My mother thinks I work too hard. She shakes her head when I tell her that I worked 24 hours straight. If I operate all day, standing in one spot for eight hours, she worries about my aching ankles, my swelling legs and varicose veins.
Oh, honey, she says, I wish you didnt work so much.
My mom isnt wrong that my job can be hard, that Im tired and sore at the end of a busy week. Still, the hardest part of my job isnt always the physical component. Often the most difficult thing I do is simply talking to patients. Its being the bearer of bad news.
Giving bad news is terrible, no matter how long youve done it. You did a breast biopsy yesterday on a 30-year-old with two kids, and today the biopsy shows an aggressive cancer. Someones son has a brain injury from a skateboard accident, and now he is in a coma.
Imagine these conversations. Theyre awful.
No matter how carefully I choose my words, no matter how precisely and thoughtfully I answer questions, I often end up feeling like a blunt instrument. At family meetings, I offer Kleenex and hold the hands of people who cry, but I feel clumsy, wishing there were some way to convey bad news that was less hurtful than simply saying it. As patients and families sit and weep, I sometimes wish I could run outside and scream or escape home for a stiff drink.
When I was in training, we werent taught much about how to have these conversations. As a resident, my husband asked for advice on telling a family that their son had died.
Dont let the family get between you and the door, he was told. That was it. No acknowledgment of how important it was or how hard it would be.
These days we have formal education on how to give bad news. We teach the residents how to run a family meeting, how to introduce themselves and identify who is present. We encourage them to try to get a sense of what a patient or family already knows and what it is that theyre most worried about. We remind them to make sure that theres Kleenex at hand, and to use words that the least sophisticated person in the room will readily understand.
All that is good, for sure. But the hard part isnt remembering to introduce yourself or to bring Kleenex into the room. The hard part is that after you deliver devastating news, you are left to witness the grief of others, the abject despair that comes on the heels of your news.
And then, you have to keep doing the other things on your to do list, while the patient and family are left with their new reality.
A couple years ago, I ran a weekly conference for junior surgical residents and I asked my husband, a psychiatrist, to talk about psychiatric issues that can affect the care of surgical patients. Instead of talking about mental illness, he asked the junior residents how they were doing and what they considered the difficult parts of their job.
What came pouring out was how they often felt inadequate in conversation with patients, how uncomfortable they were delivering any kind of bad news. They wanted to be able to speak words that were truthful and somehow comforting, words that contained some combination of hope and realism. But they didnt feel they could do it, both because they were too busy and because they hadnt yet learned how despite regularly finding themselves called upon to do so.
One intern described morning rounds as his surgical team hurried from room to room, trying to see 20 patients and a bunch of families before the O.R. started at 7:30. On busy days, when they had complex patients with bad problems, he sometimes felt that they left confusion and anxiety in their wake. He fantasized about having an explainer who would follow his team on their rounds.
I want to tell the patients not to be disappointed, he said. I want to tell them the explainer is a couple rooms behind us. We doctors dont have time to talk now, but the explainer will be along soon, and theyve got all the time in the world to talk with you and be with you.
The other interns nodded. They loved the idea of the explainer, someone who could fulfill the needs of the sick for both information and comfort, needs that the interns sensed but knew they couldnt meet.
To me the explainer sounds like a superhero whose superpower is words. I love the concept, which simply and beautifully recognizes the importance of talking to people, and of doing a good job when bearing bad news. The explainer was a fantasy for my overworked residents, but its an inspiration for me. These days when I have bad news, or when a patient looks like he needs an explanation, I try to summon my inner explainer and live up to the aspirations of my humble trainees.