How a doctor might tell you that "you are dying."

Which is worse... telling a patient directly "you are going to die," or having them leave your office having no idea because you tried to phrase it gently?

While I haven't yet been trained in breaking bad news to patients, the answer to this seems like it may be fairly obvious.

In an article published in the Journal of Clinical Oncology, author Scott Berry tackles this issue. Most interesting is a role-play situation in which physicians had to tell a patient they were dying; only one of eight oncologists used the word death. In the name of empathy and gentleness, perhaps the following statements veered too far into the realm of vague:


What the physicain said: Most people with this disease will have problems soon...Time could be very short—a few weeks to a few months. I think it is advisable to prepare for the worst and hope for the best.
What the physician meant: You are dying.

What the physicain said: Your time may be short.
What the physician meant: You are dying.

What the physicain said: If there were a hundred people in your situation, most of those people would have major problems within one month or so...let's consider that we are now at Labor Day. By the time we get to late September, early October, I would expect that you would be having major challenges or problems.
What the physician meant: You are dying.

What the physicain said: Certainly, it sounds like the disease is really threatening your life.
What the physician meant: You are dying.

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Even on my summer break...It's taking over my life.

The thing about medicine is that once you're in it, it's pretty hard to get away from it.

I started this blog over a year ago (and clearly forgot to celebrate its anniversary with fanfare of any sort), and evidently even at that tender naïve age I was aware of that fact. Enamored, actually, you could probably say. I knew that it would happen, and I was actually excited about living every moment enriched by my training in the medical sciences, making a difference in people's lives everywhere I went, breathing and living a life of medicine. I even used that phrase to name my blog.

Boy, was I delusional.

Okay, it's not that big a deal...yet. But it is happening. Here's a story to show how medicine has pretty much taken over my thoughts and day-to-day existence.

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On the plane on the way to a much-appreciated vacation last week, I got up to use the restr (those little rooms far too small to be called 'restrooms') and, wouldn't you know it, I ended up getting trapped by the beverage cart. The stewardesses had apparently taken the lighting of the final "Restroom Occupied" light as their signal to block the aisle with their large metal goodie-carts-on-wheels. They hid their glee well behind their powdered faces, perfectly poofed hair, and polyester neckerchiefs, but I could tell they were pleased with themselves and their strategic timing.


This left me stranded in their little lair at the back of the airship. I thought about popping the emergency door to get back at them (those slides look like a blast), or raiding the "Buy-on-board" cabinets when they weren't looking and stuffing my pockets with tiny liquor bottles and crusty sandwiches, or even worse, tampering with the smoke detector, but was prevented by the presence of another passenger back there, so instead I decided to talk to him instead.

"Stranded back here as well?" I asked him.

"No, actually, I've actually got arthritis and am just kindof moving around a bit so I don't get too stiff."

I replied, "How long have you had arthritis?"

"Are you currently on any medication for your arthritis?"

"Are there any factors that make your arthritis worse or better?"

"Are you frightened in any way by your arthritis?"

"Does the pain wake you up at night?"

"On a scale of 1 to 10, where 10 is the feeling of getting your eyeballs and fingernails ripped out by tiny monkeys and having scorpions invade and subsequently sting every orifice, how bad is the pain?"

And, remembering the latest research, I made sure not to tell him about my experiences with arthritis.

Actually, I didn't say any of those things. But in all seriousness, all of those questions did flood my mind, as if I was back in my OSCE again and had to think quick of something to ask him.

So, instead of carrying on a normal conversation, I was forced to wait for the storm of questions in my mind to quell, and in that time I only managed to blurt out something awkward like "Oh, that's good."

I then got to stand there uncomfortably with him while realizing that I apparently can't carry on a conversation without my med school training trying to take over.

Oh well, it's not like something like this won't happen again. In fact, it has happened to me before. And wait until I provide the list of foods I have trouble eating now, thanks to medical school.

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Fumbling with the Tools of the Trade: Empathetic Statements

"... So I pulled out this empathy comment in front of a patient at my Family Practice class on Wednesday. I figured I hadn't used one in a while. I tried hard to mean it but I guess I didn't really, and so soon after I started saying it I began hoping the patient wouldn't catch me. It was slightly misplaced, and a little bit out of context. I felt really phony and I hated myself for it for a brief few seconds..."

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I sometimes feel a little awkward using my new set of tools of the trade.

I'm not talking about the otoscope, or the opthalmascope, or the stethoscope, or the rectoscope (I can't wait!), or the tongue blade (apparently the technical term for 'tongue depressor'; the public caught on and started using the medical term 'tongue depressor,' so 'they' had to change the medical term to something more scientific and dangerous sounding. "Tongue blade should suffice," said the men in the white coats in the dimly-lit strategic medical equipment naming room.) Yeah, I'm all thumbs with all those tools still (as is my classmate who inflicted great pain on me whilst using one of the above scopes in a Clinical Skills learning session), but those aren't exactly the tools I'm referring to.

