Sometimes it seems that there is only bad news and on days like those it is harder to remember the heart-warming events of my health professional life.  Distressing episodes are more likely to pop into my mind and are more poignant. 

My earliest memory of having to break bad news as a doctor was during my house officer (intern, PGY1) year.  I don’t think I had had any specific education on how best to do this. Perhaps there had been something involving cancer diagnoses and how to prepare patients and self for that type of consultation. But my experience happened without the time for any warning shots to prepare the people involved. 

I was called to the female orthopaedic ward by the ward sister.  A patient who had had an elective hip replacement and was due to be discharged the next day had walked to the toilet, collapsed and died.  This was just before visiting time and two of her close family had arrived expecting to see their relative.  Instead they were directed to the ward office, and sister said it was my job to go in and tell them about the unexpected death.  At that point the cause of death was not certain and would not be until after a post-mortem (autopsy), which I had to advise the family would be necessary.  

Looking back now after all these years I remember clearly feeling totally unprepared for the task, yet I have no specific memories of what I said in that room.  I have no idea of how the family responded or whether my way of breaking the bad news made the situation even worse for them.  I know now, of course, that the relatives were suffering more than I was, but I doubt I was in the best state to comfort them.  Then, I had to carry on with the rest of my work. 

Since then I have been the bearer of bad news on many occasions not only of cancer diagnoses but of sexually transmitted diseases, abnormal antenatal screening tests and results indicating type 2 diabetes.  Many other times, as a GP, I have interpreted for my patients the implications of the bad news delivered by another health professional.  I hope I have become better at this challenging work with experience and through running communication skills courses for other health professionals and students. 

Learning and practising communication skills do help prepare health professional students for challenging scenarios.   Working with simulated patients has the advantage of in-time feedback and guided reflection on performance.  In real-life each situation is different, and there are few appropriate moments to ask: ‘how did I do?’  

Sixty years ago, a paper reported that doctors may wish to shield their patients from poor prognoses, even considering it inhumane or detrimental to patients to be honest about bad news.^[1]  While doctors are now more likely to be transparent, we still sometimes put off the moment of delivering the news. 

The in-between time is difficult – the time between seeing the patient when the diagnosis is probable and when it is confirmed after tests or specialist input.

A retired man comes to see me – he has noticed his skin has turned yellow in the past few days.  Our interaction confirms he has painless jaundice, a combination that at his age strongly suggests cancer of the pancreas affecting liver function.  However, I tell myself, there are other possible causes and I order investigations. He is feeling well though tired and has no specific worries about what he might have.  Should I mention the possibility of cancer at this point?  I don’t, and it is the specialist who does the hospital-based tests and confirms pancreatic cancer.  Our relationship remains strong, and I look after him until he dies at home within a few months. 

A woman in her 70s consults me as she has rectal bleeding.  There is a high probability of bowel cancer, but piles (haemorrhoids) are also a possibility.  When I stick my finger up her bottom (digital rectal examination), I feel a lump that shouldn’t be there.  I am certain she has cancer.  I ask her what she thinks might be the problem and she answers ‘piles.’  I refer her to a colorectal surgeon.  A few weeks later she returns having had the cancer removed and with a permanent colostomy.  ‘You knew what it was all along doctor, didn’t you?’ but there is no acrimony, and she says that she is glad I didn’t tell her in the first consultation.   Was that the right thing to do? 

I have many more examples like these – each person, each consultation, each day in general practice we must make decisions about what to do and say.  There is little time to reflect on interactions during and after a consultation ends.  I need to write-up my computer notes and then, running late, it is time for the next person.  

In breaking bad news sessions with learners and health professionals, it is important to explore and discuss the learners’ emotions.  I have frequently felt sad and tearful after a challenging consultation –yet I must remember that the patient has had life-changing information with far greater implications than I do.  Health professionals do need to consider their own mental health so that they can give the best care to the next patient and the one after that.  We swing from bad news to good news and back every 10-15 minutes.  After each consultation there is a need to reset and postpone emotions so that the next person has my full attention.  Each patient needs to be able to feel that they are the most important person during their consultation.  

It’s not about me until the end of the day…

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^[1] Oken D.  What to tell cancer patients: a study of medical attitudes.  JAMA 1961; 175: 1120-1128.