A Medical Economics Web Exclusive

The wrong way to break bad news

Time pressures are no excuse for insensitivity to patients’ needs, the author stresses.

By Eric C. Last, DO
Internist/Wantagh, NY

Ann is fragile, with a thin build, wan complexion, deep-set and sad eyes, and no visible muscle mass. Yet her name on our schedule warns all that the morning’s patients will be delayed.

The 15 minutes slotted for her appointment will stretch uncontrollably into 20, 30, even 40 minutes. Her multiple prescriptions must be filled out exactingly, specifying, "Dispense as written–brand medically necessary" because Ann is "allergic to all generics."

Her depression is almost contagious, trying to drag down anyone who enters its realm.

Objectively, though, Ann has every right to her sadness. Her history reads like a collection of the most technologically advanced procedures medicine has to offer.

She underwent a four-vessel CABG after presenting with atypical chest pain, which proved to be Ann’s special brand of angina. She bears the scar of a carotid endarterectomy, performed simultaneously with her coronary revascularization. Cardiac arrest on my nurse practitioner’s table heralded her malignant arrhythmia and necessitated the implantation of an AICD. It protrudes from her body like a talisman, warding off the evil spirits of tachyarrhythmia.

When Ann telephoned on a Tuesday evening, I feared what new problems could beset this woman. She had seen a local radiologist for a needle biopsy of a breast mass that was deemed suspicious on mammography, but I hadn’t received any pathology results. "I have breast cancer," Ann began. "I just got the call from the radiologist. She said I have cancer, and I need to make arrangements with you to have it taken care of. But really, Dr. Last, I didn’t hear a word after she said ‘cancer.’"

I advised Ann to let me await the final pathology reports; then we would make the appropriate referral to a breast surgeon. But something felt very wrong. Clearly this cheerless woman was the victim of more than just mitosis run amok; she had been traumatized by a physician’s phone call that delivered devastating, life changing news.

It took two days of thought before I called the radiology group to register my disgust. The first radiologist I spoke with told me, "This is just the way we do things, and there’s no other way we’ll do it." Still, I was promised a call from the group’s director of breast imaging.

When it came, I told her that I was aghast that Ann had been given such news by phone. This is a woman who already has multiple, grave diagnoses, and is being treated for depression, I explained. After the shock of this latest, telephoned diagnosis, I wouldn’t have been surprised if she’d stepped in front of an oncoming bus.

The radiologist confirmed that her group’s procedure was to deliver such news by phone and urge the patient to follow up with her primary care physician. "We’ve never had a problem with any other patient or doctor," she told me.

It was clear that the group’s policy was wrong. "The information must be conveyed in person," I begged.

"There’s no way we have the time to do that," she told me. "If you want the responsibility of giving results in person to all of the people you refer here, we’d be happy to arrange it."

I expressed my feeling that the best interests of patients were being sacrificed to the exigencies of modern, harried medical life. This prompted the radiologist to "take offense" at my implication that she provided patients with anything less than the best medicine has to offer.

We ended by agreeing that in the future the radiology group would send me my patients’ pathology results. I’d schedule appointments and impart the news face-to-face, explaining the implications and supplying emotional support.

This experience offered me a new sense of how we’ve lost so much that should be at the heart of patient care–interaction with our patients. Most of us will continue to teach students about the central importance of the human beings for whom we care, and try to practice that way. But clearly, there are those among us who have given up on the subtleties that differentiate "doctors" from "physicians." Patients will lose at every such surrender.

We must be vigilant not just of the evils that "the system" has wrought on our daily practices, but also of those doctors who have abandoned the caring part of medicine because their schedules are too crowded or their reimbursement rates are too low, the ones who decide, "I just will not do that."

I say a little prayer that those who do care will stay in the majority.

Eric Last. The wrong way to break bad news.

Medical Economics

2001;14.