How to bear bad news

My residents are learning how to give bad news. It's a good skill to have if you happen to be in medicine, where we're often telling people things they don't want to hear. One of my colleagues is teaching this skill to the residents. In her seminar, the residents role-play. One of them is the doctor doling out some dismal tidbit; one of them is the patient trying to take in the doctor's measured words.

The residents feel awkward in these sad little skits played out before their peers. They're physicians, not actors, and mostly they're focused on learning the physical skills of surgery -- knot tying, the use of the skin knife, the delicate dissection of nerves and arteries. They're anxious about these physical skills, nervous about their abilities, and I suspect that some of the residents wish they were honing their surgical technique instead of picking their way through a mess of words.

I trained before there was any formal curriculum on "communication in medicine." It was assumed that we'd simply pick it up along the way, which I did, eventually. It was a process of trial and error though, painfully weighted on the side of error.

Years ago, as a student, I was in the basement catacombs of a decaying city hospital with one of my first patients. He was a janitor, just retired after 40 years of night work at a giant suburban supermarket. Within weeks of retirement, he'd turned yellow as an egg yolk, and was in the hospital, with me at his side, to figure out why.

He was scheduled for a procedure involving a telescopic exam of his bile ducts. I'd read about the procedure, but when he'd asked me what it was like from the patient's point of view, I'd had to admit that I had no idea. So I decided to accompany him to the underground procedure room.

He was sedated for the test, which revealed an advanced cancer. When it was over, I helped to transport him to his room. He came to as we moved him from the stretcher back onto his bed and suddenly awake, he looked up at me and blurted out "I'm going to die, aren't I?"

I was speechless, then devastated. Nothing in medical school had prepared me for that, for what to say to a newly retired sick guy confronting his own mortality.

In truth, I can't recall any more what I said to him. Still, I remember his frightened eyes, the desperation in his voice. And I remember describing the encounter on rounds the next day and crying in frustration and shame as I admitted that I didn't have a clue what to say to him.

My medical student peers seemed embarrassed for me, crying publicly on rounds in a Major American Teaching Hospital. My tears, though, prompted our brusque, dapper gastroenterology attending to sit down and talk to us about talking to patients, and as he related some of his own experiences, he also cried, dabbing his cheek with a handkerchief that had seemed purely ornamental in the breast pocket of his tailored suit.

His tears consoled me. I realized as I watched him cry that this doctor job was hard -- not just because I was new to it, or inexperienced, or just plain bad. It was hard because it's hard to be the bearer of bad news.

Still, he assured me, there were ways to do it well, and as we sat in our conference room, he gave us pointers, techniques, specific phrases and gestures that I still use and that I wouldn't have learned if I hadn't broken down in the presence of this mentor.

I look at the surgery residents in the bad news seminar. They're tongue-tied, a little bit embarrassed, wishing they were in the OR. Still, I think, it's better they practice a little on their lucky still-well colleagues than find themselves alone one night, standing at some hospital bedside, rendered speechless by the anguish of some patient's fearful question.