The 'tools' I'm referring to are the tools we learned during Communications Skills class, or "We Have A Past History Of Taking Crap for Our Graduates Being Socially Awkward And Insensitive To Patients So We Will Mandate That All Of Our Medical Students Take This Class On How To Talk To Patients Without a) Them Thinking The Doctor Hates Them, b) Them Thinking That They Will Sue The Doctor, Or Worse Still, c) That They Should Stop Donating Money To The Medical School From Which The Doctor Graduated." (That's the course title. Look it up.)

These 'Tools' are the Sit Down, the Get Consent or Die a Painful Immediate Death, and the most difficult to master secret ancient ninja maneuver, the Empathetic Statement.

The first two are pretty easy. "Sit down to create the impression of spending more time with the patient," we were told. Funny, I figured I'd just create that impression by spending more time with my patients. Shows how much I know. Moving on.

The second tool, Get Consent or Die a Painful Immediate Death, is pretty self explanatory and consists of making sure that the patient is willing to be interviewed by me. I have to get permission to talk to the people and I still don't even examine them on my own yet. Even if I screw this one up, my Medical School has covered their legal bases by layering - the patients are told when they book their appointment that medical students will be there, there is a "This Doctor is Teaching Medical Students" slash "Go Easy on the Medical Students, We Can't Have Them Quit On Us This Far In" certificate in the waiting room, the doctor asks them if it's OK to be questioned by a rookie, and finally I, the Medical Student of whom the patients have heard so much and are by now wondering why they have to be so sure they want to talk to me, ask them if it's OK.

(On a bit of a side note, in case there aren't enough side notes already, there are patients who decline to have their appointment on Wednesday afternoon once they find out that there are medical students in the office then. I'm collecting names so that I can decline to treat them or their children in the future. Just kidding, there are still some things that I don't mind putting off seeing in real patients until I've had a chance to be trained with standardized patients. You may recall what I'm referring to.)

Back to the tools. While the first two could be mastered by any layman, the final one, the Empathetic Statement, has pretty much become one of those things that haunts you even when you've punched your clock and have left work. It's awkward to wield, and takes a while to master, and at times you just close your eyes and hope it's working and you're not just embarrassing yourself, but when it is effective, man is it a deadly blow. It's kindof a secret weapon of new doctors, too, so don't tell anyone I told you this, we're sworn to confidentiality (which is why I'm sworn to anonymity)... I'll tell you, but I just don't want you, in your next doctor's appointment, to start wondering if a doctor is genuinely nice, or they have had to receive training on being nice to patients and are whipping out a full blown Empathetic Statement assault on you. Assume the former.

So I pulled out this empathy comment in front of a patient at my Family Practice class on Wednesday. I figured I hadn't used one in a while so I should get some more experience. I tried hard to mean it but I guess I didn't really, and so soon after I started saying it I began hoping the patient wouldn't catch me. I was interviewing this patient about her painful urination, now on my list of afflictions that I hope to treat rarely and acquire never, and I then chose to pull out an Empathetic Statement. It was slightly misplaced, and a little bit out of context. I felt really phony and I hated myself for it for a brief few seconds. If she wasn't so busy trying to make sense of my questions while I asked her to describe her pain in terms of its location, intensity, nature, character, mood, demeanor and favourite food and color, she might have noticed that my Empathetic Statement, "That must've been difficult," isn't exactly the most ideal interviewer response to "But the pain got better when I drank cranberry juice."

Okay, it wasn't actually that bad. I think what actually happened was that she told me that the pain was worse than ever before and I said that it must have been difficult. But I still felt phony saying it. This is what I'm talking about when I say that work stays with you even after you punch out. You see, it's rough when I do say something like "That must've been really frustrating!" spontaneously, even in normal conversations, because I feel like people - especially if the conversation is with someone in my class - they think I'm just pulling that out of my ass(ignment book for Communications Skills class). We joke around enough with FIFE (ie. Classmate approaches me and tells me they locked their keys in their car; I respond, "Awwww, how is this affecting your functioning? What are your fears?") so it's logical for them to think that I'm pulling out an Empathetic Statement because we were taught to, and not because I actually mean it.

Fortunately it doesn't usually go that bad. I have never actually gotten in trouble or accused of brash falsehood when I have used an empathetic statement, genuine or not. But I still hope this will stop being so awkward soon, and that when I actually do mean the statement, or even on those rare times that I don't and am just trying hard to be a bit more human, that my efforts will be appreciated nonetheless.

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