patient fully expecting a cure.
I entered the small, empty waiting room. Gladys looked up from the open sliding window. And that's when it happened. Before I could sit down or even register the look of concern on her face.
"Oh, Paul," she said. "The doctor's not here again today; she wants you to see a physician downstairs. It looks like you have a problem with diabetes."
There it was. In my palm. The burning coal. Hot. Searing.
After leaving the building, I made a woeful, shell-shocked telephone call to my girlfriend. Together we tried to process this bombshell.
A few days later I was hospitalized, learning how to inject myself with insulin (I did not, thankfully, need to hit a vein, just pierce the skin) and how to test my own blood sugar. I began to contemplate my new life--totally dependent for survival upon insulin, syringes and blood-testing gadgetry.
All of that made me sad. But the thing that stung most was the way I'd been told the news. I felt angry at Gladys, though I later came to know her as a nice person who'd been thrust into a role she wasn't trained to play. I felt mad at the invisible Dr. X, who'd diagnosed and discharged me through an intermediary. Finally, I felt mad at myself because I might have complained, but never did.
Now, twenty-five years later, I'm a physician who on occasion delivers bad news to patients. Sometimes it's really bad, like cancer. Sometimes it's emotionally devastating, like a sexually transmitted infection in someone who believed that her partner was faithful.
Oddly, I like being the one to give the news. Not because I enjoy inflicting pain. Rather, it's a form of repair. It's a chance to rewind the clock and imagine someone taking care of me the way I wish a real doctor had.
Because of my experience, I know the impact of bad news badly delivered. And I know how long the memory lingers.
When I teach residents how to deliver bad news, I think of a cookbook recipe. Close the curtain or door. Make sure everyone is seated. Ask the patient what he or she thinks might be causing the symptoms in question. And then, making eye contact, say some version of, "I'm afraid I have some bad news to share with you..." If it feels right, touch the patient with a comforting hand.
Then comes the most difficult part: Say nothing. Wait for whatever comes. Silence. Tears. Or an impatient "So what do we do next?"
Teaching residents how to break bad news isn't much of a stretch for me. All I need to do is remember what it felt like--and what I myself wished for--when someone tossed me the burning coal.
About the author:
Paul Gross is founding editor of Pulse--voices from the heart of medicine.